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Updated: Feb 29 2024

Medial Epicondylitis (Golfer's Elbow)

Images epicondylitis 2.jpg epicondylitis.jpg
  • 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
          • degree of ulnar neuropathy correlates directly with worse clinical outcomes
  • 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
    • well-studied than lateral epicondylitis
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