eMedicine Specialties > Sports Medicine > Upper Limb

Medial Epicondylitis

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin

Updated: Jan 22, 2008

Introduction

Background

Medial epicondylitis, or "golfer's elbow," is similar to the more common lateral epicondylitis ("tennis elbow") in many respects. Both conditions are overuse tendinopathies that can be associated with racquet sports. Other activities with which medial epicondylitis is associated include golfing and throwing sports. Medial epicondylitis has also been reported in bowlers, archers, and weight lifters.^{[1 ]}

Little leaguer's elbow is sometimes considered a variant of medial epicondylitis, but this condition is technically a traction apophysitis of the medial epicondyle, which requires a different treatment course.

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education article Tennis Elbow.

Frequency

United States

Medial epicondylitis accounts for only 10-20% of all epicondylitis diagnoses^{[1 ]}; this condition is usually found in the dominant elbow of a golfer.^{[2 ]}Tennis players who hit their forehand with a heavy topspin are also at increased risk for developing medial epicondylitis.

Functional Anatomy

The medial epicondyle is the common origin of the forearm flexor and pronator muscles. The most common site of pathology is the interface between the pronator teres and the flexor carpi radialis origins.^{[3,4 ]}The flexor pronator muscle group serves as a secondary stabilizer of the medial elbow, assisting the ulnar collateral ligament (UCL).

Sport-Specific Biomechanics

Immunohistologic studies have shown that long-standing epicondylitis is associated with a degenerative state instead of a traditional inflammatory process.^{[5,6 ]}Valgus stresses are placed on the elbow by activities such as throwing and golfing; valgus stress on the medial elbow is especially high during the late cocking and acceleration phases of a throw and during a golf swing (from the top of the backswing to just before ball impact).^{[7 ]}

Clinical

History

• Athletes generally complain of aching pain over the medial elbow. Patients who have more chronic pain may also complain of grip weakness.^{[8 ]}
• Pain may be associated with the acceleration phase of throwing.
• Ulnar nerve symptoms are associated in up to 20% of athletes with medial epicondylitis.^{[2 ]}

Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches

Physical

• On physical examination, the athlete experiences pain with resisted wrist flexion, and there is palpable tenderness over the medial epicondyle. Pain is also frequently found with resisted forearm pronation.
• In more chronic cases of medial epicondylitis, there may be pain with resisted elbow flexion.
• The Tinel sign should be checked over the ulnar nerve to rule out ulnar neuropathy.
• Remember to examine the UCL, especially in baseball players. Chronic UCL deficiency is more common than medial epicondylitis in throwing athletes. However, because the origins of the flexor mass and the UCL are relatively close together, both chronic UCL deficiency and medial epicondylitis may present with medial elbow pain. A magnetic resonance imaging (MRI) study may be useful in differentiating these injuries, if they are not clinically apparent.

Causes

• Training errors: These errors may increase the risk of developing medial epicondylitis. Athletes usually have a history of increased intensity or duration of activity, and they may not warm up adequately.
• Improper technique: This is one of the major causes of medial epicondylitis. Tennis players with poor serves and forehand strokes are at greater risk of developing medial epicondylitis.^{[1 ]}
• Equipment: The use of an incorrectly sized tennis racquet grip, overly tightened racquet strings, older tennis balls, and wet tennis balls may increase elbow stress. The use of graphite racquets and larger headed racquets can decrease elbow stress.^{[1 ]}
• Functional risk factors: Weakness, poor endurance, and poor flexibility of the forearm may increase the risk of developing medial epicondylitis.

Differential Diagnoses

Cervical Radiculopathy
Elbow and Forearm Overuse Injuries
Little League Elbow Syndrome
Ulnar Collateral Ligament Injury

Other Problems to Be Considered

Epiphyseal Fracture
Flexor Pronator Strain
Growth Plate (Physeal) Fractures
Osteoarthritis [in the Orthopedic Surgery section]
Osteoarthritis [in the Physical Medicine and Rehabilitation section]
Osteoarthritis [in the Rheumatology section]
Osteochondritis Dissecans (OCD)
Stress Fracture [in the Physical Medicine and Rehabilitation section]
Stress Fracture [in the Radiology section]
Tillaux Fracture
Ulnar Neuropathy

Related Medscape topics:
Resource Center Arthritis
CME Chondroitin and Glucosamine: Hype or Hope for Osteoarthritis?
CME Curing Cartilage Injuries Part 2: Resurfacing and Restoration in the Knee
CME Current Management Opportunities for Improving Patient Outcomes in Rheumatoid Arthritis
CME Etoricoxib and Naproxen May Have Long-Term Efficacy and Tolerability for OA Treatment
CME Improving NSAID Outcomes: Stratifying Risks and Tailoring Treatment (Slides with Transcript)
Activation of WNT and BMP Signaling in Adult Human Articular Cartilage Following Mechanical Injury
Finger Length Pattern Linked to Osteoarthritis
Interventions for Preventing and Treating Stress Fractures and Stress Reactions of Bone of the Lower Limbs in Young Adults
Shock Wave Therapy Useful for Resistant Stress Fracture in Athletes

Workup

Imaging Studies

• Plain radiographs may show calcification adjacent to the medial epicondyle in 20-30% of patients with medial epicondylitis, but radiography is not usually needed in the initial workup of this condition.^{[1 ]} However, radiographs should be obtained if there is a history of a traumatic injury, when the physical examination is suspicious for a fracture, and in cases that are recalcitrant to appropriate therapy. Plain radiographs may also be useful in the evaluation for tumors and apophyseal injury.
  • Note: In pediatric patients in whom a diagnosis of medial epicondyle apophysitis, or little leaguer's elbow, is suspected, a radiograph is not only warranted, but also necessary, as the results will help to guide the patient's treatment.
• Bone scanning is useful for evaluating stress fractures, infection, and tumors.
• Computed tomography (CT) scanning is useful for evaluating OCD and stress fractures.
• MRI is useful for evaluating OCD, fractures, and soft-tissue injury. MRI arthrography is useful for evaluating rupture of the UCL.
• Ultrasonography is contraindicated in children with open growth plates.^{[9 ]}

Related Medscape topic:
Resource Center Trauma

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

The goal of treatment of acute medial epicondylitis with physical therapy is to maintain the athlete's range of motion (ROM). Modalities such as electrical stimulation, iontophoresis, phonophoresis, and ultrasonography are sometimes used to treat medial epicondylitis. However, few studies have demonstrated long-term benefits with the use of these therapies.^{[1,10,11,12 ]}

Note: Physical therapy must be considered carefully in preadolescent patients because they tend not to be compliant.

Medical Issues/Complications

Pain control is the initial treatment goal for patients with medial epicondylitis.

• The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is somewhat controversial.^{[1,13 ]}Some physicians argue that the anti-inflammatory effects of NSAIDs are helpful in decreasing swelling, thereby increasing the speed of an individual's recovery.^{[11,14,15 ]}Other authors believe that NSAID use during the acute injury phase may increase swelling by increasing the potential for bleeding via platelet inhibition.^{[13 ]}However, if NSAIDs are not used, acetaminophen may be required for pain control in some athletes.
• The rest, ice, compression, and elevation (RICE) method is the mainstay for treating soft-tissue injuries.
  • Athletes must modify activities that aggravate the condition. This modification may be as simple as decreasing the amount, frequency, or intensity of activity. Athletes are often more compliant with a decreased level of activity if they are allowed to increase other nonaggravating activities.^{[16 ]}
  • Ice is the first-line anti-inflammatory treatment for medial epicondylitis. Icing should be done after completing exercise, stretching, and strengthening. Care should be taken to avoid over-icing as there is a possibility of ulnar nerve injury (usually a temporary neuropraxia), which may occur if the ice is left on too long.
  • Ice can be applied with an ice pack or with an ice water bath. An ice pack can be made by placing crushed ice in a plastic bag that is wrapped in a towel; to increase the contact area, the ice pack should ideally mold to the elbow's shape. A good alternative is a bag of prepackaged frozen corn kernels that is wrapped in a towel.
  • Ice packs are usually placed over the area for 15-20 minutes. To make an ice bath, a shallow pad is filled with water and ice. The athlete soaks the elbow for 10-15 minutes.
• Elbow braces
  • Counterforce bracing and cock-up wrist splints can be useful adjuncts for treating medial epicondylitis.^{[1 ]}
  • Counterforce bracing is used during activities and theoretically decreases the contraction forces of the flexor-pronator muscles on the medial epicondyle.^{[17 ]}
  • Cock-up wrist splints are particularly useful for athletes who awaken with elbow pain because these splints force the athlete to maintain a neutral position.
  • Elbow taping may also be useful.^{[8 ]}

Surgical Intervention

If conservative treatment fails (usually 6-12 months), surgical treatment should be considered for medial epicondylitis. Various techniques have been described, most of which consist of release of the flexor origin and excision of the pathologic tissue. In general, good results are reported in greater than 80% of patients. Potential complications include persistent ulnar nerve symptoms. Full return to sporting activity usually occurs within 4-6 months.^{[1 ]}

Other Treatment

Studies show that injected corticosteroids result in an acute improvement of symptoms that are related to medial epicondylitis; however, the long-term outcome remains unchanged.^{[9,18,19 ]}In cases of recalcitrant medial epicondylitis, consider corticosteroid injection.^{[1 ]}In addition, other causes of elbow pain should be considered; always obtain a plain radiograph of the elbow before injecting corticosteroids.

Cortisone injection for medial epicondylitis is relatively simple. The area of maximal tenderness is palpated; then, using sterile technique, inject this area with a small amount of cortisone (see Medication, below).^{[20 ]}

An alternative treatment is autologous blood injection. The use of autologous blood that is injected into the site of tenderness is thought to stimulate an acute inflammatory reaction that leads to reinitiation of the healing process. This therapy has been shown to be effective in limited studies of chronic inflammatory musculotendinous conditions.^{[21,22,23 ]}

Another possible alternative treatment for medial epicondylitis might be injection with botulinum toxin.^{[24 ]}

Extracorporeal shock wave therapy (ESWT) has been proposed as a treatment option for epicondylitis. This treatment modality appears to have few, if any, adverse effects. However, to date, results from studies are mixed, with most investigations studying lateral epicondylitis.^{[25,26,27,28,29,30 ]}

Recovery Phase

Rehabilitation Program

Physical Therapy

The treatment plan during the recovery phase is aimed at the individual regaining full flexibility and strength. Forearm stretching is key to the recovery. Strengthening of the wrist flexors and forearm pronators is added to the therapy, as tolerated.^{[31 ]}

Occupational Therapy

Laborers whose occupations require repetitive use of the upper extremities need a stretching and strengthening program before returning to their regular duties. The person’s workspace should be evaluated, so that any necessary changes can be made (if possible) to minimize repetitive motions.

Related eMedicine topics:
Evaluation of the Injured Worker
Hand, Nerve Compression Syndromes: Upper Extremity

Related Medscape topics:
Perspectives in Prevention From the American College of Preventive Medicine - Agricultural Injuries: Improving Occupational Safety

Surgical Intervention

Surgical intervention is considered for chronic medial epicondylitis that does not respond to conservative treatment.^{[1 ]}

Maintenance Phase

Rehabilitation Program

Physical Therapy

The patient should be independent with a maintenance physical therapy program of upper extremity flexibility and strengthening exercises.

Medication

Nonsteroidal anti-inflammatory drugs

Anti-inflammatory agents may be helpful in cases of acute medial epicondylitis. However, most cases of medial epicondylitis are the result of chronic inflammatory changes for which the use of NSAIDs is somewhat controversial,^{[13 ]}as these agents may or may not be beneficial to the physiologic processes of soft-tissue healing. NSAIDs have been found to be useful in controlling pain and allowing more rapid progress in physical therapy. Disadvantages of NSAIDs are many, including the risk of gastrointestinal (GI) bleeding, gastric pain, and renal damage.^{[32 ]}

Ibuprofen (Ibuprin, Advil, Motrin)

Member of the propionic acid group of NSAIDs. Available in low-dose form as an over-the-counter medication. Highly protein bound, metabolized in the liver and eliminated primarily in urine. May reversibly inhibit platelet function.

Dosing

Adult

600-800 mg PO tid/qid

Pediatric

<40 mg/kg PO divided tid/qid

Interactions

May increase the toxicity of anticoagulants; may increase the toxicity of methotrexate; NSAIDs may diminish the antihypertensive effect of ACE-inhibitors; may diminish the natriuretic effects of furosemide and thiazides; may elevate plasma lithium levels

Contraindications

Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding

Precautions

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

Because of the risk of closure of the ductus arteriosus, NSAIDs should be avoided late in pregnancy; caution in patients with renal disease, congestive heart failure, gastrointestinal ulcers, poorly controlled hypertension, coagulation defects, and hepatic disease.

Naproxen (Anaprox, Naprelan, Naprosyn)

Member of the propionic acid group of NSAIDs. Available in low-dose form as an over-the-counter medication. Highly protein bound, metabolized in the liver and eliminated primarily in urine. May reversibly inhibit platelet function.

Dosing

Adult

250-550 mg PO bid/tid; not to exceed 1100 mg when used for pain control and acute musculoskeletal injury; not to exceed 1650 mg for all other conditions

Pediatric

10 mg/kg PO divided bid

Interactions

Probenecid may increase the toxicity of NSAIDs; coadministration with ibuprofen may decrease the effects of loop diuretics; coadministration with anticoagulants may prolong PT duration (watch for signs of bleeding); NSAIDs may increase serum lithium levels and the risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity).

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

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

Because of the risk of closure of the ductus arteriosus, NSAIDs should be avoided during the third trimester of pregnancy; caution in patients with renal disease, congestive heart failure, poorly controlled hypertension, coagulation defects, and hepatic disease

Corticosteroids

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. These agents modify the body's immune response to diverse stimuli and are strong anti-inflammatory agents. The general risks associated with corticosteroid use include skin atrophy, skin hypopigmentation, soft-tissue atrophy, infection, bleeding, and failure to work. Up to 50% of individuals who are administered corticosteroids experience a transient increase in pain for the first 24 hours.^{[33 ]}However, a steroid flare that consists of increased pain up to several days may occur in up to 2% of individuals.^{[20 ]}

Triamcinolone acetonide (Aristocort)

Injectable, intermediate-acting, steroid anti-inflammatory agent. Injectable corticosteroids are used to treat localized areas of inflammation. No good evidence exists to suggest that injected corticosteroids alter the long-term pathology of chronic inflammation.^{[13,20 ]}However, many patients have acute symptomatic improvement.^{[20 ]}

Dosing

Adult

Inject 1 mL (40 mg/mL) into the area of maximal tenderness^{[20 ]}

Pediatric

Administer as in adults

Interactions

Coadministration with barbiturates, phenytoin, and rifampin decreases the effects of triamcinolone; diluents such as local anesthetics containing the preservatives methylparaben, propylparaben, and phenol should be avoided (these and similar compounds may cause flocculation of the steroid).

Contraindications

Documented hypersensitivity; patients with fungal, viral, and bacterial skin-infections; signs of cellulitis in the overlying soft tissue

Precautions

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

Precautions

Injectable corticosteroids in pregnancy have not been studied; carefully observe for signs of hypoadrenalism in infants born to mothers who received substantial exposure to corticosteroids; caution in patients with exposure to chicken pox, Strongyloides infestation, active tuberculosis, ocular herpes simplex, psychiatric conditions, ulcerative colitis, diverticulitis, recent intestinal anastomoses, history of peptic ulcer disease, renal insufficiency, hypertension, osteoporosis, diabetes mellitus, thromboembolic disorders, seizures, hypoalbuminemia, hypothyroidism, cirrhosis, hyperlipidemias, glaucoma, cataracts, and myasthenia gravis; patients should not receive concomitant immunizations because corticosteroids may blunt the antibody response; caution in children because growth and development may be affected by prolonged courses of corticosteroids, especially if given systemically.

Betamethasone sodium (Diprolene, Betatrex)

Injectable, long-acting steroid and potent anti-inflammatory agents. Injectable corticosteroids are used to treat localized areas of inflammation. No good evidence exists to suggest that injected corticosteroids alter the long-term pathology of chronic inflammation.^{[13,20 ]}However, many patients have acute symptomatic improvement.^{[20 ]}

Dosing

Adult

Inject 0.5 mL (6 mg/mL) into area of maximal tenderness.^{[20 ]}

Pediatric

Administer as in adults

Interactions

Effects decrease with the coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases the effect of salicylates and vaccines used for immunization; diluents (eg, local anesthetics containing the preservatives methylparaben, propylparaben, and phenol) should be avoided because these and similar compounds may cause flocculation of the steroid

Contraindications

Documented hypersensitivity; patients with paronychia, cellulitis, impetigo, angular cheilitis, erythrasma, erysipelas, rosacea, perioral dermatitis, acne

Precautions

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

Precautions

Injectable corticosteroids in pregnancy have not been studied; carefully observe for signs of hypoadrenalism in infants born to mothers who received substantial exposure to corticosteroids; caution in patients with exposure to chicken pox, Strongyloides infestation, active tuberculosis, ocular herpes simplex, psychiatric conditions, ulcerative colitis, diverticulitis, recent intestinal anastomoses, history of peptic ulcer disease, renal insufficiency, hypertension, osteoporosis, diabetes mellitus, thromboembolic disorders, seizures, hypoalbuminemia, hypothyroidism, cirrhosis, hyperlipidemias, glaucoma, cataracts, and myasthenia gravis; patients should not receive concomitant immunizations because corticosteroids may blunt the antibody response; caution in children because growth and development may be affected by prolonged courses of corticosteroids, especially if given systemically.

Follow-up

Return to Play

Athletes with medial epicondylitis may return to activities, as limited by their symptoms. Because many athletes tend to ignore pain during activity, the physician should create a strict activity regimen. In general, athletes should start with noncompetitive activities such as rallying or practice.

Complications

Rarely, chronic medial epicondylitis may be related to an increased risk of muscle rupture.^{[1 ]}

Prevention

The most important preventive measure for medial epicondylitis is proper technique and equipment usage. Athletes should warm up adequately with a series of slowly increasing activities before sports competition. Athletes should stretch to maintain flexibility after finishing their sporting activity.

Prognosis

The duration of the patient's symptoms is related to the length of time before the athlete receives treatment. Those athletes who delay treatment tend to have a slower recovery course.^{[1 ]}

Education

Educate athletes about the importance of forearm strengthening and stretching, appropriate training volume and intensity, proper technique, and equipment selection to decrease the risk of future injury.

Miscellaneous

Medicolegal Pitfalls

• In cases of medial epicondylitis that do not respond to appropriate treatment, obtain a plain radiograph to ensure that a tumor or fracture was not missed.

References

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9. Assendelft WJ, Hay EM, Adshead R, Bouter LM. Corticosteroid injections for lateral epicondylitis: a systematic overview. Br J Gen Pract. Apr 1996;46(405):209-16. [Medline]. [Full Text].

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Keywords

golfer's elbow, little leaguer's elbow, overuse tendinopathy

Contributor Information and Disclosures

Author

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Disclosure: Nothing to disclose.

Pharmacy Editor

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

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

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