summary Medial Epicondylitis, also know as Golfer's elbow, is an overuse syndrome caused by eccentric overload of the flexor-pronator mass at the medial epicondyle. Diagnosis is made clinically with tenderness around the medial epicondyle made worse with resisted forearm pronation and wrist flexion. Treatment is generally nonoperative with rest, icing, activity modifications and bracing. Rarely, operative management is indicated for patients with persistent symptoms who fail nonoperative management. 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. Etiology 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 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 EMG/NCS may be used to further evaluate for ulnar nerve compression if identified on history and physical 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 Prognosis More difficult to treat than lateral epicondylitis Sess well-studied than lateral epicondylitis