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Introduction
  • An overuse syndrome of the flexor-pronator mass origin
    • more difficult to treat than lateral epicondylitis
    • less well-studied than lateral epicondylitis
  • Epidemiology
    • incidence
      • 5 to 10 times less common than lateral epicondylitis
    • demographics
      • affects men and women equally
      • dominant extremity in 75% of cases
      • age 30s to 60s, most commonly in 30s to 40s.
  • Pathophysiology
    • risks
      • sports that require repetitive wrist flexion/forearm pronation during ball release
        • common in golfers, baseball pitchers, javelin throwers, bowlers, weight lifters, racquet sports
        • tennis
          • late ball strike (raquet head behind elbow at ball contact)
          • poor forehand stroke mechanics
          • failure to use vibration dampeners attached to strings 
      • in athletes, may develop in response to large valgus forces on elbow
        • flexor-pronators reduce force seen by anterior band of medial ulnar collateral ligament (MUCL)
          • anterior band MUCL 
            • primary static restraint to valgus force at elbow
            • lies deep to pronator teres and FCR
      • jobs involving lifting >20kg, forceful grip, exposure to constant vibration at elbow (plumbers, carpenters, construction workers)
      • can also occur post-traumatically
    • pathoanatomy
      • micro-trauma to insertion of flexor-pronator mass caused by repetitive activities
        • traditionally thought to affect pronator teres (PT) > flexor carpi radialis (FCR) 
        • new studies show all muscles of common flexor tendon (CFT) affected except palmaris longus
      • stages
        • peritendinous inflamation
        • angiofibroblastic hyperplasia
        • breakdown/fibrosis/calcification
  • Associated conditions
    • ulnar neuropathy
      • inflammation may affect ulnar nerve
    • ulnar collateral ligament insufficiency
      • should rule this out, especially in throwing athletes
    • associated occupational conditions (present in 84% of occupational medial epicondylitis)
      • carpal tunnel syndrome
      • lateral epicondylitis
      • rotator cuff tendinitis
Anatomy
  • Common flexor tendon (CFT) 
    • 3 cm long
    • attaches to medial epicondyle (anterior aspect), anterior bundle of MCL
    • fibers run parallel to MCL
    • ulnar head of PT becomes confluent with hyperplastic part of anteromedial joint capsule
  • 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
  • History
    • may include acute traumatic blow to elbow causing avulsion of CFT
    • repetitive elbow use, repetitive gripping, repetitive valgus stress
    • +/- numbness or tingling in ulnar digits
  • Symptoms
    • insidious onset pain over medial epicondyle 
      • worse with wrist and forearm motion 
      • worse with gripping
      • during late cocking/early acceleration
  • Physical exam
    • tenderness 5-10 mm distal and anterior to medial epicondyle
    • soft tissue swelling and warmth if inflammation present
    • provocative tests post
      • pain with resisted forearm pronation and wrist flexion
    • examine for associated conditions
      • valgus instability in overhead athlete (milking maneuver, valgus stress, moving valgus stress test)
      • ulnar neuritis (2-pt discrimination in ulnar distribution, hypothenar bulk, Tinel's along length of nerve)
        • elbow flexion test involves maximal flexion, forearm pronation, wrist hyperextension x 30-60s
        • ulnar subluxation
    • flexion contracture in chronic cases
Imaging
  • Radiographs
    • usually unremarkable
    • 25% have calcification of CFT or UCL
    • can identify posterior-medial osteophytes or degenerative changes
    • stress radiography used in some centers for assessing valgus instability
  • Ultrasound
    • characteristics
      • >90% sensitivity, specificity, positive and negative predictive values
      • allows dynamic examination
    • findings
      • hypoechoic/anechoic areas of focal degeneration
  • MRI
    • standard of care
    • indications
      • evaluate concomitant pathology (e.g. UCL injury in overhead thrower)
      • unclear source of medial elbow pain
      • evaluate for loose bodies
      • rule out rupture of flexor pronator origin
    • findings
      • tendinosis / tendon disruption of CFT 
        • increased signal on T2 images    
        • peritendinous edema
      • UCL or osteochondral injuries
Studies
  • EMG/NCS
    • may be used to further evaluate for ulnar nerve compression if identified on history and physical
Histology
  • Angiofibroblastic hyperplasia, as described for lateral epicondylitis
  • Inflammation uncommon
Differential
  • MCL injury 
  • Cubital tunnel syndrome 
  • Fracture
  • Cervical radiculopathy
  • Triceps tendinitis
  • Herpes zoster (shingles)
Treatment
  • Nonoperative
    • rest, ice, activity modification (stop throwing x 6-12wks), PT (passive stretching), bracing, NSAIDS
      • indications
        • first line of treatment
        • prolonged trial of conservative management appropriate due to less predictable success of operative treatment (compared to lateral epicondylitis)
      • technique
        • counter-force bracing / kinesiology taping
        • ultrasound shown to be beneficial
        • multiple corticosteroid injections should be avoided
    • extracorporeal shockwave therapy (ESWT)
      • no definitive recommendations at present
      • promotes angiogenesis, tendon healing, short term analgesia
    • corticosteroid injections into peritendinous tissue
      • complications
        • skin depigmentation (if dark skinned)
        • subcutaneous atrophy
        • tendon weakening
        • ulnar nerve injury
    • acupuncture
  • Operative
    • open debridement of PT/FCR, reattachment of flexor-pronator group
      • indications
        • up to 6 months of nonoperative management that fails in a compliant patient
        • symptoms severe and affecting quality of life
        • clear diagnosis
      • outcomes
        • good to excellent outcomes in 80% (less than lateral epicondylitis)
        • worse outcomes when ulnar nerve symptoms present pre-operatively
Techniques
  • Open debridement and reattachment of flexor-pronator mass
    • approach
      • medial approach to elbow 
    • technique
      • use the PT-FCR interval
      • excise regions of pathologic tissue near flexor-pronator mass 
        • followed by side-to-side repair at site
      • can perform epicondyle microfracture to 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 x 1-2 weeks in sling
        • avoid volar flexion of wrist immediately postoperatively
      • ROM exercises after 2 weeks
      • strengthening at 6-8 weeks
      • return to sport at 3-6 months
Complications
  • Medial antebrachial cutaneous nerve neuropathy
    • may result from avulsion or transection
      • if injury noticed during surgery, transpose nerve into brachialis muscle
  • Ulnar nerve injury
  • Infection
 

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