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Medial Epicondylitis (Golfer's Elbow)

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Topic updated on 08/22/13 8:18pm
Introduction
  • An overuse syndrome of the flexor-pronator mass
    • more difficult to treat than lateral epicondylitis
  • Epidemiology
    • incidence
      • 5X less common than lateral epicondylitis
    • demographics
      • affect men and women equally
      • dominant extremity in 75% of cases
  • Pathophysiology
    • mechanism
      • found in activities that require repetitive wrist flexion/forearm pronation
        • common in golfers, pitchers, racquet sports, plumbers
    • pathoanatomy
      • micro trauma to insertion of  flexor-pronator mass caused by repetitive activities
        • pronator teres (PT) and flexor carpi radialis (FCR) are most affected
  • Associated conditions
    • ulnar neuropathy
      • inflammation may affect to ulnar nerve
    • ulnar collateral ligament insufficiency
      • should rule this out especially in throwing athletes
Anatomy
  • Flexor-pronator mass includes 
    • Pronator Teres (median n.)  
    • Flexor Carpi Radialis (median n.)  
    • FDS (median n.)  
    • Palmaris Longus (median n.)  
    • Flexor Carpi Ulnaris (ulnar n.)  
Presentation
  • Symptoms
    • pain over medial epicondyle 
      • worse with wrist and forearm motion
  • Physical exam
    • tenderness over the origin of PT and FCR at the medial epicondyle
    • provocative tests post
      • pain with resisted forearm pronation and wrist flexion
Imaging
  • Radiographs
    • usually unremarkable
  • MRI
    • may show tendinosis of pronator teres and FCR
      • increased signal on T2 images    
Differential
  • MCL injury 
  • Cubital tunnel syndrome 
Treatment
  • Nonoperative
    • rest, ice, activity modification, PT, bracing, NSAIDS, corticosteroid injections
      • indications
        • first line of treatment
      • technique
        • counter-force bracing
        • ultrasound shown to be beneficial
        • multiple corticosteroid injections should be avoided
  • Operative
    • open debridement of PT/FCR, reattachment of flexor-pronator group
      • indications
        • up to 6 months of nonoperative management that fails in compliant patient
        • symptoms severe and affecting quality of life
      • outcomes
        • good to excellent outcomes in 80% (less than lateral epicondylitis)
Techniques
  • Open debridement and reattachment of flexor-pronator mass 
    • approach
      • medial approach to elbow 
    • technique
      • excise regions of pathologic tissue near flexor-pronator mass 
        • followed by side to side repair at site
      • enhance vascular environment
      • reattach flexor-pronator mass to medial epicondyle
        • if proximal origin involved
      • can also perform cubital tunnel release or transposition 
        • for concomitant ulnar nerve symptoms
    • rehabilitation
      • short period of immobilization
      • ROM exercises
      • avoid volar flexion of wrist in immediate postoperative period
Complications
  • Medial antebrachial cutaneous nerve neuropathy
    • may result from avulsion or transection
      • if injury noticed during surgery, than transpose nerve into brachialis muscle

 

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