Surgery for Medial Epicondylitis (Golfer's Elbow) Treatment & Management

The mainstay of treatment for medial epicondylitis (golfer's elbow) is conservative management, which includes the following:

• Patient education and modification of the golf swing (or other relevant activity)
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Therapy with flexibility and strengthening modalities
• Wrist splints
• Corticosteroid injections

Nonsteroidal anti-inflammatory drugs

If the patient does not have a contraindication, NSAIDs should be started immediately to decrease inflammation and pain. Be cautious in using these agents in patients who have renal insufficiency, a history of gastrointestinal (GI) problems, or both.

Therapy with stretching and strengthening modalities

Wilks and Andrews developed a rehabilitation protocol to address the acute, subacute, and chronic phases of medial epicondylitis and lateral epicondylitis (tennis elbow).

The primary goal of managing the acute phase is to decrease inflammation and pain. ^[29] Patients are instructed on activity modifications and avoidance of painful movements. Stretching is started to increase flexibility, and therapeutic modalities such as cryotherapy, whirlpool, phonophoresis, iontophoresis, and friction massage are used with success.

The primary goals of the subacute phase are to improve flexibility, to improve strength, and to increase functional activities. Hand, wrist, elbow, and shoulder strengthening and range-of-motion (ROM) exercises are started and continued. A counterforce brace/splint is applied. Cryotherapy is used before and after therapy, and the previously painful movements are reinitiated.

The primary goal of the chronic phase is maintenance of strength and flexibility with gradual return to higher-level activities. The flexibility and strengthening exercises are continued, with gradual diminishing of the counterforce brace/wrist splint. Sports activities are gradually reinitiated. The equipment can be modified at this point. Modalities are used in the evening, and a maintenance program/home-exercise program is started.

Wrist splints

The wrist splint is placed in a neutral position to rest the flexors. A counterforce brace is applied to the anteromedial/proximal forearm distal to the epicondyle. Avoid placing the medial counterforce brace over the ulnar nerve. ^[7]

Corticosteroid injections

If the patient's symptoms persist after 2 weeks of conservative management, then consider a corticosteroid injection. With a 25-gauge 0.5-in. needle, inject 1-2 mL of equal amounts 2% lidocaine and triamcinolone acetonide at 10 mg/mL over the medial epicondyle at the area of maximal tenderness. Direct the patient to position the elbow in extension to avoid the ulnar nerve; some patients may have ulnar nerve subluxation with flexion. To avoid the tendon, never inject under pressure; and to avoid the ulnar nerve, do not inject if the patient reports a sharp, radiating sensation.

Stahl and Kaufman conducted a prospective, randomized, double-blind study to analyze the short- and long-term effects of local injections of methylprednisolone for the treatment of medial epicondylitis. ^[30]  Fifty-eight patients were monitored over 1 year. The authors concluded that the local injection provided only short-term (≤ 6 wk) benefits. In comparison with the group that did not receive steroids, the outcome was the same with regard to pain at 3 months and at 1 year. Therefore, the injection should be considered early in treatment, with the goal of pain relief.

Other approaches

Other techniques, such as low-level laser therapy and shockwave therapy, have been attempted but have not been established as effective. ^[31]

A prospective study by Rogers et al found that low-dose radiotherapy in patients with medial epicondylitis led to pain relief at rest and during activity, as well as a significant increase in handgrip strength. ^[32]

A cohort study by Bohlen et al included 33 patients with type I medial epicondylitis who had failed an initial nonoperative treatment program and were subsequently treated with either surgery (n = 18) or injection of platelet-rich plasma (PRP; n = 15). ^[33]  Successful outcomes were observed in 80% of patients treated with PRP and 94% of those treated operatively. The PRP group had significantly shorter times both to full ROM (42.3 vs 96.1 days) and to pain-free status (56.2 vs 108.0). No significant differences were found in return-to-activity rates, overall successful outcomes, Mayo Elbow Performance Score (MEPS), or Oxford Elbow Score (OES).

Surgical treatment should be considered in cases where conservative treatment has failed after 6-12 months and after all other pathology has been excluded. Medial epicondylitis is classified according to the presence and severity of concomitant ulnar neuropathy. Type IA has no associated ulnar neuropathy, type IB has mild symptoms that are associated with ulnar neuropathy, and type II has moderate-to-severe symptoms that are associated with ulnar neuropathy. ^[34]

Gabel and Morrey described the following classification system to guide surgical treatment ^[7] :

• Type IA requires epicondylar debridement
• Type IB requires debridement with or without cubital tunnel decompression
• Type II requires debridement with submuscular transposition of the ulnar nerve

The following technique is used for type IA medial epicondylitis. ^[7]  Variations with epicondylar debridement can be used, depending on the literature and surgical preference.

Epicondylar debridement begins with a 3- to 7-cm incision just anterior to the medial epicondyle. The posterior division of the medial antebrachial cutaneous nerve (MACN) must be identified and avoided during the approach through the subcutaneous tissue. The common flexor pronator origin is identified, and in order to protect the ulnar nerve, the nerve is identified in the ulnar groove.

The flexor pronator fascia is incised, and a 2-mm rim of superficial fascia is preserved on the medial epicondyle for later repair. The lesion is identified at the medial conjoint tendon (MCT), and the anterior oblique ligament (AOL) is also identified. The lesion is excised, and the AOL is protected for elbow stability.

The anterior cortex is roughened with a curette or by drilling multiple small holes to increase the blood supply. The common flexor-pronator origin is then repaired to the superficial fascia with interrupted sutures, and the subcutaneous tissue and skin are closed in routine fashion.

In type IB cases with ulnar nerve compression, the cubital tunnel release is performed along with epicondylar debridement. If ulnar subluxation or adhesions are encountered, a submuscular transposition is performed. In type II cases, a debridement is performed with a submuscular transposition of the ulnar nerve. ^[7]

Postoperative management includes an immobilizing splint or cast for 1-3 weeks. ROM exercises are started after removal of the splint or cast. A stretching and strengthening flexor-pronator program is started 6 weeks after surgery.

Surgical results correlate with the type of medial epicondylitis. Type IA or IB medial epicondylitis has a 95% good or excellent postoperative success rate. ^[7]  Type II cases with more involved ulnar neuropathy have a poorer prognosis secondary to the failure of the neuropathy to respond to surgical management. ^[7]

Medial epicondylitis has not been routinely managed arthroscopically. Some authorities have reported an arthroscopic technique for medial epicondylitis. ^[19] A cadaver study suggested that arthroscopic debridement of the medial epicondyle can be performed, with a low potential for injury to the medial collateral ligament or the ulnar nerve. ^[35]  

A small (N = 7) retrospective study by do Nascimento et al found arthroscopic treatment to yield good outcomes as measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the visual analogue scale (VAS), and the Short Form (SF)-6 survey, without significant complications. ^[36]

Kwon et al conducted a retrospective review to evaluate the use of fascial elevation and tendon origin resection (FETOR) for surgical treatment of medial epicondylitis in 22 elbows of 20 patients (mean age, 48.8 y; mean follow-up, 35.6 mo). ^[37]  Outcome assessments included the VAS for average pain, pain at rest, and pain experienced during hard work or heavy lifting; the DASH questionnaire; and assessment of pain-free grip strength.

Comparison of preoperative and postoperative data revealed significant improvement with FETOR in all measures used in assessing pain and strength. ^[37]  There were no major complications. The investigators concluded that the FETOR technique is a safe and effective method for treating chronic, recalcitrant medial epicondylitis.

Tasto et al reported midterm (up to 9 y) results of the use of radiofrequency microtenotomy to treat medial and lateral epicondylitis of the elbow. ^[38]  In the 11 patients treated for medial epicondylitis, the VAS score improved by 79%, from 6.1 before surgery to 1.3 after surgery. No complications were reported.

In a retrospective review of 31 consecutive patients (33 elbows) with recalcitrant medial epicondylitis, Wu et al found a double-row repair to be effective in decreasing pain and improving overall function. ^[39] The presence of preoperative ulnar neuritis was associated with higher patient-reported preoperative pain scores but not with poor outcomes.

A single-center retrospective cohort study by Lee et al assessed the effectiveness and safety of transcatheter arterial embolization (TAE) for chronic medial epicondylitis refractory to conservative treatments. ^[40]  They reported clinical success in 12 of 14 procedures, with no major complications during follow-up. Mean VAS scores, from a baseline of 7.6, were significantly decreased at 1 day (3.6), 1 week (3.6), 1 month (3.6), 3 months (3.0), and 6 months (0.9) after treatment. Mean Quick-DASH scores, from a baseline of 71.9, also were significantly decreased at 1 day (48.5), 1 week (44.0), 1 month (37.7), 3 months (30.2), and 6 months (8.4). Improvements endured in nine patients for up to 12 months.

Important complications of treatment include the well-known adverse effects of NSAIDs—most commonly, GI bleeding, ulceration, and renal dysfunction. Local steroid injections may increase the risk of infection, skin pigmentary changes and skin atrophy, ulnar nerve damage, and tendon rupture. ^[22]

Complications of surgical treatment include restricted ROM, neuropathic pain from injury to the MACN or the ulnar nerve, and medial elbow instability. In most patients, medial epicondylitis resolves with conservative treatment at 6 months, but this may take up to 2 years.