eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
Medial Epicondylitis: Treatment & Medication
Updated: Aug 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
The physician may recommend that the patient with ME receive physical or occupational therapy. The discipline of therapy usually depends on the type of facility available, the accessibility of therapists, and physician preference. The proper means of treatment for ME are discussed below, in the Occupational Therapy section.
Occupational Therapy
Treatment begins with rest, ice, compression, and bracing, to decrease pain and inflammation. One to 6 weeks of relative rest of the affected muscles and tendons is typically advised, until discomfort subsides. Icing is employed for 5-10 minutes, 4-6 times per day and is particularly important if a patient presents after an acute event. Patients should be instructed to avoid icing over the ulnar nerve.
Compression with a medial counterforce brace (ie, a tennis elbow splint) with a pad placed anteromedially on the proximal forearm over the flexor-pronator mass is routine. Discontinue if symptoms of an ulnar neuropathy worsen. In addition, if the symptoms are severe, brace with a wrist splint worn in the neutral position in order to rest the wrist flexors. In milder cases, a counterbalance brace may be used alone instead of a rigid splint; this limits extremes of motion while allowing some movement for functional activities. In the case of ulnar nerve involvement, a nighttime elbow extension splint should be considered. The splint is made in 30-45 º of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.
After the patient's initial discomfort has subsided, a rehabilitation program with an occupational therapist should be initiated for muscle/tendon reconditioning. Begin with gentle stretching and add gradual strengthening of the flexor-pronator muscles, as the patient tolerates. Follow this with functional activities and with patient education aimed at avoiding re-injury.
The patient should be advised to perform very slow stretching exercises 10-15 times to warm up muscles and increase flexibility, before doing any strengthening exercises or functional activities. Strengthening begins slowly with isometrics and progresses to eccentric exercises (see Images 2-3), with a gradual increase in resistance. Take care to cut back on exercises if they cause a recurrence of symptoms. Icing for 5-10 minutes after exercise is reasonable, especially if the patient reports pain in the affected area following exercise.
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 supination has been reached.
Concomitant modalities may include ultrasound, iontophoresis, phonophoresis, transcutaneous electrical nerve stimulation, and low-energy, extracorporeal shock-wave therapy. Successful relief from symptoms is variable. Shock-wave therapy has been shown to be less effective for ME than it is for LE.7
Surgical Intervention
Epicondylar debridement is rarely indicated but has proven to be effective in cases in which conservative treatment has failed. In addition, the ulnar nerve may be decompressed surgically.8
Consultations
Referral to an orthopedic surgeon is appropriate after 6-10 months if conservative treatment fails.
Other Treatment
If conservative measures fail, injection with local anesthetic and steroid to the point of maximal tenderness is appropriate. Special care should be taken to avoid injection directly into the tendon or the ulnar nerve. If concern for dislocation of the ulnar nerve exists, the injection should be performed with the elbow extended or semiflexed. The number of injections should be limited to 3 to decrease the risk of tendon atrophy or rupture. Short-term relief of discomfort with cortisone injection may be expected, but a complete rehabilitation program, as previously described, is a more effective and long-lasting way to treat ME.
Medication
Nonsteroidal anti-inflammatory drugs (NSAIDs), taken orally, are the medicines of choice for ME to help control pain and any associated inflammation. NSAIDs are used on average only for the first 7-10 days of the treatment period. For the patient, taking these medications with food may help to decrease the possible gastrointestinal side effects. The following list is not meant to be comprehensive but simply to provide examples of options.
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Ibuprofen (Motrin, Advil, Nuprin)
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400 mg PO q4-6h, 600 mg PO q6h, or 800 mg PO q8h; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
(Consult pediatrician)
May decrease the effects of loop diuretics with coadministration; coadministration with anticoagulants may increase prothrombin time (PT); monitor and watch for signs of bleeding; may increase serum lithium levels and the risk of methotrexate toxicity; probenecid may increase the toxicity of NSAIDs
Documented hypersensitivity; avoid in peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, decreased renal and hepatic function, anticoagulation abnormalities, or during anticoagulant therapy
Naproxen (Naprosyn, Aleve, Naprelan, Anaprox)
For the relief of mild to moderate pain; naproxen inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis
Adult
500 mg PO bid; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d (Consult pediatrician)
May decrease the effects of loop diuretics with coadministration; coadministration with anticoagulants may increase prothrombin time (PT); monitor and watch for signs of bleeding; may increase serum lithium levels and the risk of methotrexate toxicity; probenecid may increase the toxicity of NSAIDs
Documented hypersensitivity; avoid in peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; acute renal insufficiency; interstitial nephritis; hyperkalemia; hyponatremia and renal papillary necrosis may occur; patients with pre-existing renal disease or compromised renal perfusion, risk of acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug
Etodolac (Lodine, Lodine XL)
For relief of mild to moderate pain; etodolac inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Adult
200-400 mg PO q8h prn; not to exceed 1200 mg/d
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious, NSAID-related side effects; probenecid may increase the concentrations and possibly the toxicity of NSAIDs; may decrease the effect of beta-blockers, hydralazine, and captopril; may decrease the diuretic effects of furosemide and thiazides; may prolong prothrombin time when administered concurrently with anticoagulants; monitor PT closely and instruct patients to watch for signs and symptoms of bleeding; etodolac may increase the risk of methotrexate toxicity; phenytoin levels may increase when coadministered with etodolac
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; acute renal insufficiency; interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk of acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of the drug
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 |
| « Previous Page | Next Page » |
References
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].
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].
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].
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].
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].
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].
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].
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].
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.
Ciccotti MG, Ramani MN. Medial epicondylitis. Tech Hand Up Extrem Surg. Dec 2003;7(4):190-6. [Medline].
Gabel GT, Morrey BF. Medial epicondylitis. In: Morrey BF, ed. The Elbow and Its Disorders. 3rd ed. Philadelphia, Pa: WB Saunders; 2000:537-42.
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].
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].
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].
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].
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].
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
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
