You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > UPPER LIMB MUSCULOSKELETAL CONDITIONS Medial EpicondylitisArticle Last Updated: Nov 26, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Sharon J Gibbs, MD, Physician, Texas Back Institute Sharon J Gibbs is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and Texas Medical Association Coauthor(s): Kenneth S Dauber, MD, PA, Consulting Staff, Department of Physical Medicine and Rehabilitation, Plano Orthopedic and Sports Medicine Center Editors: Daniel D Scott, MD, Program Director, Department of Rehabilitation Medicine, Associate Professor, University of Colorado Health Sciences Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, UMDNJ-New Jersey Medical School; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center Author and Editor Disclosure Synonyms and related keywords: golfer's elbow, medial tennis elbow, reverse tennis elbow INTRODUCTIONSection 2 of 11
  BackgroundMedial epicondylitis (ME) is an overuse injury affecting the flexor-pronator muscle origin at the anterior medial epicondyle of the humerus. ME is often discussed in conjunction with lateral epicondylitis (LE), which occurs much more frequently. ME is the most common cause of medial elbow pain, although the clinician is likely to see at least 5 cases of LE for every case of ME. Patients who develop medial elbow pain appreciate their physician's knowledge of the subtle differences in the diagnosis and treatment of the 2 disorders. (See also Medial Epicondylitis [in the Orthopedic Surgery section], Medial Epicondylitis [in the Sports Medicine section], and Overuse Injury.) PathophysiologyME involves primarily the flexor-pronator muscles (ie, pronator teres, flexor carpi radialis, palmaris longus) at their origin on the anterior medial epicondyle. Less often, ME also affects the flexor carpi ulnaris and flexor digitorum superficialis. Repetitive stress at the musculotendinous junction and its origin at the epicondyle leads to tendinitis in its most acute form and to tendinosis in its more chronic form. In addition, an ulnar neuropraxia caused by compression of the ulnar nerve in or around the medial epicondylar groove has been estimated to occur in up to 50% of ME cases. The tendinosis that occurs is primarily the result of failure of the damaged tendon to heal. Microscopic examination of the involved tissue shows granulation tissue, fibrovascular and fibrocartilaginous tissue, tendon microfragmentation, calcification, and necrosis. Histologically, damage to the involved tendons has been described as angiofibroblastic hyperplasia tendinosis and fibrillary degeneration of collagen. A simple, acute inflammatory reaction is noted to be a much less common finding than are the previously described tendinosis changes. RaceNo studies indicate a race predilection. SexA male-to-female ratio of 2:1 has been reported. AgePeak incidence is in patients aged 20-49 years, but ME is also seen in teens and older adults, especially if they engage in hobbies, jobs, or sports activities that make them prone to overuse injuries. (See also the article Prevalence of Orthopaedic Maladies in People Who Flyfish: An Internet-Based Survey, on Medscape.) CLINICALSection 3 of 11
HistoryME is characterized by pain over the medial epicondyle. Pain worsens with wrist flexion and forearm pronation activities. Patients may report discomfort even when simply shaking hands with someone. Up to 50% of patients with ME complain of occasional or constant numbness and/or tingling sensation that radiates into their fourth and fifth fingers, suggesting involvement of the ulnar nerve. The patient's history may include the occurrence of an acute injury as a result, for instance, of taking a divot in golf, throwing a pitch in baseball, or hitting a hard serve in tennis.
PhysicalTenderness with palpation over the anterior aspect of the medial epicondyle is the most consistent finding. Other characteristics of ME include the following:
CausesThe causes of ME include the following:
DIFFERENTIALSSection 4 of 11
Lateral Epicondylitis Olecranon Bursitis Other Problems to Be ConsideredArthritis
WORKUPSection 5 of 11
Lab Studies
Imaging Studies
Other Tests
TREATMENTSection 6 of 11
Rehabilitation ProgramPhysical TherapyThe physician may recommend that the patient with ME receive physical or occupational therapy. The discipline of therapy usually depends on the type of facility available, the accessibility of therapists, and physician preference. The proper means of treatment for ME are discussed below, in the Occupational Therapy section. Occupational TherapyTreatment begins with rest, ice, compression, and bracing, to decrease pain and inflammation. One to 6 weeks of relative rest of the affected muscles and tendons is typically advised, until discomfort subsides. Icing is employed for 5-10 minutes, 4-6 times per day and is particularly important if a patient presents after an acute event. Patients should be instructed to avoid icing over the ulnar nerve. Compression with a medial counterforce brace (ie, a tennis elbow splint) with a pad placed anteromedially on the proximal forearm over the flexor-pronator mass is routine (see Image 1). Discontinue if symptoms of an ulnar neuropathy worsen. In addition, if the symptoms are severe, brace with a wrist splint worn in the neutral position in order to rest the wrist flexors. In milder cases, a counterbalance brace may be used alone instead of a rigid splint; this limits extremes of motion while allowing some movement for functional activities. In the case of ulnar nerve involvement, a nighttime elbow extension splint should be considered. The splint is made in 30-45º of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve. After the patient's initial discomfort has subsided, a rehabilitation program with an occupational therapist should be initiated for muscle/tendon reconditioning. Begin with gentle stretching and add gradual strengthening of the flexor-pronator muscles, as the patient tolerates. Follow this with functional activities and with patient education aimed at avoiding re-injury. The patient should be advised to perform very slow stretching exercises 10-15 times to warm up muscles and increase flexibility, before doing any strengthening exercises or functional activities. Strengthening begins slowly with isometrics and progresses to eccentric exercises (see Images 2-3), with a gradual increase in resistance. Take care to cut back on exercises if they cause a recurrence of symptoms. Icing for 5-10 minutes after exercise is reasonable, especially if the patient reports pain in the affected area following exercise. Concomitant modalities may include ultrasonography, iontophoresis, phonophoresis, transcutaneous electrical nerve stimulation, and low-energy, extracorporeal shock-wave therapy. Successful relief from symptoms is variable. Shock-wave therapy has been shown to be less effective for ME than it is for LE.2 Surgical InterventionEpicondylar debridement is rarely indicated but has proven to be effective in cases in which conservative treatment has failed. In addition, the ulnar nerve may be decompressed surgically.3 ConsultationsReferral to an orthopedic surgeon is appropriate after 6-10 months if conservative treatment fails. Other TreatmentIf conservative measures fail, injection with local anesthetic and steroid to the point of maximal tenderness is appropriate. Special care should be taken to avoid injection directly into the tendon or the ulnar nerve. If concern for dislocation of the ulnar nerve exists, the injection should be performed with the elbow extended or semiflexed. The number of injections should be limited to 3 to decrease the risk of tendon atrophy or rupture. Short-term relief of discomfort with cortisone injection may be expected, but a complete rehabilitation program, as previously described, is a more effective and long-lasting way to treat ME. MEDICATIONSection 7 of 11
Nonsteroidal anti-inflammatory drugs (NSAIDs), taken orally, are the medicines of choice for ME to help control pain and any associated inflammation. NSAIDs are used on average only for the first 7-10 days of the treatment period. For the patient, taking these medications with food may help to decrease the possible gastrointestinal side effects. The following list is not meant to be comprehensive but simply to provide examples of options.
Drug Category: Nonsteroidal anti-inflammatory drugsNSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
FOLLOW-UPSection 8 of 11
Further Outpatient Care
Deterrence
Prognosis
Patient Education
MISCELLANEOUSSection 9 of 11
Medical/Legal Pitfalls
Special ConcernsWaiting too long from symptom onset to treatment could make recovery much more prolonged and may increase the chance that surgical intervention will be required; thus, early identification and treatment is of great importance. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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