eMedicine Specialties > Sports Medicine > Upper Limb
Medial Epicondylitis: Treatment & Medication
Updated: Jan 22, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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
Anabolic Steroid Use and Abuse
Corticosteroid-Induced Myopathy
Therapeutic Injections for Pain Management
Related Medscape topics:
Resource Center Pain Management: Pharmacologic Approaches
CME Current Treatment Options in Arthritic Pain: Optimizing Clinical Care
CME GI Risks and Benefits of Traditional and COX-2-Selective NSAIDs
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
The goal of pharmacotherapy is to reduce patient morbidity and prevent complications.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.
Adult
600-800 mg PO tid/qid
Pediatric
<40 mg/kg PO divided tid/qid
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
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
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.
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
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).
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
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
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).
Documented hypersensitivity; patients with fungal, viral, and bacterial skin-infections; signs of cellulitis in the overlying soft tissue
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
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
Documented hypersensitivity; patients with paronychia, cellulitis, impetigo, angular cheilitis, erythrasma, erysipelas, rosacea, perioral dermatitis, acne
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.
More on Medial Epicondylitis |
| Overview: Medial Epicondylitis |
| Differential Diagnoses & Workup: Medial Epicondylitis |
 Treatment & Medication: Medial Epicondylitis |
| Follow-up: Medial Epicondylitis |
| References |
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Further Reading
Keywords
golfer's elbow, little leaguer's elbow, overuse tendinopathy
