Medial Epicondyle Tendinopathy

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Original Editors - Anouk Toye

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Search Strategy

Websites:
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Keywords:
- Medial epicondylitis
- Golfer’s elbow
- Elbow injuries

- Physical therapy
- Treatment
- Diagnosis

Each time I’ve combine one of the first three words with one of the last three words.

Definition/Description

Epicondylitis is a painful inflammation or tenderness of the muscles and soft tissues around an epicondyle.

Medial epicondylitis is mostly an overload injury. The most sensitive region is located near the origin of the wrist flexors on the medial epicondyle of the humerus. Sometimes the patient also experiences pain on the ulnar side of the forearm, the wrist and occasionally in the fingers. Although epicondylitis means there is an inflammation, there is some controversy with this pathology. Histologically it has been shown that medial epicondylitis is the result of microtearing in the tendon that isn’t fully relapsed. Some physical therapists prefer the term tendonosis instead of epicondylitis.

Clinically Relevant Anatomy

Osteology:
- Medial epicondyle of the Humerus

Musculature: Wrist Flexor Group
- M. pronator teres
- M. flexor carpi radialis
- M. palmaris longus
- M. flexor digitorum superficialis
- M. flexor carpi ulnaris

All these muscles have the same origin: the medial epicondyle.

Epidemiology /Etiology

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Characteristics/Clinical Presentation

Patients often denote pain in the area just distal to the medial epicondyle of the humerus. As said previously the most sensitive region is located near the origin of the wrist flexor group. Sometimes the patient complains about pain on the ulnar side of the forearm, the wrist and occasionally in the fingers.

In the beginning epicondylitis may show inflammation or some synovitic characteristics. Later on it shows evidence of microtearing.

Differential Diagnosis

When diagnosing a medial epicondylitis, the therapist always has to consider other pathologies such as[1]:

- a compression neuropathy of the ulnar and the median nerve
- ulnar collateral ligament instability
- ulnar neuritis
- Obsessive compulsive disorder (OCD)
- Medial collateral ligament sprain
- Capsulitis
- Radiculopathy
- Osteoarthritis
- Flexor-pronator strain

Diagnostic Procedures

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Outcome Measures

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Examination

- Tenderness to palpation (usually over m. pronator teres and m. flexor carpi radialis)
- Local swelling and warmth
- Range of motion in the beginning of the disease can be full, but later on there is a possibility of a decreased range of motion[2]

Medical Management

If a patient doesn’t respond to the conservative treatment there is a possibility to a surgical treatment. Before starting a surgical treatment the conservative treatment had to be followed for 3 to 6 months and all other pathologies need to have been considered. Sometimes it’s recommended to do the surgical treatment earlier but that’s mostly with athletes with a diagnosis of a tendon disruption. [2]

Physical Therapy Management

Nonsurgical treatment
The main goal of the conservative treatment is to obtain pain relieve and an inflammation reduce. These two things will help to achieve a proper rehabilitation and later a return to activities.

Nonsurgical treatment can be divided into three phases.

- Phase 1: The patient immediately has to stop the offending activities. It’s not recommended to stop all activities or sports since that can cause atrophy of the muscles.
The therapy starts with ‘PRICEMM’, which stands for ‘prevention/protection, rest, ice, compression, elevation, modalities and medication. The affected elbow should be iced several times a day for about a quarter. This improves the local vasoconstrictive and analgesic effects. As for medication the patient can take nonsteroidal anti-inflammatory medication (NSAID).
If the patient’s condition doesn’t improve, a period of night splinting is adequate. This is usually accompanied with a local corticosteroid injection around the origin of the wrist flexor group. Some examples of a physical therapy modality are ultrasound and high-voltage galvanic stimulation (but there’s not yet a study that notes their efficacy).
Counterforce bracing is recommended for athletes with symptoms of medial epicondylitis. It can also aid when the patient is returning to sport.

- Phase 2: As soon as we see an improvement of phase 1, a well guided rehabilitation can be started. The first goal of the second phase is to establish full, painless, wrist and elbow range of motion. This is soon followed by stretching and progressive isometric exercises. These exercises first should be done with a flexed elbow to minimize the pain. As soon as the patient has made some progress the flexion of the elbow can be decreased. As the flexibility and the strength of the elbow area return, concentric and eccentric resistive exercises are added to the rehabilitation program. The final part of this phase is a simulation of sport or occupation of the patient.

- Phase 3: When the patient is able to return to his sport it is necessary to take a look at his equipment and/or technique. These precautions ought to be taken to allow a safe return to activities[2]

Postoperative management
7 to 10 days after the operation, the splint and skin sutures are removed. At this point the physical therapy can start. The beginning of the treatment is characterized by gentle passive and active hand, wrist and elbow exercises. 3 to 4 weeks later gentle isometrics can be done and at 6 weeks the patient can start with more resistive exercises. At last a progressive strengthening program has to be followed. In normal cases the patient can return to activities 3 to 6 months after the operation.[2]

Key Research

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Resources

[1] Richard B. Birrer, Francis G. O’Conner, Sports medicine for the primary care physician, 3th Edition, 2004, CRC Press LLC, Boca Raton, Florida

[2]Michael C. Ciccotti , MA, RA, Michael A. Schwartz, MD, Michael G. Ciccotti, MD. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med 23 (2004) 693-705

[3]Walter R. Frontera, Julie K. Silver, Thomas D. Rizzo, Jr. Essentials of physical medicine and rehabilitation; musculoskeletal disorders, pain, and rehabilitation, 2nd edition, 2008, by Saunders , an imprint of Elsevier Inc.

[4] R. Putz , R. Pabs, Sobotta atlas of human anatomy, 3th Edition, 2006, Bohn Stafleu van Loghum, Houten, p180

Clinical Bottom Line

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References

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