Medial Epicondylitis

Description

Medial Epicondylitis is the most common cause of medial elbow pain(1). It is an overuse injury of the flexor pronator mass (see Figure 1) at the anterior medial epicondyle. The flexor pronator mass includes the Pronator teres, Flexi carpi radialis, flexor digitorum superficialis, Palmaris Longus and flexor carpi ulnaris. (2)

Figure 1 – Medial Elbow Anatomy

 

 

(Image: http://www.gms-books.de/book/living-textbook-hand-surgery/chapter/ulnar-nerve-compression)

 

 

 

 

 

 

 

Injury Mechanism

Repetitive microtrauma at the insertion site of the flexor pronator mass leads to:

Peritendinous inflamation, angiofibroplastic hyperplasia and finally fibrosis/calcification.(2)

This type of injury is often seen in people who repetitively flex their wrist and pronate their forearm. For example, golfers, pitchers, racquet sports (tennis) and plumbers.(3)

Differential Diagnosis

– Ulnar colateral ligament insufficiency

-Myofascial pain

– Cervical radiculopathy

– Ulnar neuritis

– Osteoarthritis

– Rheumatoid arthritis

– Snapping triceps tendon

History

Patients will often have insidious onset pain over the medial aspect of the elbow with or without a change in sensation in their ulnar digits. Patients will often have history of repetitive elbow use, valgus stress or gripping. (2)

Physical Exam

Localized tenderness at the medial epicondyle with possible soft tissue swelling.

Tenderness at the proximal wrist flexor mass (See figure 1)

Pain with resisted wrist flexion with the elbow extended

Pain with passive terminal wrist extension with the elbow extended

Pain with resisted forearm pronation (4)

Anatomy of the elbow Figure 2 Muscular, Figure 3 ligamentous (UCL on left, and Radial collateral ligaments on right)

It is also important to examine for associated conditions such as ulnar collateral ligament insufficiency (often seen in overhead throwing athletes) and ulnar neuropathy. This is done via valgus stress, the moving valgus stress test, Tinel’s test and assessing hypothenar bulk. (2)

Investigations

Radiographs/Xrays are often not needed for initial treatment, however in treatment resistant cases they can be obtained. Findings can often be unremarkable, but they can help identify osteoarthritis (osteophytes, degenerative changes) and calcifications of tendons and/or ligaments.(4)

Figure 2 – Labelled radiograph of elbow

 

 

 

 

 

 

 

Ultrasound can be used for dynamic  examination while also being non-invasive. It can help identify tendon thickening, tears and calcification.(3)

Indications for MRI include an unclear source of medial elbow pain, evaluation of associated pathology (Ex. Ulnar Collateral Ligament injury), looking for loose bodies and ruling out a rupture of the flexor pronator origin. Findings include tendinosis, tendon disruption of the common flexor tendon and Ulnar collateral ligament or osteochondral injuries. (2)

Nerve conduction studies can also be done to evaluate for ulnar nerve compression.

Management 

First line treatment involves conservative measures. This includes; rest, ice, activity modification for 6-12 weeks (in athletes, this includes correcting poor mechanics), counter force bracing , nonsteroidal antiinflammatory drugs (topical and oral) and passive range of motion exercises with light eccentric strengthening.(4)

In patients who do not improve after initial treatment, the appropriate imaging should be obtained along with a trial of other modalities. These include glucocorticoid injections, acupuncture, shockwave therapy and platelet rich plasma injections. (4)

Although evidence is lacking specifically for medial epicondylitis transdermal nitroglycerin has also been used as an adjunct treatment.

Operative treatment is reserved for patients who have been compliant for six months or greater with non-operative treatment OR in patients with severe symptoms which are greatly impacting their life. Operative treatment involves open debridement of the pronator teres/flexor carpi radialis and reattachment of the flexor-pronator group.(2)

Return to Sport

Returning to sport can vary depending on the athlete and the severity of the injury. Generally, patients can return to their sport as long as the aggravating activities can be avoided, this can involve playing in a modified fashion. It is also important to correct poor mechanics as that can lead to exacerbation of pain. (4)

Author:  Jaspreet Ubhi (July 24, 2017 PR ND)

References

  1. http://emedicine.medscape.com/article/327860-overview#showall
  2. http://www.orthobullets.com/sports/3083/medial-epicondylitis-golfers-elbow?expandLeftMenu=true
  3. Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management.  J Am Acad Orthop Surg. 2015 Jun;23(6):348-55. doi: 10.5435/JAAOS-D-14-00145.
  4. https://www.uptodate.com/contents/epicondylitis-tennis-and-golf-elbow?source=search_result&search=medial%20epicondylitis%20evaluation%20andmanagement&selectedTitle=3~9