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, 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.
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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.
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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.
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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]
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. [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]
Maintenance Phase
Rehabilitation Program
Physical Therapy
The patient should be independent with a maintenance physical therapy program of upper extremity flexibility and strengthening exercises.
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Medial epicondyle.
