Introduction & Etiology
The medial epicondyle is home to the flexor-pronator group of muscles, which includes the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris. (1) In addition to their stated mission, the flexor-pronators serve as a secondary stabilizer to the ulnar collateral ligament and medial elbow. (2)
Repetitive flexion and pronation create a strain on the common flexor origin, resulting in irritation. Recurring valgus stress is thought to be another principal trigger for medial epicondyle pain. (1,3,4) Injuries to the common flexor origin may occur abruptly as a result of a trauma, excessive stretch, or eccentric overload, but the majority of medial elbow problems can be blamed on chronic, degenerative “tendinopathies,” rather than any acute inflammatory response (tendonitis). (6-8) Tendinopathies begin from repetitive overloading & micro-tearing and culminate with a disorganized healing process that fails to regenerate a “normal” tendon. The origin of the pronator teres and flexor carpi radialis muscles on the medial supracondylar ridge is the most common site of pathology. (1,6,9,10)
Medial epicondylopathy is the most frequent cause of medial elbow pain but is 3-10 times less common than lateral epicondylopathy. (2,12-15) It is most prevalent in the fourth and fifth decades and affects men and women fairly equally. (6,12) The condition strikes the dominant arm in 75% – 82% of cases. (6,16-18)
Although the condition is named “golfer’s elbow,” one study found that 90- 95% of those affected were not even athletes, much less golfers. (13) Nonetheless, the condition is more common in certain populations, particularly those participating in sports that require repetitive flexion/pronation or exposure to valgus stress, such as golf and throwing. (19) Golfers are most vulnerable from the top of their backswing until ball impact. (19) Similarly, in baseball players, the medial elbow is at the highest risk during the acceleration phase of throwing. (19,20) The condition is common in racquet sports, particularly those who hit with heavy topspin. (16,21) Bowling, javelin throwing, football, archery, and weight lifting are potential triggers. (6,21,22) Occupations that require repetitive flexion and pronation, like carpentry, predispose patients to medial epicondylopathy. (6)
Several factors may increase an athlete’s risk of medial epicondylopathy, including inadequate warm-up, poor conditioning, weakness, inflexibility, and improper technique. (21) An improperly sized racquet grip excessively tightened racquet strings and using old or wet tennis balls increase elbow stress. (21) Smoking, obesity, and Type II diabetes are additional known risk factors. (12,55)
Symptoms include an insidious onset, “dull aching” pain over the medial elbow that becomes more acute with use. (23) Patients with more significant irritation may complain of grip weakness and notice limitations in activities of daily living, like shaking hands, grasping objects, and opening jars. (24) Patients may notice local swelling. (25)
The peak area of tenderness is generally less than one fingerbreadth distal and anterior to the center of the medial epicondyle. (23) Reproduction of the chief complaint upon resisted forearm pronation is the most sensitive clinical finding for medial epicondylopathy. (26) Resisted wrist flexion will likely provoke discomfort. (26,27) In cases of chronic epicondylopathy, resisted elbow flexion may induce symptoms. (27) Initially, the active range of motion should be relatively full. Throwing athletes with chronic medial epicondylopathy may develop a flexion contracture that limits extension. (28,29) Up to 50% of professional baseball pitchers have a flexion contracture. (30)
The Golfer’s elbow test may assist with diagnosis. The test is performed on a seated patient with their palms resting on their knees. The clinician grasps the patient’s hand and elbow and simultaneously supinates the hand while extending the wrist and elbow. Reproduction of pain suggests medial epicondyle involvement.
Alternate diagnoses commonly co-exist with medial epicondylopathy. Clinical evaluation should specifically seek to identify: ulnar neuritis, cubital tunnel syndrome, and ulnar collateral ligament instability. Cubital tunnel syndrome is present in up to 20% of patients with medial epicondylopathy. (16) Cubital tunnel patients frequently report paresthesia or pain extending distally from the medial epicondyle to the fourth or fifth digit. Nocturnal symptoms are common in cubital tunnel syndrome. Tenderness over the ulnar nerve or a positive Tinel sign would suggest ulnar nerve involvement (i.e. cubital tunnel syndrome).
The “Moving valgus stress test” is an accurate examination for the diagnosis of medial (ulnar) collateral ligament instability. (31) The test is performed on a seated patient with the shoulder abducted to 90 degrees and elbow maximally flexed. The clinician stabilizes the patient’s elbow with one hand, then grasps the patient’s wrist and maximally externally rotates the arm to apply a valgus stress to the elbow. After slack is removed, the clinician smoothly extends the patient’s elbow to approximately 30 degrees, assessing for reproduction of pain or instability. Pain over the medial collateral ligament, between 120 and 70 degrees of elbow flexion, or any perception of laxity suggests medial collateral ligament involvement. Evaluation for UCL stability is particularly important in throwers, as UCL deficiency is more common than medial epicondylopathy in this population. (27)
Diagnostics & Differential
Plain film radiography is often unnecessary for the diagnosis of medial epicondylopathy. (21) Radiographs may be required in cases of trauma and in those patients who are unresponsive to a trial of therapy. Radiographs are warranted in adolescents complaining of medial epicondyle pain, in order to rule out avulsion fracture. In children and adolescents, the open epiphyseal growth plate is two to five times weaker than in adults, where the growth plate is closed. This means that children are more likely to suffer apophyseal injuries (i.e. “Little League Elbow”) from stressors that would likely cause tendinopathies in adults. (32) Twenty to thirty percent of patients complaining of medial epicondyle pain will demonstrate radiographic evidence of calcification adjacent to the medial epicondyle, consistent with calcific tendinitis (hydroxyapatite deposition disorder). (21) Advanced imaging may be necessary to further define the diagnosis. Bone scanning can help spot: stress fractures, infections, and tumors. MRI can demonstrate ligamentous injury and osteochondritis dissecans. MRI arthrography may be more appropriate to identify ruptures of the medial collateral ligament. Diagnostic ultrasonography is a useful imaging tool for medial epicondylopathy. (33)
In addition to cubital tunnel syndrome, medial collateral ligament instability, and traction apophysitis (Little League Elbow), the differential diagnosis for medial epicondyle pain includes: muscle strain, cervical radiculopathy, fracture, infection, neoplasm, bursitis, flexion contracture, pronator quadratus syndrome, intra-articular injury, osteochondritis dissecans, anterior interosseous nerve entrapment, and rheumatologic disease.
Medial epicondylopathy can prove to be a defiant condition. Between 5 and 26% of patients experience recurrent episodes, and 40% suffer prolonged discomfort. Almost twenty-five percent of unmanaged patients will continue to experience symptoms for over one year. (34) Nineteen percent of patients continue to experience symptoms after three years. (14,35) Conservative, non-surgical management is the most appropriate treatment for medial epicondylopathy. (6) Conservative care of chronic tendinopathy has proven to be as effective as surgery for long-term pain relief, ROM, function, tendon force, and quality of life. (63)
Selective rest, ice, and NSAIDs may help alleviate acute inflammation, but do little to alter the long-term course of chronic tendinopathy. A more comprehensive management approach for chronic complaints adds bracing eccentric rehabilitation, and activity modification. Athletes may need to limit or temporarily discontinue offensive activities. Applying ice or ice massage may help alleviate acute pain. Modalities including e-stim, ultrasound, and laser, have varying levels of support and may be useful to help control symptoms. (56) Clinicians should consider the use of a counter-force brace to dampen flexion/pronation forces to the medial epicondyle. (21,36) Counter-force braces should not be used in cases of concurrent cubital tunnel syndrome, as the additional pressure will likely exacerbate compressive neuropathy symptoms. Cock-up wrist splints may be useful at night to allow the tendon to “heal” in a neutral or lengthened position. (21,37)
Soft tissue manipulation, stretching, and myofascial release techniques are necessary to promote flexibility of the forearm muscles. (6) Clinicians should consider the use of IASTM to release adhesions within the common flexor tendon. As an additional benefit, IASTM may facilitate a healing response by inducing controlled microtrauma. (38) Maintaining range of motion and addressing flexion contractures is particularly important in throwing athletes. Mobilization or oscillatory manipulation may help restore full extension in cases of flexion contracture. (39) The benefit of cervical spine manipulation has been established for patients with elbow pain. (40) Cervical manipulation leads to immediate increases in voluntary activation of the elbow flexors and facilitation of motor cortical output. (62) Clinicians should address restrictions at the elbow, wrist, and shoulder, as well.
The goal of tendinopathy rehab is to carefully balance stimulating a controlled musculotendinous inflammatory response without causing greater injury or exacerbating symptoms. Rehab should begin with moderate effort and low repetitions. Response to tensile loading may be assessed by the patient’s change in night pain. Increases in night pain indicate the current rehab load is excessive. Progression advances when the patient tolerates a given level of tensile load. (61)
Like other tendinopathies, eccentric strengthening of the wrist flexors and forearm pronators is believed to be a critical component of treatment. (3,41,57) The “Tyler Twist” exercise, utilizing a Theraband Flexbar, is a novel approach to eccentric strengthening that has shown significant pain reduction and excellent outcomes in limited trials for lateral epicondylopathy. (58,59) The “Reverse Tyler Twist” exercise was created for the treatment of medial epicondylopathy. (58,59)
NSAIDS may provide some temporary analgesic benefit, but since medial epicondylopathy is not a true inflammatory condition, their usefulness is limited. Likewise, corticosteroid injections have demonstrated short-term improvement with little long-term effect. (42,43)
The benefit of utilizing autologous blood injections, PRP injections, and Extracorporeal Shock-Wave Therapy (ESWT) for the treatment of medial epicondylopathy, has not been examined closely, but mixed data supports their use for lateral epicondylopathy. (44-52,60). The addition of dry needling to autologous blood injection has proven beneficial in recalcitrant cases of medial epicondylopathy. (52) Nitroglycerin patches applied over the damaged tendon are thought to stimulate collagen production and vasodilation and have shown benefit in the treatment of elbow tendinopathies. (53)
Surgical intervention should be considered for chronic tendinopathy cases that are unresponsive after three to 6-12 months of care. (54,63) Various surgical techniques exist to release the flexor origin and excise pathologic tissue. Good surgical outcomes have been demonstrated in greater than 80% of recalcitrant cases. (21)
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