Medical Epicondylitis

Medial epicondylitis is pain at the inner aspect of the elbow and is often referred to as golfers elbow. Symptoms are most common in adults age forty to sixty, during their peak working years, and are described as a burning or pain near the bony prominence on the medial aspect of the elbow joint that can radiate into the forearm. The pain is caused by repetitive microtrauma and degeneration of the common flexor tendon that can occur with repetitive loading during wrist flexion and forearm pronation, particularly if the elbow is also loaded into a valgus position. Stress in this position is common with overhead throwing motions, swinging a golf club or tennis racket, or in occupational setting that involve a strong grip such as hammering.

Initially the repetitive loading will cause infammation around the tendon. If the trauma continues vascular and fibrous elements can invade the tendon and eventually replace the normal tendon with a condition called angiofibroblastic hyperplasia that will cause the tendon to breakdown into a state of irreparable fibrosis and calcification. The common flexor tendon is about three centimeters long and spans from the medial humerus to the ulnar collateral ligament, where part of the elbow capsule and five muscles join together. These include the pronator teres, flexor carpi radialist, palmaris longus, flexor carpi ulnaris and flexor digitorum superficialis. Cadaver studies have shown that all of the muscles joining together at the common flexor tendon can be involved in medial epicondylitis with the exception of palmaris longus.

Medial epicondylitis can sometimes be mistaken for ulnar neuritis, tendinopathy, ligamentous instability, joint pathology or trauma. A thorough history that includes a description of symptoms, onset and aggravating factors can help with diagnosis. Clinical presentation may include tenderness and swelling at or near the medial epicondyle. Pain can be reproduced with resisted wrist flexion, forearm pronation or gripping. These movements may also be identified as weak in comparison to the nonaffected arm. Though uncommon, range of motion can also be lost as the patient can present with a flexion contracture at the elbow that is in reaction to guarding against the pain. Other tests that can help with diagnosis include examination for valgus instability with assessment of the ulnar collateral ligament and testing for adjacent musculoskeletal disorders that can commonly present with medial epicondylitis, such as carpal tunnel, lateral epicondylitis, and rotator cuff tendinitis.

Ulnar neuritis and cervical radiculopathy are neurologic conditions that can often be mistaken for medial epicondylitis. Ulnar neuritis can be identified with a positive Tinel's sign or altered sensory with two point discrimination testing in the ulnar nerve distribution. Sensory changes can be reproduced with stress or pressure anywhere along the ulnar nerve path or by applying stress on the nerve by placing the elbow in maximal flexion, forearm pronation and wrist extension for 30-60 seconds. Ulnar nerve subluxation can also be involved and should be ruled out particularly if the patient reports a popping sensation. Cervical radiculopathy stemming from the C6-7 nerve roots may also take place. The patient will likely present with a forearm muscle imbalance along with symptoms at the medial elbow.

Diagnostic testing for medial epicondylitis includes radiographs, ultrasounds testing and MRI. Of the three, MRI is the gold standard for diagnosis, as it can detect changes in the tendon and also help rule out other elbow pathology. Intervention can be surgical or non-surgical depending on the symptoms, but regardless the goal is to rehabilitate the injured tendon and prevent future damage. Conservative care is typically chosen first and often involves rest from activities that increase symptoms, use of ice and NSAIDS, and taping, bracing or splinting designed to limit forces at the elbow. Modalities, such as ultrasound and electrical stimulation, and steroid injections can also be incorporated into treatment to assist with control of inflammation and symptom management. Once acute symptoms are managed, physical therapy becomes an important component of recovery. Therapy will first focus on gaining full painfree range of motion at the shoulder, elbow and wrist. After range of motion has been achieved strengthening of the flexor and pronator muscles will begin, progressing the intensity of the exercises by gradually increasing speed and resistance, building from concentric to eccentric movement. In addition to strengthening at the elbow it is imperative the core, scapula and shoulder girlde are assessed and properly strengthened. Sport specific and occuptional demands must be taken into consideration when designing the final phase of strengthening after medial epicondylitis. Proper ergonomics, proper technique and equipment, such as golf club length or tennis racket grip size, should also be evaluated with to return to sport/work.

In cases where medial epicondylitis symptoms are persistent, surgical debridement or repair may be necessary. Surgical goals are guided by the Morrey classification. Type One lesions require epicondylar debridement. Type Two lesions that involve the ulnar nerve are separated into Type two A that requires decompression and Type Two B that requires submuscular transposition. The procedure is an open surgery where an incision is made at the medial epicondyle. The common flexor tendon is debrided then the ulnar nerve is examined to determine if it requires decompression, transposition, ligament repair, or reconstruction. The more extensive the tendon damage, the more debridement is necessary often requiring reattachment of the common flexor tendon to the medial epicondyle. To facilitate reattachment, the epicondyle is microfractured to allow bleeding and provide a vascular bed for the tendon insertion. Surgical success rates are fairly high for medial epicondylitis without or with mild ulnar neuritis with return to full activity in three to six months. When moderate to severe ulnar neuritis is involved, success rates significantly decrease. New surgical procedures are being tried and described in the literature with hopes to increase the success rates regardless of ulnar neuritis severity.

References: Amin, NH et al. Medial Epicondylitis:Evaluation and Management. In the Journal of the American Academy of Orthopedic Surgeons. Vol.23. Pp 348-355.