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Medial Epicondylitis

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Other Names

  • Golfers Elbow
  • Medial Epicondylosis
  • Medial Epicondylalgia
  • Golfer’s Elbow
  • Flexor–Pronator Tendinopathy
  • Medial Epicondyle Tendinopathy
  • Medial Elbow Tendinopathy
  • Common Flexor Tendon Tendinopathy
  • Medial Epicondylalgia
  • Flexor Tendon Overuse Injury

Background

  • This page describes medial epicondylitis, more commonly called Golfer's Elbow

History

  • Possibly first descried by Henry J Morris in the Lancet in 1882 (need citation)

Epidemiology

  • Significantly less common than Lateral Epicondylitis (need citation)
  • Most commonly seen ages 30s-60s[1]
  • 75% of cases are right hand dominant (need citation)
  • Affects up 8.2% of occupational workers[2]
  • Equally affects men and women

Introduction

Illustration of Golfer's Elbow and anatomy of the Flexor Pronator Group (FPG) of the elbow. The FPG attaches to the medial epicondyle and is composed of four muscles: Pronator Teres (PT), Flexor Carpi Radialis (FCR), Palmaris Longus (PL), and Flexor Carpi Ulnaris (FCU).[3]
Anatomy of the Common Flexor Tendon
Repeated loading of the musculotendinous units of the FPG during activity, such as golf[3]

General

  • Degenerative tendon condition affecting the common flexor-pronator origin at the medial epicondyle of the elbow
  • Presents with persistent medial sided elbow pain exacerbated by daily activities and exercise
  • Nonsurgical management is succesful in most cases including activity modification, NSAIDS and physical therapy
  • See: Tendinopathies (Main)

Mechanism

  • Repetitive eccentric loading of the muscles conducting wrist flexion and forearm pronation combined with valgus overload at the elbow[4]
  • Repetitive microtrauma at the common flexor tendon, sometimes referred to as the flexor-pronator mass

Pathogenesis

  • Initially considered to be a tendinitis and inflammatory condition
  • Now considered a tendinosis or tendinopathy from chronic degenerative process
  • Note that these terms are often used interchangeably
  • Abnormal stress leads to increased cross-linkage, collagen deposition[5]
  • When the force loads exceed the tolerance of the tendon, micro-tears occur and the adaptive response leads to tendinosis

Histopathology

  • Histological analysis demonstrates a paucity of inflammatory cells[6]
  • Stages of repetitive microtrauma
    • Stage 1: acute inflammatory response
    • Stage 2: sustained injury leads to angiofibroblastic hyperplasia (fibroblasts, hyperplasia, disorganied collagen)
    • Stage 3: further pathological changes lead to structural failure with micro-tearing
    • Stage 4: in addition to angiofibroblastic hyperplasia, fibrosis, calcification are seen

Anatomy of the Common Flexor Tendon

Associated Conditions

Risk Factors

Sports

  • Golfers
  • Baseball pitchers
  • Javelin throwers
  • Bowlers
  • Weight lifters
  • Racquet sports
  • Tennis

Occupations

  • Lifting >20kg
  • Forceful grip
  • Exposure to constant vibration at elbow

Differential Diagnosis

Differential Diagnosis Elbow Pain

Clinical Features

Tenderness at the medial epicondyle
Clinical demonstration of the Golfer's Elbow Test

History

  • Patients complain of persistent medial sided elbow pain
  • Typically will endorse a repetitive activity or sport that makes the pain worse[8]
    • In particular, wrist flexion and forearm pronation activities
    • Less commonly, acute trauma may occur
  • Onset is often gradual
  • Throwers and golfers may feel pain during the late cocking or early acceleration phase[9]
    • Performance may decline affecting power, speed, acuracy, endurance
  • Patient may endorse parasthesias in an ulnar nerve distribution

Physical: Physical Exam Elbow

  • Tenderness at the medial epicondyle, proximal flexor tendon insertion and 5-10 mm distally
    • Need to clarify that pain is not greater at the UCL or insertion on the sublime tubercle
  • There may be warmth, swelling
  • Pain with resisted pronation, wrist flexion should reproduce symptoms
  • Pronation weakness at 90 degrees of elbow flexion may be present
  • Range of motion is typically preserved
  • Important to evaluate the Ulnar Nerve

Special Tests

Evaluation

Anteroposterior radiographic view of the right elbow in a 48-year-old man with chronic medial elbow pain shows a region of calcium deposition (arrow) adjacent to the medial epicondyle[10]
Ultrasound examination of common flexor attachment. Images (a,b)—a method of applying the probe to obtain both (a)—longitudinal, (b)—transverse sections, (c)—long axis view of a common flexor attachment (precisely above the attachment of the part corresponding to the flexor carpi radialis—FCR); open arrows—superficial, more tendinous portion of the FCR; open arrowheads—deep part of the FCR, with preserved muscular echo structure; white arrows—partially visible anterior part of the medial collateral ligament; ME—medial epicondyle. (d)—Short axis view of the common flexor attachment—open arrows; ME—medial epicondyle; PT—proximal part of the pronator teres muscle (the humeral head). (e)—Scans from strain elastography, (f)—normal CFT in power Doppler mode, (g)—normal CFT assessed with MicroFlow option[11]
Coronal fat-suppressed intermediate-weighted fast spin-echo image of the elbow shows thinning and high signal intensity within the common flexor tendon origin (small arrow). Note the intact underlying proximal attachment of the anterior bundle of the ulnar collateral ligament (large arrow).[12]

Radiographs

  • Standard Radiographs Elbow
  • Initial imaging modality of choice
    • Not required to make the diagnosis
    • Useful to exclude other etiologies[13]
  • Potential fndings
    • Calcific tendinopathy
    • Cortical irregularity of the medial epicondyle
  • Calcific tendinosis
    • Up to 25% may have calcification of the common flexor tendon or UCL[4]
    • Anatomic insertion site of the common flexor tendon (33%), pronator teres (18%), medial collateral ligament (10%)
    • Associated with higher pain scores, history of steroid injection, and concomitant ulnar neuropathy[14]

Ultrasound

  • Diagnostic accuracy
    • Excellent diagnostic accuracy for medial epicondylitis
    • Park et al showed that a sonogram performed by a radiologist had sensitivity, specificity, and positive and negative predictive values of .90% for diagnosis of medial epicondylitis[15]
  • Tendon may demonstrate:
    • Thickening or thinning
    • Hypoechogenic foci (intra-substance degenerative changes)
    • Tendon tears
    • Calcification
    • Bony irregularity
    • Calcific deposits
  • Advtanges of US[16]
    • Dynamic evaluation allowing visualization of structures under stress and motion
    • Cost-effectiveness and point-of-care availability
    • Detection of associated pathology including ulnar collateral ligament tears
  • Advanced techniques[17]
    • Shear wave elastography and strain elastography show excellent diagnostic performance
    • May be superior to conventional gray-scale ultrasound

MRI

  • General[18]
    • Preferred imaging modality for chronic elbow pain
    • Necessary if any diagnostic uncertainty or co-occurring injuries
    • More comprehensive evaluation of tendons, ligaments, nerves, and bone
  • Classic findings
    • Thickening and increased signal intensity of the common flexor tendon (present in 85% of cases)
    • Degenerative changes
    • Tendon tears
    • Paratendinous soft tissue edema (the most specific finding)
    • Intermediate to high T2 signal intensity within the tendon
  • Excellent for detecing associated pathology[19]
    • Common flexor tendon signal changes (66%)
    • Ulnar neuritis (40%)
    • Ulnar collateral ligament insufficiency (30%)
    • Calcification (27%)
    • Bony changes (18%)

EMG

  • In cases of unclear etiology, may be useful to exclude neurological causes

Classification

  • N/A

Elbow Counterforce Brace

Padded Elbow Compression Sleeve

Management

Prevention

  • General
    • Avoid training errors (sudden changes in volume and intensity of wrist/arm activity, especially excessive pronation)
    • Optimize sport mechanics
    • Ensure proper equipment fit
    • Maintain upper extremity strengthening

General

  • Note that medial epicondylitis is less common and less well studied than its lateral counterpart
  • Subsequently, many of the management and treatment techniques are extrapolated from the research for lateral epicondylitis

Nonoperative

  • General
    • Discontinuation of offending activity
    • In athletes, correction of mechanics and improper technique
    • In workers, ergonomic changes or periods of rest may help reduce symptoms
  • Ice after activity
  • Physical Therapy
  • Bracing
  • NSAIDS
    • May improve short term function
    • One study found diclofenac superior to placebo, however naproxen was similar[20]
  • Topical Nitroglycerin

Procedural

Physical Therapy Modalities

Operative

  • Indications
    • Chronic symptoms with failure of conservative management, typically 6-12 months or more
  • Technique
    • Release of common flexor tendon (tenotomy)
    • Open vs arthroscopic
  • Up to 80% of patients respond well to surgical release (need citation)

Rehabilitation and Return to Play

Tyler twist for medial humeral epicondylitis includes eccentric loading of the wrist flexors moving from a position of wrist flexion to wrist extension[25]

Rehabilitation

  • Flexor-pronator mass rehabilitation[26]
    • Follow a progressive laoding program
    • Maintain and improving the physical qualities of the tendon-entheseal complex without exacerbating symptoms
  • Initial phase
    • Gentle stretching (especially to improve pronation)
    • Isometric or isotonic exercises for local strengthening, particularly cocontractions
    • Avoid stiffness
  • Progressive Phase
    • Heavy, slow resistance training
    • Gradual increases in load, volume, intensity, and time under tension as pain subsides
  • Active Phase
    • Incorporation of plyometrics or exercises at faster speeds if needed for sport-specific demand
  • Additional treatment goals[27]
    • Strengthen kinetic chain
    • Shoulder external rotation and core stability, as deficits in these areas contribute to elbow overload
    • Modification of sport technique and equipment should be addressed to prevent recurrence

Return to Play

  • Requirements[28]
    • Restoration of pain-free full range of motion
    • Muscular strength
    • Endurance
    • Neuromuscular controls
    • Gradual progression through sport specific skills
  • Overhead athlets
    • Must progress through a specific, structured throwing program
    • Helps avoid overstressing healing tissues while restoring the athlete's prior level of function

Prognosis and Complications

Prognosis

  • General
    • Generally favorable, most patients respond to conservative treatment
  • Conservative
    • 3-year recovery rate is approximately 81% in occupational settings[29]
    • Symptoms frequently persist or recur, and resolution typically requires a minimum of 3 to 6 month
  • Surgical intervention[30]
    • Long-term surgical results show 43% excellent and 51% good outcomes
    • Significant improvements in pain scores, functional scores, and grip strength
  • Mean time to return to work is 2.8 months and return to exercise is 4.8 months following surgery[31]
  • Poor prognosis[32]
    • High levels of physical strain at work
    • Non-neutral wrist postures during work activity
    • Involvement of the dominant elbow

Complications

  • Other work related upper limb MSK disorders
    • Workers with medial epicondylitis have a significantly higher prevalence[29]
  • Medial antebrachial cutaneous nerve neuropathy
  • Ulnar Nerve Injury
  • Infection

See Also

References

  1. ↑ Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M: Prevalence and determinants of lateral and medial epicondylitis: A population study. Am J Epidemiol 2006;164(11):1065-1074.
  2. ↑ Descatha A, Leclerc A, Chastang JF, Roquelaure Y; Study Group on Repetitive Work: Medial epicondylitis in occupational settings: Prevalence, incidence and associated risk factors. J Occup Environ Med 2003;45(9):993-1001.
  3. ↑ 3.0 3.1 DeLuca, Meridith K., et al. "Medial epicondylitis: current diagnosis and treatment options." Journal of Orthopaedic Reports 2.3 (2023): 100172.
  4. ↑ 4.0 4.1 Ciccotti MG, Ramani MN: Medial epicondylitis. Tech Hand Up Extrem Surg 2003;7(4):190-196.
  5. ↑ 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;81-A:259–278.
  6. ↑ Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg [Am] 1991;73-A:1507–1525.
  7. ↑ Otoshi K, Kikuchi S, Shishido H, Konno S: The proximal origins of the flexor-pronator muscles and their role in the dynamic stabilization of the elbow joint: An anatomical study. Surg Radiol Anat 2014;36(3):289-294.
  8. ↑ Amin, Nirav H., Neil S. Kumar, and Mark S. Schickendantz. "Medial epicondylitis: evaluation and management." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 23.6 (2015): 348-355.
  9. ↑ Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
  10. ↑ Walz, Daniel M., et al. "Epicondylitis: pathogenesis, imaging, and treatment." Radiographics 30.1 (2010): 167-184.
  11. ↑ Konarski, Wojciech, et al. "Ultrasound in the differential diagnosis of medial epicondylalgia and medial elbow pain—imaging findings and narrative literature review." Healthcare. Vol. 10. No. 8. MDPI, 2022.
  12. ↑ Wenzke, Daniel R. "MR imaging of the elbow in the injured athlete." Radiologic Clinics 51.2 (2013): 195-213.
  13. ↑ Chen, Karen C., et al. "ACR Appropriateness Criteria® Acute Elbow and Forearm Pain." Journal of the American College of Radiology 21.11 (2024): S355-S363.
  14. ↑ Kang, Kyu Bok, Seung Hee Cheon, and Hee Dong Lee. "Radiologic evaluation and clinical effect of calcification in medial epicondylitis." Journal of Shoulder and Elbow Surgery 31.2 (2022): 375-381.
  15. ↑ Park GY, Lee SM, Lee MY: Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil 2008;89(4):738-742.
  16. ↑ Hultman, Kristi L., et al. "Ultrasound examination techniques for elbow injuries in overhead athletes." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 29.6 (2021): 227-234.
  17. ↑ Bang, Jin-Young, et al. "Clinical applicability of shear wave elastography for the evaluation of medial epicondylitis." European Radiology 31.9 (2021): 6726-6735.
  18. ↑ Dewan, Ashvin K., et al. "Magnetic resonance imaging of the hand and wrist: techniques and spectrum of disease: AAOS exhibit selection." JBJS 95.10 (2013): e68.
  19. ↑ Bae, Kee Jeong, et al. "Magnetic resonance imaging evaluation of patients with clinically diagnosed medial Epicondylitis."
  20. ↑ Wolf JM, Ozer K, Scott F, Gordon MJ, Williams AE. Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study. J Hand Surg Am 2011;36:1269–1272.
  21. ↑ Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003:CD004258.
  22. ↑ McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001:CD000232
  23. ↑ Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg. 2005;23:425–430.
  24. ↑ Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC. Rehabilitation for patients with lateral epicondylitis: a systematic review. J Hand Ther. 2004;17:243–266.
  25. ↑ Ellenbecker, Todd S., Robert Nirschl, and Per Renstrom. "Current concepts in examination and treatment of elbow tendon injury." Sports Health 5.2 (2013): 186-194.
  26. ↑ Crowe, Lindsay AN, et al. "Pathways driving tendinopathy and enthesitis: siblings or distant cousins in musculoskeletal medicine?." The Lancet Rheumatology 5.5 (2023): e293-e304.
  27. ↑ Hume, Patria A., Duncan Reid, and Tony Edwards. "Epicondylar injury in sport: epidemiology, type, mechanisms, assessment, management and prevention." Sports medicine 36.2 (2006): 151-170.
  28. ↑ Wilk, Kevin E., and Christopher A. Arrigo. "Rehabilitation of elbow injuries: nonoperative and operative." Clinics in sports medicine 39.3 (2020): 687-715.
  29. ↑ 29.0 29.1 Descatha, Alexis, et al. "Medial epicondylitis in occupational settings: prevalence, incidence and associated risk factors." Journal of Occupational and Environmental Medicine 45.9 (2003): 993-1001.
  30. ↑ Han, Soo-Hong, et al. "The result of surgical treatment of medial epicondylitis: analysis with more than a 5-year follow-up." Journal of Shoulder and Elbow Surgery 25.10 (2016): 1704-1709.
  31. ↑ Han, Soo-Hong, et al. "The result of surgical treatment of medial epicondylitis: analysis with more than a 5-year follow-up." Journal of Shoulder and Elbow Surgery 25.10 (2016): 1704-1709.
  32. ↑ Shiri, Rahman, and Eira Viikari-Juntura. "Lateral and medial epicondylitis: role of occupational factors." Best practice & research Clinical rheumatology 25.1 (2011): 43-57.
Created by:
John Kiel on 11 June 2019 01:33:38
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