eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions

Medial Epicondylitis

Author: Sharon J Gibbs, MD, Physiatrist, Multidisciplinary Spine Practice at Texas Back Institute
Coauthor(s): Kenneth S Dauber, MD, PA, Consulting Staff, Department of Physical Medicine and Rehabilitation, Plano Orthopedic and Sports Medicine Center
Contributor Information and Disclosures

Updated: Aug 12, 2009

Introduction

Background

Medial epicondylitis (ME) is an overuse injury affecting the flexor-pronator muscle origin at the anterior medial epicondyle of the humerus. ME is often discussed in conjunction with lateral epicondylitis (LE), which occurs much more frequently. ME is the most common cause of medial elbow pain, although the clinician is likely to see at least 5 cases of LE for every case of ME. Patients who develop medial elbow pain appreciate their physician's knowledge of the subtle differences in the diagnosis and treatment of the 2 disorders. (See images below and Images 1-3.)

Medial epicondyle.

Medial epicondyle.

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Medial epicondyle.

Medial epicondyle.



Strengthening exercises are performed once pain h...

Strengthening exercises are performed once pain has subsided with active range of motion. The starting position (slight pronation) of an eccentric exercise for medial epicondylitis is shown. In order to prevent further injury, a trained therapist should instruct patients in exercises to confirm proper weight and technique. (The X indicates the medial epicondyle).

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Strengthening exercises are performed once pain h...

Strengthening exercises are performed once pain has subsided with active range of motion. The starting position (slight pronation) of an eccentric exercise for medial epicondylitis is shown. In order to prevent further injury, a trained therapist should instruct patients in exercises to confirm proper weight and technique. (The X indicates the medial epicondyle).



The eccentric exercise proceeds until full supina...

The eccentric exercise proceeds until full supination has been reached.

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The eccentric exercise proceeds until full supina...

The eccentric exercise proceeds until full supination has been reached.

Pathophysiology

ME involves primarily the flexor-pronator muscles (ie, pronator teres, flexor carpi radialis, palmaris longus) at their origin on the anterior medial epicondyle. Less often, ME also affects the flexor carpi ulnaris and flexor digitorum superficialis. Repetitive stress at the musculotendinous junction and its origin at the epicondyle leads to tendinitis in its most acute form and to tendinosis in its more chronic form.1 In addition, an ulnar neuropraxia caused by compression of the ulnar nerve in or around the medial epicondylar groove has been estimated to occur in up to 50% of ME cases.

The tendinosis that occurs is primarily the result of failure of the damaged tendon to heal. Microscopic examination of the involved tissue shows granulation tissue, fibrovascular and fibrocartilaginous tissue, tendon microfragmentation, calcification, and necrosis. Histologically, damage to the involved tendons has been described as angiofibroblastic hyperplasia tendinosis and fibrillary degeneration of collagen.2 A simple, acute inflammatory reaction is noted to be a much less common finding than are the previously described tendinosis changes.

Race

No studies indicate a race predilection.

Sex

A male-to-female ratio of 2:1 has been reported.

Age

Peak incidence is in patients aged 20-49 years, but ME is also seen in teens and older adults, especially if they engage in hobbies, jobs, or sports activities that make them prone to overuse injuries.

Clinical

History

ME is characterized by pain over the medial epicondyle. Pain worsens with wrist flexion and forearm pronation activities. Patients may report discomfort even when simply shaking hands with someone. Up to 50% of patients with ME complain of occasional or constant numbness and/or tingling sensation that radiates into their fourth and fifth fingers, suggesting involvement of the ulnar nerve.

The patient's history may include the occurrence of an acute injury as a result, for instance, of taking a divot in golf, throwing a pitch in baseball, or hitting a hard serve in tennis.

Physical

Tenderness with palpation over the anterior aspect of the medial epicondyle is the most consistent finding. Other characteristics of ME include the following:

  • Typically, pain is reproduced with resisted wrist flexion or resisted forearm pronation.
  • Occasionally, the area of tenderness extends approximately 1 inch toward the proximal flexor-pronator muscle mass just distal to the epicondyle.
  • The range of motion of the elbow and wrist is usually within normal limits.
  • Patients may have symptoms of an ulnar neuropathy (eg, decreased sensation in the ulnar nerve distribution, a positive elbow-flexion test, a positive Tinel sign). In more severe cases, decreased sensation is associated with intrinsic weakness; intrinsic muscle atrophy may be noted.

Causes

The causes of ME include the following:

  • The condition can result from the repetitive use of flexor-pronator muscles, especially with valgus stress at the medial epicondyle.
  • The onset can be related to the patient's occupation (if, for example, his/her job requires repetitive actions, such as the consistent use of a screwdriver or hammer).3
  • ME's onset can accompany acute injury.
  • An excessive topspin in tennis, excessive grip tension, improper pitching techniques in baseball, and an improper golf swing4 are common sports-related causes of ME.

More on Medial Epicondylitis

Overview: Medial Epicondylitis
Differential Diagnoses & Workup: Medial Epicondylitis
Treatment & Medication: Medial Epicondylitis
Follow-up: Medial Epicondylitis
Multimedia: Medial Epicondylitis
References
Further Reading
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References

  1. Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epicondylitis, biceps and triceps ruptures. J Hand Surg Am. Mar 2009;34(3):566-76. [Medline].

  2. Budoff JE, Hicks JM, Ayala G, et al. The reliability of the "scratch test". J Hand Surg Eur Vol. Apr 2008;33(2):166-9. [Medline].

  3. van Rijn RM, Huisstede BM, Koes BW, et al. Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rheumatology (Oxford). May 2009;48(5):528-36. [Medline].

  4. Farber AJ, Smith JS, Kvitne RS, et al. Electromyographic analysis of forearm muscles in professional and amateur golfers. Am J Sports Med. Feb 2009;37(2):396-401. [Medline].

  5. Banks KP, Ly JQ, Beall DP, et al. Overuse injuries of the upper extremity in the competitive athlete: magnetic resonance imaging findings associated with repetitive trauma. Curr Probl Diagn Radiol. Jul-Aug 2005;34(4):127-42. [Medline].

  6. Park GY, Lee SM, Lee MY. Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil. Apr 2008;89(4):738-42. [Medline].

  7. Krischek O, Hopf C, Nafe B, et al. Shock-wave therapy for tennis and golfer's elbow--1 year follow-up. Arch Orthop Trauma Surg. 1999;119(1-2):62-6. [Medline].

  8. Gabel GT, Morrey BF. Operative treatment of medical epicondylitis. Influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. Jul 1995;77(7):1065-9. [Medline].

  9. Carson WG. Overuse injuries of the elbow in the throwing athlete. In: Baker CL, ed. The Hughston Clinic Sports Medicine Book. Baltimore, Md: Williams & Wilkins; 1995:324-31.

  10. Ciccotti MG, Ramani MN. Medial epicondylitis. Tech Hand Up Extrem Surg. Dec 2003;7(4):190-6. [Medline].

  11. Gabel GT, Morrey BF. Medial epicondylitis. In: Morrey BF, ed. The Elbow and Its Disorders. 3rd ed. Philadelphia, Pa: WB Saunders; 2000:537-42.

  12. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. Feb 1999;81(2):259-78. [Medline].

  13. Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow. A prospective analysis. Am J Sports Med. Mar-Apr 1995;23(2):214-21. [Medline].

  14. Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis. A prospective study of sixty elbows. J Bone Joint Surg Am. Nov 1997;79(11):1648-52. [Medline].

  15. Stahl S, Kaufman T. Ulnar nerve injury at the elbow after steroid injection for medial epicondylitis. J Hand Surg [Br]. Feb 1997;22(1):69-70. [Medline].

  16. Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis. Results in 35 elbows. J Bone Joint Surg Br. May 1991;73(3):409-11. [Medline]. [Full Text].

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Further Reading

Related eMedicine topics:
Injection, Medial Epicondyle
Lateral Epicondylitis [Orthopedic Surgery]
Lateral Epicondylitis [Physical Medicine and Rehabilitation]
Lateral Epicondylitis [Sports Medicine]
Little League Elbow Syndrome
Medial Epicondylitis [Orthopedic Surgery]
Medial Epicondylitis [Sports Medicine]
Overuse Injury

Clinical guidelines:
ACR Appropriateness Criteria® chronic elbow pain. American College of Radiology - Medical Specialty Society.  1998 (revised 2008).  8 pages.  NGC:006997

Elbow (acute & chronic). Work Loss Data Institute - Public For Profit Organization.  2003 (revised 2008 May 28).  161 pages.  NGC:006555

Elbow disorders. American College of Occupational and Environmental Medicine - Medical Specialty Society.  1997 (revised 2007).  67 pages.  NGC:005681

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Keywords

medial epicondylitis, elbow pain, epicondylitis, tendonitis elbow, elbow injury, overuse injuries, elbow tendinitis, overuse injury, golfer's elbow, medial tennis elbow, reverse tennis elbow

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Contributor Information and Disclosures

Author

Sharon J Gibbs, MD, Physiatrist, Multidisciplinary Spine Practice at Texas Back Institute
Sharon J Gibbs, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and Texas Medical Association
Disclosure: emedicine Honoraria Other

Coauthor(s)

Kenneth S Dauber, MD, PA, Consulting Staff, Department of Physical Medicine and Rehabilitation, Plano Orthopedic and Sports Medicine Center
Kenneth S Dauber, MD, PA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Daniel D Scott, MD, MA, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver and Health Sciences Center
Daniel D Scott, MD, MA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, National Multiple Sclerosis Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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