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Medial Epicondylitis

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Other Names

  • Golfers Elbow
  • Medial Epicondylosis
  • Medial Epicondylalgia

Background

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

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


Clinical Features

  • General: Physical Exam Forearm
  • History
    • Typically will endorse a repetitive activity
    • Less commonly, acute trauma may occur
    • Patient may endorse parasthesias in an ulnar nerve distribution
  • Physical
    • Tenderness at the medial epicondyle and 5-10 mm distally
    • There may be warmth, swelling
    • Pain with resisted pronation, wrist flexion
  • Special Tests

Evaluation

  • Radiographs
    • 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[7]
    • 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-occuring 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

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


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 Ciccotti MG, Ramani MN: Medial epicondylitis. Tech Hand Up Extrem Surg 2003;7(4):190-196.
  4. 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.
  5. 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.
  6. 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.
  7. Park GY, Lee SM, Lee MY: Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil 2008;89(4):738-742.
  8. 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.
  9. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003:CD004258.
  10. McLauchlan GJ, Handoll HH. Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev. 2001:CD000232
  11. Stasinopoulos DI, Johnson MI. Effectiveness of low-level laser therapy for lateral elbow tendinopathy. Photomed Laser Surg. 2005;23:425–430.
  12. 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
Authors:
Last edited:
11 November 2020 14:45:45
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