Medial Epicondylitis Treatment & Management
- Author: Craig C Young, MD; Chief Editor: Craig C Young, MD more...
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, 13, 14, 15]
The authors of a 2013 systematic review of the literature sorted through 12 reviews and 227 randomized, controlled trials; after assessing the methodological quality of each, they authors summarized the results of 1 review and 12 randomized, controlled trials using a best-evidence synthesis technique. They concluded moderate evidence supported a short-term effect of stretching plus strengthening exercises compared with other treatment types.
Note: Physical therapy must be considered carefully in preadolescent patients because they often are not compliant.
Pain control is the initial treatment goal for patients with medial epicondylitis.
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is somewhat controversial. [1, 17] Some physicians argue that the anti-inflammatory effects of NSAIDs are helpful in decreasing swelling, thereby increasing the speed of an individual's recovery. [14, 18, 19] Other authors believe that NSAID use during the acute injury phase may increase swelling by increasing the potential for bleeding via platelet inhibition.  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.
- 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.
- Counterforce bracing and cock-up wrist splints can be useful adjuncts for treating medial epicondylitis.
- Counterforce bracing is used during activities and theoretically decreases the contraction forces of the flexor-pronator muscles on the medial epicondyle.
- 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.
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.
A study evaluated the outcomes of a new technique, fascial elevation and tendon origin resection (FETOR), in a case series of 22 elbows, for the treatment of chronic recalcitrant medial epicondylitis. The study concluded that the FETOR technique is an effective and safe method for treatment of this condition.
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.[12, 23, 24, 25] In cases of recalcitrant medial epicondylitis, consider corticosteroid injection. 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).
Alternative treatments are either autologous blood injection or platelet-rich plasma (PRP) injection. The use of autologous blood or PRP injected into the site of tenderness is thought to stimulate an acute inflammatory reaction and concentrate various growth factors (eg, transforming growth factor-beta, basic fibroblast growth factor, platelet-derived growth factor, epidermal growth factor, vascular endothelial growth factor, connective-tissue growth factor), which leads to reinitiation of the healing process. This therapy has been shown to be effective in limited studies of chronic inflammatory musculotendinous conditions.[27, 28, 29, 30, 31, 32]
Another possible alternative treatment for medial epicondylitis might be injection with botulinum toxin. However, at this time, the use of botulinum toxin for treatment of medial epicondylitis is an off-label, experimental use.
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.[34, 35, 36, 37, 38, 39]
The use of nitroglycerin patches as modulators of nitric oxide, which would then stimulate collagen production by fibroblasts, has also been studied for the treatment of lateral epicondylitis. Significant improvement was noted in the treatment group compared with the placebo group. However, a more recent randomized, double-blind study of patients with chronic patellar tendinopathy showed no significant effect. The authors of a meta-analysis of 7 clinically relevant, high-quality randomized controlled trials involving 446 subjects (including 2 that focused on lateral epicondylitis) concluded that topical nitroglycerin patches were significantly more effective than placebo for the treatment of chronic tendinopathies.
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.
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.
Surgical intervention is considered for chronic medial epicondylitis that does not respond to conservative treatment.
The patient should be independent with a maintenance physical therapy program of upper extremity flexibility and strengthening exercises.
Plancher KD, Halbrecht J, Lourie GM. Medial and lateral epicondylitis in the athlete. Clin Sports Med. 1996 Apr. 15(2):283-305. [Medline].
Jayanthi N, Esser S. Racket sports. Curr Sports Med Rep. 2013 Sep-Oct. 12(5):329-36. [Medline].
Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015 Jun. 23 (6):348-55. [Medline].
Kohn HS. Prevention and treatment of elbow injuries in golf. Clin Sports Med. 1996 Jan. 15(1):65-83. [Medline].
Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin Sports Med. 1988 Apr. 7(2):289-308. [Medline].
Nirshal RP. Muscle and tendon trauma: tennis elbow. The Elbow and Its Disorders. Philadelphia, Pa: WB Saunders Co; 1993. 481-96.
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. 1999 Feb. 81(2):259-78. [Medline]. [Full Text].
Ljung BO, Forsgren S, Fridén J. Substance P and calcitonin gene-related peptide expression at the extensor carpi radialis brevis muscle origin: implications for the etiology of tennis elbow. J Orthop Res. 1999 Jul. 17(4):554-9. [Medline].
Hannah GA, Whiteside JA. The elbow in athletics. Sports Medicine Secrets. Philadelphia, Pa: Hanley & Belfus; 1994. 249-55.
Vicenzino B, Brooksbank J, Minto J, Offord S, Paungmali A. Initial effects of elbow taping on pain-free grip strength and pressure pain threshold. J Orthop Sports Phys Ther. 2003 Jul. 33(7):400-7. [Medline].
Vinod AV, Ross G. An effective approach to diagnosis and surgical repair of refractory medial epicondylitis. J Shoulder Elbow Surg. 2015 Aug. 24 (8):1172-7. [Medline].
Klaiman MD, Shrader JA, Danoff JV, et al. Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exerc. 1998 Sep. 30(9):1349-55. [Medline].
Baskurt F, Ozcan A, Algun C. Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis. Clin Rehabil. 2003 Feb. 17(1):96-100. [Medline].
Nirschl RP, Rodin DM, Ochiai DH, Maartmann-Moe C, and the DEX-AHE-01-99 Study Group. Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. A randomized, double-blinded, placebo-controlled study. Am J Sports Med. 2003 Mar-Apr. 31(2):189-95. [Medline].
Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013 Nov. 47(17):1112-9. [Medline].
Stanley KL, Weaver JE. Pharmacologic management of pain and inflammation in athletes. Clin Sports Med. 1998 Apr. 17(2):375-92. [Medline].
Burnham R, Gregg R, Healy P, Steadward R. The effectiveness of topical diclofenac for lateral epicondylitis. Clin J Sport Med. 1998 Apr. 8(2):78-81. [Medline].
Labelle H, Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. The University of Montreal Orthopaedic Research Group. Arch Fam Med. 1997 May-Jun. 6(3):257-62. [Medline].
Quillen WS, Magee DJ, Zachazewski JE. The process of athletic injury and rehabilitation. Athletic Injuries and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996. 3-8.
Thurston AJ. Conservative and surgical treatment of tennis elbow: a study of outcome. Aust N Z J Surg. 1998 Aug. 68(8):568-72. [Medline].
Kwon BC, Kwon YS, Bae KJ. The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis. Am J Sports Med. 2014 Apr 23. 42(7):1731-1737. [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. 1997 Nov. 79(11):1648-52. [Medline].
Verhaar JA, Walenkamp GH, van Mameren H, et al. Local corticosteroid injection versus Cyriax-type physiotherapy for tennis elbow. J Bone Joint Surg Br. 1996 Jan. 78(1):128-32. [Medline].
Foster ZJ, Voss TT, Hatch J, Frimodig A. Corticosteroid Injections for Common Musculoskeletal Conditions. Am Fam Physician. 2015 Oct 15. 92 (8):694-9. [Medline].
Pfenninger JL. Joint and soft tissue aspiration and injection. Procedures for Primary Care Physicians. St Louis, Mo: Mosby; 1994. 1036-54.
Suresh SP, Ali KE, Jones H, Connell DA. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment?. Br J Sports Med. 2006 Nov. 40(11):935-9; discussion 939. [Medline].
Connell DA, Ali KE, Ahmad M, et al. Ultrasound-guided autologous blood injection for tennis elbow. Skeletal Radiol. 2006 Jun. 35(6):371-7. [Medline].
Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg [Am]. 2003 Mar. 28(2):272-8. [Medline].
Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010 Feb. 38(2):255-62. [Medline].
Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A. Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med. 2011 Oct. 39(10):2130-4. [Medline].
Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA. Efficacy of Platelet-Rich Plasma for Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Randomized Controlled Trial of 230 Patients. Am J Sports Med. 2013 Dec 12. [Medline].
Keizer SB, Rutten HP, Pilot P, et al. Botulinum toxin injection versus surgical treatment for tennis elbow: a randomized pilot study. Clin Orthop Relat Res. 2002 Aug. 401:125-31. [Medline].
Speed CA, Nichols D, Richards C, et al. Extracorporeal shock wave therapy for lateral epicondylitis--a double blind randomised controlled trial. J Orthop Res. 2002 Sep. 20(5):895-8. [Medline].
Haake M, König IR, Decker T, et al. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial. J Bone Joint Surg Am. 2002 Nov. 84-A(11):1982-91. [Medline].
Melikyan EY, Shahin E, Miles J, Bainbridge LC. Extracorporeal shock-wave treatment for tennis elbow. A randomised double-blind study. J Bone Joint Surg Br. 2003 Aug. 85(6):852-5. [Medline].
Chung B, Wiley JP. Effectiveness of extracorporeal shock wave therapy in the treatment of previously untreated lateral epicondylitis: a randomized controlled trial. Am J Sports Med. 2004 Oct-Nov. 32(7):1660-7. [Medline].
Mehra A, Zaman T, Jenkin AI. The use of a mobile lithotripter in the treatment of tennis elbow and plantar fasciitis. Surgeon. 2003 Oct. 1(5):290-2. [Medline].
Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. 2003 Nov-Dec. 31(6):915-20. [Medline].
Steunebrink M, Zwerver J, Brandsema R, Groenenboom P, van den Akker-Scheek I, Weir A. Topical glyceryl trinitrate treatment of chronic patellar tendinopathy: a randomised, double-blind, placebo-controlled clinical trial. Br J Sports Med. 2013 Jan. 47(1):34-9. [Medline]. [Full Text].
Gambito ED, Gonzalez-Suarez CB, Oquiñena TI, Agbayani RB. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2010 Aug. 91(8):1291-305. [Medline].
Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004 Oct. 23(4):693-705, xi. [Medline].
McCarthy D. Nonsteroidal anti-inflammatory drug-related gastrointestinal toxicity: definitions and epidemiology. Am J Med. 1998 Nov 2. 105(5A):3S-9S. [Medline].
Wang AA, Whitaker E, Hutchinson DT, Coleman DA. Pain levels after injection of corticosteroid to hand and elbow. Am J Orthop. 2003 Aug. 32(8):383-5. [Medline].