Medial Epicondylitis

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 are associated include golfing and throwing sports. Medial epicondylitis has also been reported in bowlers, archers, and weight lifters.[1, 2, 3, 4]

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 patient education resources, see the Hand, Wrist, Elbow, and Shoulder Center, as well as Tennis Elbow.

Frequency

United States

Medial epicondylitis accounts for only 10-20% of all epicondylitis diagnoses[1] ; the annual incidence is between 3-4 per 10,000 patients in the United States and more common in patients aged 40 years and older[49] . The condition is classically described in the dominant elbow of a golfer.[5] Tennis players who hit their forehand with a heavy topspin are also at increased risk for developing medial epicondylitis.

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.[6, 7] The flexor pronator muscle group serves as a secondary stabilizer of the medial elbow, assisting the ulnar collateral ligament (UCL).

See the image below.

Immunohistologic studies have shown that long-standing epicondylitis is associated with a degenerative state instead of a traditional inflammatory process and probably should more accurately be called "epicondylosis."[8, 9] 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).[10]

Athletes generally complain of aching pain over the medial elbow. Patients who have more chronic pain may also complain of grip weakness.[11]

Pain may be associated with the acceleration phase of throwing.

Ulnar nerve symptoms are associated in up to 20% of athletes with medial epicondylitis.[5]

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.

A study by Vinod et al found that pronation weakness at 90° is a reliable physical examination finding for determining clinically significant pathologic changes in patients with medial epicondylitis.[12]

See the list below:

• 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 excessive top spin, 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, 2]

• Functional risk factors: Weakness, poor endurance, and poor flexibility of the forearm may increase the risk of developing medial epicondylitis.

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.[13]

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, 14, 15, 16]

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.[17]

Note: Physical therapy must be considered carefully in preadolescent patients because they often are not 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, 18] Some physicians argue that the anti-inflammatory effects of NSAIDs are helpful in decreasing swelling, thereby increasing the speed of an individual's recovery.[15, 19, 20] Other authors believe that NSAID use during the acute injury phase may increase swelling by increasing the potential for bleeding via platelet inhibition.[18] 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.[21]

  • 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.[22]

  • 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.[11]

Surgical Intervention

Surgical intervention is usually not needed, as evidenced by a study that reported that only 52 (2.8%) of 1,837 patients who received therapeutic injections for medial epicondylitis required ipsilateral surgery following injections. The study also found that risk factors for requiring surgical intervention included being younger than 65 years of age and obesity.[23] . However, if conservative treatment fails (usually 6-12 months), surgical treatment may be considered for medial epicondylitis.[24]

Various techniques have been described, most of which consist of release of the flexor origin and excision of the pathologic tissue. A newer technique is fascial elevation and tendon origin resection (FETOR). A case series of elbows with chronic recalcitrant medial epicondylitis that underwent the FETOR surgical treatment showed that it was an effective and safe method for treatment of this condition in these patients.[25] In general, good results are reported in greater than 80% of patients. Potential complications of any surgical technique 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.[13, 26, 27, 28] 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).[29]

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.[30, 31, 32, 33, 34, 35]

Another possible alternative treatment for medial epicondylitis might be injection with botulinum toxin.[36] 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.[37, 38, 39, 40, 41, 42]

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.[43] However, a more recent randomized, double-blind study of patients with chronic patellar tendinopathy showed no significant effect.[44] 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.[45]

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.[46]

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.

Surgical Intervention

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

Rehabilitation Program

Physical Therapy

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

The goal of pharmacotherapy is to reduce patient morbidity and prevent complications.

Class Summary

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,[18] 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.[47]

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.

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.

Class Summary

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.[48] However, a steroid flare that consists of increased pain up to several days may occur in up to 2% of individuals.[29]

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. However, many patients have acute symptomatic improvement.

Betamethasone (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. However, many patients have acute symptomatic improvement.

Class Summary

Use of nitroglycerin transdermal patches as modulators of nitric oxide has been studied. The mechanism of action is not completely understood, but it is postulated that nitric oxide stimulates collagen production by fibroblasts.[43]

Nitroglycerin transdermal (NitroDur, Minitran)

Organic nitrate; nitric oxide released from nitroglycerin. Elicits muscle relaxation as a result of guanylate cyclase activation and resulting increased cyclic GMP in smooth muscle and other tissues, causing myosin dephosphorylation and, ultimately, vasodilatation. Limited off-label data suggest cutting transdermal nitroglycerin patch (5 mg/24 h) and applying one fourth of the patch to the affected area. Transdermal nitroglycerin patches are a matrix patch and, unlike reservoir patches, they do not leak or release product all at once when cut.

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.

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

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.

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]

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.