Continuing Education Activity

Medial epicondylitis refers to the chronic tendinosis of the wrist flexors and pronators that attach to the medial epicondyle. Medial epicondylitis occurs most commonly through repetitive pronation of the forearm or flexion of the wrist. This activity describes the evaluation and treatment of medial epicondylitis and explains the importance of the role of the interprofessional team in early recognition and treatment to return patients to prior function and improve outcomes.

Objectives:

• Identify the etiology of medial epicondylitis.
• Describe the key history and physical exam findings for accurate diagnosis of medial epicondylitis.
• Summarize a comprehensive treatment plan for medial epicondylitis.
• Outline the importance of collaboration and communication amongst an interprofessional team to enhance outcomes for patients with medial epicondylitis.

Introduction

Epicondylitis is a common cause of elbow pain in athletes and the general population. It can occur both at the medial and lateral epicondyle with medial epicondylitis occurring less frequently than lateral epicondylitis.[1][2] Medial epicondylitis, also known as “golfer’s elbow” or “thrower’s elbow”, refers to the chronic tendinosis of the flexor-pronator musculature insertion on the medial epicondyle of the humerus as a result of overuse or repetitive stress. The flexor-pronator muscle group is composed of the pronator teres and the common flexor tendon, which includes tendons of the flexor digitorum superficialis, flexor carpi ulnaris, flexor carpi radialis, and palmaris longus. The flexor carpi radialis and the pronator teres are the most commonly involved tendons in medial epicondylitis.[3] The medial epicondyle also serves at the origin of the ulnar (or medial) collateral ligament (UCL). The common flexor tendon and UCL provide stability to flexion and valgus forces at the elbow. The ulnar nerve runs posterior to the medial epicondyle within the cubital tunnel.

Although termed epicondylitis, a more appropriate description, especially in a chronic setting, would be epicondylosis or epicondylalgia. Current literature shows that the underlying process appears to be degeneration and granulation tissue formation that is referred to as “angiofibroblastic hyperplasia or tendinosis” without the presence of a definitive inflammatory process. However, it should be noted, that there is no clear evidence that the early stages of the condition do not have an inflammatory component.[4][5]

Etiology

Medial epicondylitis is primarily caused by repetitive strain from activities that involve frequent loaded gripping, forearm pronation, and/or wrist flexion. In the sports world, it can be seen in throwing athletes (baseball pitchers, javelin throwers), golfers, tennis players, bowlers, rock climbers, archers, and weightlifters. However, most commonly it occurs in golfers, tennis players, and baseball pitchers. The intense valgus forces during the late cocking and acceleration phases of throwing or the late phases of the golf swing just before and during contact with the ball or ground contribute to the prevalence among these athletes.[6][7] Although it is often associated with athletes, this condition is also prevalent in the general population, commonly seen in carpenters, utility workers, butchers, and caterers. Medial epicondylitis is often precipitated by poor body mechanics, improper techniques, and/or inadequate equipment or tools.[8]

Epidemiology

Although epicondylitis is one of the most prevalent disorders of the arm, medial epicondylitis is much less common than lateral epicondylitis; about 7 to 10 times less common.[1] It is estimated that medial epicondylitis makes up approximately 10% of all cases of epicondylitis.[9] In a Finnish study of 4783 subjects, the prevalence of medial epicondylitis was found to be 0.4%.[10] One study in the US military population showed an incidence of 5.6 per 1000 person-years.[9] It is found to affect more females than males and most commonly affects middle-aged individuals in the fourth and fifth decades. Due to the nature of the underlying etiology, symptoms develop primarily in the patient’s dominant arm.[8]

Risk factors in the development of medial epicondylitis include smoking, diabetes, obesity, and tasks requiring repetitive wrist flexion or forearm pronation for at least two hours daily.[11][12] The natural course of the condition is usually self-limiting with recovery within one to three years in 80% percent of patients.[5]

Pathophysiology

Epicondylitis is primarily considered a chronic tendinosis as opposed to an acute inflammatory process. Along with the degenerative changes associated with overuse, there are findings of angiofibroblastic hyperplasia or tendinosis. Nirshel has previously proposed four stages of epicondylar tendinosis:[13]

• Generalized inflammation
• Angiofibroblastic degeneration
• Structural failure
• Fibrosis and calcification

Throughout these four stages, the overarching theme is repetitive micro-tearing at the tendon origin with a failed reparative process. The pronator teres and flexor carpi radialis are the most commonly affected tendons, but studies have shown that all flexor tendons can be affected equally.[3] Although mainly thought to be due to chronic repetitive microtrauma, acute trauma from a sudden contraction of the muscles can lead to findings of medial epicondylitis as well.[8]

Histopathology

Multiple studies have reported the histopathologic findings involved in lateral epicondylitis, with few studies focused on medial epicondylitis. However, the chronic degenerative process is understood to be similar in both conditions with histologic findings consisting of:

• Hypertrophic immature fibroblasts
• Poorly organized collagen
• Vascular hyperplasia
• Lack of inflammatory cells

The above chronic degeneration with failed healing findings are thought to be a consequence of the repetitive microtrauma and the poor blood supply of the tendons.[8][12]

History and Physical

Patients typically present with pain in the medial aspect of the elbow that is worse with activities, specifically gripping, throwing, and forearm flexion/pronation. Symptoms are normally relieved with rest. The pain most often develops gradually but can be acute in onset when due to trauma or injury.[12] Occasionally, patients will present with radiating pain into the forearm or wrist. More chronic presentations can also be associated with a decrease in grip strength.[11] Patients may complain that the pain is worse after waking up in the morning. A detailed social history should be investigated to include occupations, activities, and hobbies to identify those with potential involvement of repetitive elbow flexion and valgus stress as well as wrist flexion and pronation. It is not uncommon for the patient to endorse associated numbness in the ulnar nerve distribution of the hand due to the ulnar nerve’s anatomical location posterior to the medial epicondyle within the cubital tunnel.[8]

Depending on the acuity of pain onset, there may be signs of swelling or erythema on inspection of the elbow. However, most chronic cases of medial epicondylitis have limited visible signs on inspection. Tenderness to palpation is generally most notable about 5 to 10 mm distal to the medial epicondyle at the insertion of the flexor-pronator mass.[14] The pain is generally aggravated with resisted wrist flexion and pronation, with resisted wrist pronation being the most sensitive exam finding.[15] When testing, the elbow should be flexed at 90 degrees to isolate the pronator teres.[5] Flexion contracture could be a late finding in an untreated case of medial epicondylitis.[8] As ulnar neuritis can occur in patients with medial epicondylitis, a careful neurologic examination should be performed including sensory and motor testing of the hand and wrist, Tinel’s sign at the medial elbow at the cubital tunnel, and evaluation for subluxation of the ulnar nerve out of the ulnar groove at the elbow.[16] Ulnar collateral ligament stability should also be assessed with the milking maneuver and valgus stress test.

Evaluation

Diagnosis can be established clinically through history and physical examination, therefore further diagnostic investigation is not always necessary.[6] However, in settings in which clinical presentation is not straightforward, imaging may help confirm the suspected diagnosis of medial epicondylitis as well as ruling out alternative etiologies.

Findings on plain radiographs may consist of calcification in the flexor-pronator tendons or traction osteophytes.[11] Radiographs can be particularly helpful in patients who present with traumatic or acute onset of pain. In the pediatric population, growth plates are more likely to be injured than the tendons, so plain radiographs would be a useful addition to evaluate for underlying bony abnormalities.[12]

Magnetic resonance imaging (MRI) is generally regarded as the gold standard for the diagnosis of medial epicondylitis.[5] Findings on MRI of a thickened common flexor tendon sheath with increased T2 signal intensity are the most specific findings in medial epicondylitis.[17] MRI may also help rule out other intra-articular or soft tissue pathologies, such as osteochondritis dissecans, loose bodies, or ulnar collateral ligament injury.

Musculoskeletal ultrasound (US) evaluation has a sensitivity and specificity, 95.2% and 92% respectively, for the diagnosis of medial epicondylitis.[18] The most common findings on ultrasound are focal, hypoechoic changes in the common flexor tendon, thickening of the tendon sheath, partial or full-thickness tears, neovascularization using Doppler, and cortical irregularities at the medial epicondyle.[12][18] Ultrasound also allows for dynamic imaging studies, which can add the additional benefit in regards to evaluation for ulnar nerve subluxation and ulnar collateral ligament instability with valgus stress.

Although MRI and US evaluations are found to be clinically the most beneficial in the diagnosis of medial epicondylitis, bone scans, and computed tomography may also be useful for ruling out other etiologies.

In patients whose exam is suggestive of ulnar neuritis or neuropathy, electromyography and nerve conduction studies could be a helpful adjunctive diagnostic tool.

Treatment / Management

Nonoperative management is the foundation for the treatment of medial epicondylitis. Ciccotti et al. divided the nonoperative treatment of medial epicondylitis into three phases. Phase 1 consists of the cessation of offending activities or exercises in combination with pain-relieving modalities. Phase 2 consists of guided physiotherapy and rehabilitation. Phase 3 focuses on modifications to previously offending activities.[8]

Initial pain relief is achieved with icing, especially after activities, and non-opiate analgesic medications, such as acetaminophen (first line) and nonsteroidal anti-inflammatories (NSAIDs).[12] When using NSAIDs, topical preparations are preferred, but if oral NSAIDs are used, a 10 to 14 day course should be used to limit possible side effects/complications. 

Some patients benefit from bracing, which is done with a counterforce elbow strap or night splint. The counterforce strap should be placed about 2 cm distal to the medial epicondyle to provide compression and unload the tendon.[12] A nighttime volar wrist splint can prevent stress caused by sleeping positioning. An alternative to traditional bracing is the application of kinesiology tape. Although outcome studies in medial epicondylitis are limited, a benefit has been seen with kinesiology tape use in lateral epicondylitis.[19]

Patients with medial epicondylitis should be actively involved in physical therapy. The first goal of physical therapy is establishing full, painless range of motion. This is followed by stretching and progressive isometric exercises. As the patient continues to improve, resistive exercises are added to the program. The overall goal is to increase muscle strength beyond that of pre-injury strength. Once the patient can perform repetitive exercises without discomfort, they are progressed back into sports or occupation-specific activities. At the end of the guided therapy, patients should transition to a maintenance exercise program to continue overall flexibility and strength and decrease the chance of recurrence.[8]

Corticosteroid injections have been shown to be helpful for symptom relief in the short term (up to 6 weeks post-injection), but there was no difference when compared to controls in the long term (3 and 12 months post-injection).[20] Prolotherapy, platelet-rich plasma (PRP), autologous blood, and botulinum toxin injections may also be beneficial in treating epicondylitis.[21][22][23][24] However, most studies were focused on treating lateral epicondylitis and further studies are needed to determine overall efficacy.[25][26][27] Care should be taken with any injection for medial epicondylitis, given the target site's proximity to the ulnar and medial antebrachial cutaneous nerves. As a result, the authors recommend the use of ultrasound needle guidance for the aforementioned procedures when possible.

Topical nitroglycerin or glyceryl trinitrate has shown short-term benefits in lateral epicondylitis, but overall results for treatment for tendinopathy have been mixed depending on the site of application.[28] Other complementary modalities, including extracorporeal shock wave therapy, massage, transcutaneous electrical stimulation, iontophoresis, phonophoresis, and ultrasonography, may provide benefit; however, studies regarding efficacy are limited.

Surgery is typically not required. However, if no benefit is seen with the above conservative treatments for 6 to 12 months, then surgical management may be considered. Given the proximity to the ulnar nerve and UCL, an open surgical technique is preferred. The operative treatment involves debridement of the degenerated tendon, the release of the common flexor tendon at the medial epicondyle, and cortical drilling of the epicondyle to increase vascularity. If there is concomitant ulnar neuropathy, a transposition is also performed at the time of surgery.[5] Postoperatively, rest and splinting are used in the first week to decrease pain and swelling. Therapy is initiated 7 to 10 days postoperatively to increase passive range of motion. At 3 to 4 weeks postoperatively, gentle isometric exercises are introduced. A progressive strengthening program is usually started between 6 to 12 weeks. At around 3 to 6 months, patients begin a progressive return to sport-specific activities.[5][8]

Prevention includes adjustments to sporting or occupational equipment and modifications to technique. For example, in a tennis player, a larger grip size on the racquet, stringing the racquet less tight, and improving the serve and forehand techniques may help reduce the stress on the flexor-pronator mass.[8]

Differential Diagnosis

The differential diagnosis for medial epicondylitis includes, but is not limited to, the following:[5][14]

• Ulnar neuropathy
• Cervical radiculopathy
• Ulnar or medial collateral ligament sprain or tear
• Valgus extension overload syndrome
• Posteromedial elbow impingement
• Synovial plica
• Synovitis
• Elbow bursitis
• Rheumatoid arthritis
• Osteoarthritis
• Osteochondritis dessicans
• Occult fracture(s)
• Myofascial pain complex
• Shingles

Prognosis

The prognosis for medial epicondylitis is favorable, with most individuals obtaining relief from physical therapy, NSAIDs, and bracing. However, prognosis compared to those with lateral epicondylitis is more variable. Those not gaining relief from initial treatments may benefit from corticosteroid injection, prolotherapy, or platelet-rich plasma (PRP) injection. Surgical correction is rarely needed. Patients have shown a worse prognosis if they have concomitant ulnar neuritis.[5]

Complications

With successful treatment, most individuals return to normal tasks and function. Although complications are rare, the most common is persistent pain or recurrent symptoms. In cases managed surgically, complications include nerve injury (medial antebrachial cutaneous nerve and/or ulnar nerve), or infection. For refractory cases treated surgically, pain is likely to improve, but about 20% of patients do not return to the prior level of sporting activities.[11]

Consultations

The majority of cases of medial epicondylitis can be effectively managed by a primary care clinician. However, in severe or refractory cases, a sports medicine consult is indicated. An orthopedic surgery consult should be obtained for patients with minimal improvement with conservative treatment for surgical consideration.

Deterrence and Patient Education

It is important to educate the patient about the importance of early rehabilitation and modification or avoidance of repetitive offending activities. Treatment planning should also address the patient’s understanding and expectations. Home stretches and a maintenance exercise program should also be explained and demonstrated to decrease the risk of recurrence.

Pearls and Other Issues

• Medial epicondylitis is often associated with repetitive activities in athletes (throwing, racquet sports, golf, rock climbing, or weight lifting) or occupation responsibilities (carpenters, utility workers, butchers, or caterers).
• Patients generally have pain at the medial elbow that is worse with wrist flexion and pronation.
• Concomitant ulnar nerve symptoms are common.
• Treatment is typically successful with conservative management including a combination of non-opiate medications, physical therapy, bracing, and injections.
• Education on adjustments to sporting or occupational equipment and modifications to technique is key to preventing recurrence of symptoms.

Enhancing Healthcare Team Outcomes

Medial epicondylitis is a diagnosis that can be made in the primary care office based on history and physical examination. It is important to remember that early identification and treatment is the key to adequate symptom improvement and return to the prior level of function. This is best accomplished with an interprofessional team approach. Prompt activity modification and initiation of non-opioid analgesics are helpful in the early/acute phase. Physical therapy is useful for patients not only in the treatment phase of the condition but in developing an effective prevention program to avoid recurrence of symptoms upon return to work/sport. Referrals should include a summary of the history of present illness, physical exam, a detailed social history (including occupation, hobbies, and sports), patient’s goals of treatment, and treatments already trialed. This information sharing allows for a more complete and holistic view of the patient's problem and allows all healthcare providers access to the tools and information necessary to treat the individual and improve his or her quality of life.