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Medial Epicondylitis
From WikiSM
Contents
Other Names
- Golfers Elbow
- Medial Epicondylosis
- Medial Epicondylalgia
Background
- Defined as an overuse syndrome of the Common Flexor Tendon attachment at the medial epicondyle of the Humerus
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
Pathophysiology
- See: Tendinopathies (Main)
- Mechanism: repetitive eccentric loading of the muscles conducting wrist flexion and forearm pronation combined with valgus overload at the elbow[3]
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[4]
- 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[5]
- 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
Pathoanatomy
- Repetitive microtrauma at the common flexor tendon, sometimes referred to as the flexor-pronator mass
- Common Flexor Tendon[6]
- 3 CM long
- Crosses the ulnohumeral joint medially
- Attaches to the medial humeral epicondyle anteriorly
- Attaches proximally to the anterior bundle of the Ulnar Collateral Ligament
- Becomes confluent with the anteromedial joint capsule.
- Muscles that coalesce to form the common flexor tendon
Associated Conditions
- Ulnar Collateral Ligament Injury
- Ulnar Nerve Injury
- Carpal Tunnel Syndrome
- Lateral Epicondylitis
- Rotator Cuff Tendinitis
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
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
Clinical Features
- History
- Typically will endorse a repetitive activity
- Less commonly, acute trauma may occur
- Patient may endorse parasthesias in an ulnar nerve distribution
- Physical: Physical Exam Elbow
- Tenderness at the medial epicondyle and 5-10 mm distally
- There may be warmth, swelling
- Pain with resisted pronation, wrist flexion
- Special Tests
- Golfers Elbow Test: Pain with passive supination and wrist extension
- Resisted Wrist Flexion Pronation Test: Elbow flexed, supination and wrist extended against resistance
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[7]
Radiographs
- Standard Radiographs Elbow
- Not required to make the diagnosis
- Useful to exclude other etiologies
- Up to 25% may have calcification of the common flexor tendon or UCL[3]
Ultrasound
- 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[8]
- Tendon may demonstrate:
- Thickening or thinning
- Hypoechogenic foci (intra-substance degenerative changes)
- Tendon tears
- Calcification
- Bony irregularity
- Calcific deposits
MRI
- Necessary if any diagnostic uncertainty or co-occurring injuries
- May demonstrate:
- Degenerative changes
- Tendon tears
- Edema of tendon
EMG
- In cases of unclear etiology, may be useful to exclude neurological causes
Classification
- N/A
Management
- 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[9]
- Corticosteroid Injection
- Extracorporeal Shock Wave Therapy
- Low-level Laser Treatment (LLLT)
- Acupuncture
- Botox
- Topical Nitroglycerin
- Autologous Blood Injection
- Platelet Rich Plasma
- Percutaneous Radiofrequency Thermocoagulation
- Iontophoresis and Phonophoresis
- Therapeutic Ultrasound
- Dextrose Prolotherapy
- Needle Tenotomy
- Sclerotherapy
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)
Return to Play
- Needs to be updated
Complications
- Medial antebrachial cutaneous nerve neuropathy
- Ulnar Nerve Injury
- Infection
See Also
- Internal
- External
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 3.1 Ciccotti MG, Ramani MN: Medial epicondylitis. Tech Hand Up Extrem Surg 2003;7(4):190-196.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Walz, Daniel M., et al. "Epicondylitis: pathogenesis, imaging, and treatment." Radiographics 30.1 (2010): 167-184.
- ↑ Park GY, Lee SM, Lee MY: Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil 2008;89(4):738-742.
- ↑ 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.
- ↑ Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003:CD004258.
- ↑ McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001:CD000232
- ↑ Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg. 2005;23:425–430.
- ↑ 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.
Created by:
John Kiel on 11 June 2019 01:33:38
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Last edited:
13 January 2023 15:17:08
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