Medial Epicondyle Tendinopathy
Original Editors - Anouk Toye
- 1 Definition/Description
- 2 Clinically Relevant Anatomy
- 3 Epidemiology /Etiology
- 4 Characteristics/Clinical Presentation
- 5 Differential Diagnosis
- 6 Diagnostic Procedures
- 7 Outcome Measures
- 8 Examination
- 9 Medical Management
- 10 Physical Therapy Management
- 11 Key Research
- 12 Resources
- 13 Clinical Bottom Line
- 14 References
Medial epicondylitis or ‘golfer’s elbow’ is mostly a tendinous overload injury leading to microtearing. Thereby tendon degeneration appears instead of repair.  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.
Clinically Relevant Anatomy
Osteology: Medial epicondyle of the Humerus
Musculature: Wrist Flexor Group
Moving radially to ulnarly the muscles are:
|M. pronator teres||
||middle of the facies lateralis and dorsalis radii||A. recurrens ulnaris||N. medianus||
|M. flexor carpi radialis||fascia antebrachii of the epicondylus medialis humeri||base of the ossis metacarpalis 2||A. radialis||N. medianus||
|M. palmaris longus||fascia antebrachii of the epicondylus medialis humeri||aponeurosis palmaris||A. recurrens ulnaris||N. medianus||
|M. flexor digitorum superficialis||
||palmar side of the phalanges mediales of the 2nd to 5th finger||
|M. flexor carpi ulnaris||
A. recurrens ulnaris
All these muscles have the same origin: the medial epicondyle of the humerus. Most frequently the pathology occurs in the musculotendinous origin of the flexor carpi radialis and pronator teres. But large diffuse tears can also occur in the palmaris longus, flexor digitorum superficialis and flexor carpi ulnaris.
Medial epicondylitis has a lower incidence than lateral epicondylitis (tennis elbow), with the former containing only 9 to 20% of all epicondylitis diagnoses.  The ‘golfer’s elbow’ and ‘pitcher’s elbow’  are synonyms. The pathology occurs in baseball pitchers as a result of high-energy valgus forces created by the overhead throw. It has also been reported with tennis, bowling, archery, weightlifting, javelin throwing, racquetball and american football.  However 90 to 95% of all cases do not involve sportsmen  . Because chronic repetitive concentric or eccentric contractile loading of the wrist flexors and pronator are the most common etiology, occupations such as carpentry, plumbing and meat cutting have also been implicated. The pathology may also be produced by sudden violence to these tendons in a single traumatic event.  In many cases trauma at work had been identified as the cause of the symptoms .
More specific occupational physical factors associated with medial epicondylitis are forceful activities among men and with repetitive movements of the arm among women.
Current smokers and former smokers are also associated with medial epicondylitis, so do patients who suffer from diabetes type 2 .
Although epicondylitis means there is an inflammation, there is some controversy with this pathology. The pathologic process does not involve bony inflammation.  Histologically it has been shown that medial epicondylitis is the result of microtearing in the tendon that isn’t fully relapsed (=To fall or slide back into a former state). Some physical therapists prefer the term tendonosis instead of epicondylitis.  Another terminology for this condition is epicondylalgia, referring to pain rather than inflammation. 
Most of the time, golfer's elbow is not caused by inflammation. Rather, it is a problem within the cells of the tendon. In tendonosis, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibers and fiber separation by increased mucoid ground substance. There can also be an increased prominence of cells and vascular spaces and focal necrosis or calcification.  When this happens, the collagen loses its strength. It becomes fragile and can break or be easily injured. Each time the collagen breaks down, the body responds by forming scar tissue in the tendon. Eventually, the tendon becomes thickened from extra scar tissue.  The tendon changes from a white, glistening and firm surface to a dull-apearing, slightly brown and soft surface. 
As medial epicondylitis is a tendonosis of the flexor group tendons attached to the medial epicondyle of the humerus, the most sensitive region will be located near the origin of the wrist flexor group.
The patient usually complains about pain of the elbow distal to the medial epicondyle of the humerus with radiation up and down the arm, most common on the ulnar side of the forearm, the wrist and occasionally in the fingers  .
Local tenderness over the medial epicondyle and the conjoined tendon of the flexor group, without evidence of swelling or erythema, are also characteristics that can occur. Other symptoms are stiffness of the elbow, weakness in the hand and the wrist and a numb or tingling feeling in the fingers (mostly ring and little finger). 
The pain is evoked by resisted flexion of the wrist and by pronation. The pain is usually accompanied by a weakness of hand grip. Pain can begin suddenly or can develop gradually over time. 
|C6 and C7 radiculopathy||Neurological examination of muscle strength, sensory loss and reflexes|
|A compression neuropathy of the ulnar and the median nerve||
|Ulnar/medial collateral ligament instability||valgus stress test|
|Ulnar neuritis (Cubital Tunnel Syndrome II)||
|Ulnar/medial collateral ligament sprain||Moving valgus stress test|
|Anterior interosseous nerve entrapment||Upper Limb Tension Test 1|
|Medial epicondyle avulsion||Magnetic resonance imaging|
|Synovitis||Color or Power Doppler Ultrasound|
|Tardy ulnar nerve palsy||
|Valgus extension overload||
As epicondylitis is essentially a musculotendinous condition, diagnosis is essentially clinical.
Radiographs are typically negative unless the chronicity of the condition had allowed periostitis to develop on the affected epicondyle .
The diagnosis of medial epicondylitis is based on local pain at the elbow, tenderness and pain with palpation distal and anterior of the medial epicondyle. An increase in pain at the medial epicondyle with resisted isometric flexion, repetitive flexion and pronation of the wrist can also be examined.  
In particular the Golfer’s Elbow Test, an orthopedic test, is described as being helpful to diagnose medial epicondylitis .
- DASH (Disabilities of the Arm, Shoulder and Hand)  is a questionnaire with 30 items to rate the ability, of a person with an upper extremity disorder, to perform daily life activities. The short version of this test is called the QuickDash questionnaire, with only 11 items.
- Maximal grip strength and force sense can be measured with a hand dynamometer. 
- The strain index evaluates the risk of developing a distal upper extremity disorder. 
- The Upper Extremity Functional Index (UEFI) is an 8-item questionnaire used to determine the impact of upper extremity disorders on function. 
- Tenderness to palpation (usually over m. pronator teres and m. flexor carpi radialis)
- Local swelling and warmth
- Medial epicondylitis test 
- It includes a passive and an active test to determine medial epicondylitis. In severe cases of epicondylitis, the patient will complain of pain when he simply shakes hands or pulls an open door. For the active resistance test, the patient should resist wrist flexion. This must be carried out with elbow extended while fully supinating the forearm. For the passive test, the therapist extends the wrist with the elbow extended.
- 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 
- An evaluation of the entire upper extremity kinetic chain can be needed. A particular focus goes to the shoulder and the scapular strength, motion and stabilization. Overuse injuries in the elbow often occur with shoulder or scapular dysfunction 
Surgical treatment of medial epicondylitis
When conservative management fails and there is persistent pain after 6 to 12 months and all other pathologies are considered, surgical treatment must be considered.
Surgery for failure of conservative treatment relieves pain, restored strength and allows a return to the previous level of daily living and sports activity. 
Mini-open muscle resection procedure under local anesthesia
For medial epicondylitis the degenerative tissue at the origin of the flexor carpi radialis brevis is removed during a mini-open muscle resection procedure.
This procedure produces low levels of postoperative pain, a short hospital stay and rehabilitation period and early return to daily activities.
The limitations of and open flexor carpi radialis brevis release include late return to work and sporting activities due to a prolongation of the postoperative recovery time, a risk of posterolateral instability, and the formation of neuroma after surgery. 
Fascial elevation and tendon origin resection (FETOR)
Fascial elevation and tendon origin resection facilitates the complete visualization and resection of the CFPO (Chronic Flexor Palmar Origin) with limited soft tissue dissection.
FETOR decreases the average pain, pain at rest, and pain during hard work or heavy lifting. There is also an improvement of the mean pain-free grip strength. 
The indication for injection therapy for epicondylitis is usually chronic pain and disability not relieved by more conservative means, or severe acute pain with functional impairment that calls for a more rapid intervention.
These injections seem to have a short term effect (2-6 weeks) and effective in providing early symptom relief .
Autologous blood injection
The combined treatment of dry needling and ultrasound guided autologous blood injection is described as an effective way to treat patients with refractory lateral and medial epicondylitis. There was a significant decrease in the VAS pain scores. The hypothesis of the mechanism is that the transforming growth factor-β and basic fibroblast growth factor carried in the blood act as humoral mediators to induce the healing cascade. 
Extracorporeal shock wave therapy
Extracorporeal shock wave therapy is effective for the patients with newly diagnosed as lateral or medial epicondylitis. This can be another option when local steroid injection is contraindicated in the treatment of the patient .The pressure-focused pulses may cause tissue regeneration at the specific site. This method can also be used when there is presence of recalcitrant chronic epicondylitis 
Physical Therapy Management
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. Although not yet conclusive, is the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in Medial epicondylitis. 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.
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 .
Hoogvliet, P. ,Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review, (Ann Rehabil Med. 2012 Oct).., geraadpleegd op 2 mei 2014, http://www.ncbi.nlm.nih.gov/pubmed/23709519
Sandra J. Shultz, Peggy A. Houglum, David H. Perrin. Examination of musculoskeletal injuries. USA, Human Kinetics, 2000, p295.
Clinical Bottom Line
Epicondylitis medialis is a tendinosis of the common tendon insertion from the flexors of the wrist. Most of the time it’s caused by making too much use of the flexors of the wrist, but in some cases it can also emerge spontaneously. Some examples of activities that may hold many risks are playing tennis, cleaning, painting, washing windows,…
The treatment of epicondylitis medialis exists first of all of enough rest together with local application of ice and in some cases the giving of anti-inflammatory medication and stretching. In case of a serious form of epicondylitis medialis, some injections of cortisone can be given (maximum three injections). If all these treatments won’t help, an operation will be inevitable.
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