High Yield Topics

Medial Epicondylitis

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Ovid: 5-Minute Sports Medicine Consult, The


Medial Epicondylitis
Craig C. Young
Emily Porter
Basics
Description
Medial epicondylitis is clinically defined as pain at the medial epicondyle due to repetitive flexion and pronation at the elbow. It is usually an overuse injury that can affect both athletes and nonathletes. Golfer's elbow is a common term used for medial epicondylitis.
Epidemiology
  • Diagnosed less often than lateral epicondylitis, a similar condition affecting the origin of the common extensor tendon on the lateral epicondyle
  • Estimated prevalence of 0.4% in 2006 observational study in Finland (1)[C]
  • Diagnosis is often made in the 4th and 5th decades, although the condition has been seen in patients ranging from 12–80 yrs of age.
  • Men and women are affected equally.
  • The dominant hand is most often affected.
Etiology
  • Initially thought to be an inflammatory process.
  • Inflammation may play a role in the initial acute injury when microtearing of the tendon occurs
  • Histologic studies of chronic epicondylitis have shown abnormal collagen architecture due to a fibroblastic and immature vascular response, which causes incomplete tendon repair.
  • Notable lack of acute and chronic inflammatory cells in chronic epicondylitis.
  • Degenerative changes often seen in the pronator teres and flexor carpi radialis muscles and their tendons.
    • Palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris may also be involved.
  • Common causes:
    • Activities that involve forceful and/or continuous flexion and pronation at the wrist or a large amount of stabilization applied by the wrist, such as racquet sports, swimming, swinging a golf club, throwing, playing tennis, using a computer keyboard or playing piano.
    • Certain occupations (carpenters, plumbers, meat cutters, etc.) may be more at risk.
Diagnosis
History
  • Pain and tenderness along the medial elbow, extending into the forearm, which worsens with resisted forearm pronation or wrist flexion at 90° of elbow flexion and/or full elbow extension.
  • Difficulty gripping without pain
  • Decreased wrist strength
  • Tightness/stiffness when stretching elbow and wrist
Physical Exam
  • Tenderness to palpation over the medial epicondyle, pronator teres and flexor carpi radialis
  • Local swelling and warmth may be present
  • Active and resisted range of motion may be full or limited depending on the severity of the injury.
Diagnostic Tests & Interpretation
Imaging
  • Generally not needed for initial evaluation
  • In cases that are refractory to treatment or where the diagnosis is in question, basic elbow x-rays followed by US or MRI may be considered (2)[C].
Differential Diagnosis
  • Entrapment neuropathy (ie, cubital tunnel syndrome, carpal tunnel syndrome)
  • Ulnar neuritis
  • UCL insufficiency
  • Medial elbow apophysitis (ie, “Little leaguer's elbow”)
  • Inflammatory arthritis
  • Cervical radiculopathy
  • Thoracic outlet syndrome
  • Myofascial pain
Treatment
  • Initial treatment includes relative rest, ice, acetaminophen or OTC NSAIDs as needed.
  • The mainstay of treatment involves stretching and strengthening with progression to eccentric training exercise with or without formal physical therapy.
  • Bracing may be helpful.
  • If no improvement in 6 wks, consider obtaining x-rays and initiating formal physical therapy.
  • If still symptomatic, consider injection. Various techniques have been proposed including dry needling of tendon, corticosteroid injection, or use of newer techniques including prolotherapy or injection of platelet-rich plasma or autologous blood (3)[C].
  • Other treatments to consider include nitric oxide via topical nitroglycerin or extra-corporeal shock wave therapy (4,5)[C].
  • If symptoms persist, consider advanced imaging with US or MRI to confirm diagnosis.
  • Rarely, recalcitrant symptoms >6 mos in duration may require surgical intervention.

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Ongoing Care
Home exercise program as follows:
  • Strengthening:
    • Continue regular breathing during the exercises
    • Stay below the level of pain
    • Perform 2 to 3 sets of 10–15 repetitions, 2–4 times a week. Once 3 sets of 15 repetitions can be performed easily, increase the weight, reduce the repetitions to 10, and build back up to 15.
    • Exercises:
      • Wrist extension curls: With the forearm supported on a firm surface and the palm facing downward, lift and lower the weight.
      • Wrist flexion curls: With the forearm supported on a firm surface and the palm facing upward, lift and lower the weight.
      • Forearm pronation/supination: With the forearm supported on a firm surface, turn the palm up and then down while holding onto a weight.
      • Gripping: Gently grip a rubber ball, a towel, or putty and then advance to items with more resistance. Perform 10–30 repetitions, increasing in intensity once 30 repetitions can be performed.
    • Finger extension: Wrap a rubber band around the outside of all the fingers and thumb, gently extend the hand by opening the fingers, and then close the fingers. Perform 10–30 repetitions.
  • Stretching:
    • Keep the stretch to a comfortable level.
    • Continue regular breathing during the exercises.
    • Hold each stretch for ∼30 sec.
    • Repeat each stretch 3–6 times.
    • Exercises:
      • Wrist flexion stretch: Bend the involved wrist down gently by grasping it with the other hand until a pulling sensation is felt. Keep the elbow straight.
      • Wrist flexion stretch (advanced): Same as for the wrist flexion stretch, but with the addition of wrist movement toward the side of the little finger.
      • Wrist extension stretch: Bend the involved wrist up gently by grasping it with the opposite hand until a pulling sensation is felt. Keep the elbow straight.
References
1. Shiri R, Viikari-Juntura E, Varonen H, et al. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006.
2. Park G, Lee S, Lee M. Diagnostic value of ultrasonography for clinical medial epicondylitis. Arch Phys Med Rehabil. 2008;89:738–742.
3. Suresh SP, Ali KE, Jones H, et al. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment? Br J Sports Med. 2006;40:935–939.
4. Paoloni JA, et al. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. 2003;31:915–920.
5. Rompe JD, et al. Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. Am J Sports Med. 2004;32:734–743.
Additional Reading
Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004;23:693–705.
Jayanthi N. (2009). Epicondylitis. Accessed online on August 12, 2009 from UpToDate Web site: www.uptodate.com
Codes
ICD9
726.31 Medial epicondylitis
Clinical Pearls
  • Wrist splints are often more helpful then counter-force bracing if the patient has significant pain upon awakening. However counter-force braces are often better tolerated during the day.
  • The cost of nitroglycerin patches can be decreased by cutting them in half or quarters.


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