Medial Epicondyle Tendinopathy
Original Editors - Anouk Toye
Medial epicondylopathy or ‘golfer’s elbow’ is mostly a tendinous overload injury leading to tendinopathy.Flexor-pronator tendon degeneration occurs with repetitive forced wrist extension and forearm supination during activities involving wrist flexion and forearm pronation 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 epicondylar tendinopathy has a lower incidence than lateral epicondylopathy (tennis elbow), with the former containing only 9 to 20% of all epicondylopathy diagnoses.  The ‘golfer’s elbow’ and ‘pitcher’s elbow’  are synonyms. A staged process of pathologic change in the tendon can result in structural breakdown and irreparable fibrosis or calcification. Patients typically report persistent medial-sided elbow pain that is exacerbated by daily activities. Athletes may be particularly symptomatic during the late cocking or early acceleration phases of the throwing motion, 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 aetiology, 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 epicondylopathy are forceful activities among men and with repetitive movements of the arm among women. Current smokers and former smokers are also associated with medial epicondylopathy, 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 tendinopathy is the result of micro-tearing in the tendon that isn’t fully relapsed (=To fall or slide back into a former state). more recently the term tendinopathy instead of tendinitis.  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 tendinopathy, wear and tear is thought to lead to tissue degeneration. A degenerated tendon usually has an abnormal arrangement of collagen fibres and fibre 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 appearing, slightly brown and soft surface. 
As medial epicondylopathy 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 epicondylopathy 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 epicondylopathy 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.  
- 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 pronator teres and flexor carpi radialis)
- Local swelling and warmth
- Medial epicondylopathy test 
- It includes a passive and an active test to determine medial epicondylopathy. In severe cases of epicondylopathy, 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 stabilisation. Overuse injuries in the elbow often occur with shoulder or scapular dysfunction 
Mini-open muscle resection procedure under local anesthesia:
For medial epicondylopathy 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 epicondylopathy 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 .The injection must be in the proper location for maximal benefit to the patient.
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 epicondylopathy. 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 epicondylopathy. 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 epicondylopathy 
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.
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 epicondylopathy. It can also aid when the patient is returning to sport.
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 epicondylopathy. 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. There is an evidence that supports the usage of Muscle Energy Techniques (METs) to improve ROM .METs are (relatively pain-free techniques) that could be used in clinical practice for restricted range of motion (ROM).
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 .
A systematic review done by(Hoogvliet et al., 2013)Showed that, a moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and mid-term effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found.
- Tendon Anatomy
- Tendinopathy Treatment Adjuncts
- Tendon Biomechanics
- Tendon Pathophysiology
- Tendon Physiology
- Tendinopathy Rehabilitation
- Tendinopathy Exercises
- Amin NH, Kumar NS, Schickendantz MS. Medial epicondylitis: evaluation and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2015 Jun 1;23(6):348-55.
- Lee AT. The Prevalence of Medial Epicondylitis Among Patients With C6 and C7 Radiculopathy. Orthopaedic surgery. 2010 august.
- MARKSCHICKENDANTZ M. 28 Medial: Flexor-Pronator Tendon Injury. Shoulder and Elbow Injuries in Athletes: Prevention, Treatment and Return to Sport. 2017 Oct 17:461.
- R. Putz RP. Sobotta atlas of human anatomy. 3rd ed.; 2006.
- The Mcgraw-Hill Companies, geraadpleegd op 4 mei, http://www.rci.rutgers.edu/~uzwiak/AnatPhys/APFallLect15_files/image023.jpg
- Ciccotti MG. Medial epicondylitis. Techniques in Hand and Upper Extremity Surgery, 7(4):190–196. 2003.
- Shiri R. et al. Prevalence and determinants of the lateral and medial epicondylitis: a population study. American journal of epidemiology, vol. 164 n° 11, pag 1065 – 1074. 2006 September.
- Polkinghorn BS. A novel method for assessing elbow pain resulting from epicondylitis. Journal of chiropractic medicine, vol. 1 n° 3, pag. 117 – 121. 2002.
- Schipper ON et al. Nirschl Surgical Technique for Concomitant Lateral and Medial Elbow Tendinosis: A Retrospective Review of 53 Elbows With a Mean Follow-up of 11.7 Years. The American Journal of Sports Medicine 39: 972. 2011.
- Birrer RB. Sports medicine for the primary care physician. 3rd ed. Florida: CRC Press LLC; 2004.
- KM K. Overuse tendinosis, not tendinitis—Part 1: A new paradigm for a difficult clinical problem. Physician Sportsmed. 2000.
- methodistorthopedics. [Online]. Available from: http://www.methodistorthopedics.com/medial-epicondylitis-golfers-elbow.
- L M. Medial epicondylitis. vol. 91 n° 1, pag.23. 1959 July.
- Mayo clinic, symptoms. [Online]. [cited 2015 april. Available from: http://www.mayoclinic.org/diseases-conditions/golfers-elbow/basics/symptoms/con-20027964
- Frontera WR. Essentials of physical medicine and rehabilitation; musculoskeletal disorders, pain, and rehabilitation. 2nd ed.: Saunders; 2008.
- Dlabach JA. et al. LATERAL AND MEDIAL EPICONDYLITIS IN THE OVERHEAD ATHLETE. Operative Techniques in Orthopaedics, Vol 11, N° 1, pp 46-54. 2001 January. (level of evidence 3A)
- Phillips BB. et al. Arthroscopic Treatment of Arthrofibrosis of the Elbow Joint. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 1 : pp 38–44. 1998 January-February. (level of evidence 4)
- Konin GP. et al. US of the Elbow: Indications, Technique, Normal Anatomy, and Pathologic Conditions. RadioGraphics ; 33:E125–E147. 2013. (level of evidence 3A)
- Miller MD et al. Presentation, Imaging and Treatment of Common Musculoskeletal Conditions: MRI-ARTHROSCOPY CORRELATION chapter 35, p144-p145; 2012. (level of evidence 5)
- Cardone DA. Diagnostic and therapeutic injection of the elbow region. American family physician, vol. 66 n° 11, pag. 2097 – 2100. 2002 December.
- Shahid M. et al. Operative treatment improves patient function in recalcitrant medial epicondylitis. Ann R Coll Surg Engl ; 95: 486–488. 2013.
- Chang HY et al. The Effectiveness of Kinesio Taping for Athletes with Medial Elbow Epicondylar Tendinopathy. Int J Sports Med ; 34:1003–1006. 2013.
- Fan JZ et al. Predicting Work-Related Incidence of Lateral and Medial Epicondylitis Using the Strain Index. AMERICAN JOURNAL OF INDUSTRIAL MEDICINE, 57:1319–1330. 2014.
- Pransky G. et.al Measuring Functional Outcomes in Work-Related Upper Extremity Disorders: Development and Validation of the Upper Extremity Function Scale. Journal of Occupational & Environmental Medicine: Volume 39 - Issue 12 - pp 1195-1. 1997 December.
- Shultz SJ. Examination of musculoskeletal injuries.. USA, Human Kinetics, p295. 2000.
- Ciccotti MC. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004.
- Todd S. Ellenbecker RNPR. Current Concepts in Examination and Treatment of Elbow Tendon Injury. Sports Health; 5(2): 186–194. 2013 March.
- Cho BK et al. Mini-open muscle resection procedure under local anesthesia for lateral and medial epicondylitis. Clinics in orthopedic surgery, vol. 1 n° 3, pag. 123 – 127. 2009.
- Kwon B. The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis. [Online].; 2014 [cited 2014 May 2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24758782.
- Waryasz GR, Tambone R, Borenstein TR, Gil JA, DaSilva M. Review of anatomical placement of corticosteroid injections for uncommon hand, wrist, and elbow pathologies. Rhode Island Medical Journal. 2017 Mar 1;100(3):31.
- Suresh SPS. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment? biomedical journal of sports medicine, pag. 935 – 939. 2006 september.
- Suresh SP, Ali KE, Jones H, Connell DA. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment?. British journal of sports medicine. 2006 Nov 1;40(11):935-9.
- Sang Seok L. et al. Effectiveness of Initial Extracorporeal Shock Wave Therapy on the Newly Diagnosed Lateral or Medial Epicondylitis.Ann Rehabil Med 2012; 36(5): 681-687.
- Kertzman P. LM,PA,EB. Shockwave treatment for musculoskeletal diseases and bone consolidation: qualitative analysis of the littératur. rev bras ortop.;50(1):3–8. 2015.
- Vellilappily DV, Rai HR, Varghese J, Renjith V. COUNTERFORCE ORTHOSIS IN THE MANAGEMENT OF LATERAL EPICONDYLITIS. Journal of Ayub Medical College Abbottabad. 2017 Apr 8;29(2):328-34.
- Hoogvliet, P. (2013). 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
- Faqih AI, Bedekar N, Shyam A, Sancheti P. Effects of muscle energy technique on pain, range of motion and function in patients with post-surgical elbow stiffness: A randomized controlled trial. Hong Kong Physiotherapy Journal. 2019 Jun 11;39(01):25-33.
- 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
- Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Br J Sports Med. 2013 Nov 1;47(17):1112-9.