Medial Epicondylitis (or as it called Golfer’s Elbow) involves a tendinopathy of the common flexor origin, specifically the flexor carpi radialis muscle and the humeral head of the pronator teres.

To a lesser extent, the palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis may also be involved.

Medial epicondylitis is only one-third as common as lateral epicondylitis.

It effects the dominant extremity in 75% of cases.

Medial Epicondylitis is more common in golfers, baseball pitchers, javelin throwers, bowlers, weight lifters, racquet sports.

See Also: Lateral Epicondylitis (Tennis Elbow)

Related Anatomy

Common flexor tendon (CFT):

  • 3 cm long.
  • attaches to medial epicondyle (anterior aspect), anterior bundle of MCL
  • Its fibers run parallel to MCL.

Flexor-pronator mass includes:

  • Pronator Teres (Innervated by the median nerve).
  • Flexor Carpi Radialis (Innervated by the median nerve).
  • FDS (Innervated by the median nerve).
  • Palmaris Longus (Innervated by the median nerve).
  • Flexor Carpi Ulnaris (Innervated by the ulnar nerve).
See Also: Elbow Anatomy
Medial Epicondyle anatomy
Medial Epicondyle Anatomy

Medial Epicondylitis Causes

The mechanism for medial epicondylitis is not usually related to direct trauma, but rather to overuse. This commonly
occurs for three reasons:

  1. Fatigue of the flexor–pronator tissues in response to repeated stress.
  2. A predisposition for medial ligamentous injury due to a sudden change in the levels of stress.
  3. The MCL fails to sufficiently stabilize against the valgus forces.

Medial epicondylitis usually begins as a microtear at the interface between the pronator teres and FCR origins with subsequent development of fibrotic and inflammatory granulation tissue.

An inflammation develops in an attempt to speed up tissue production to compensate for the increased rate of microdamage caused by increased use and decreased recovery time.

Chronic symptoms result from a loss of extensibility of the tissues, leaving the tendon unable to cope effectively against tensile loads.

Medial Epicondylitis

Golfer’s Elbow Symptoms

The typical clinical presentation for medial epicondylitis is pain and tenderness over the flexor – pronator origin, slightly distal and anterior to the medial epicondyle.

The symptoms are typically reported to be exacerbated with either resisted wrist flexion and pronation or passive wrist extension and supination.

Differential diagnosis for medial elbow symptoms includes:

  1. MCL injury or insufficiency.
  2. ulnar nerve entrapment;
  3. medial elbow intra-articular pathology,
  4. Cervical radiculopathy,
  5. Fracture.
See Also: Golfer’s Elbow Test

Medial Epicondylitis Treatment

Non-operative treatment of medial epicondylitis has been shown to have success rates as high as 90%.

The Non-operative treatment for this condition initially involves:

  1. Rest,
  2. activity modification,
  3. NSAIDs medication.
  4. Corticosteroid injections (multiple injection should be avoided).
  5. Extracorporeal shockwave therapy.
Golfer's elbow Extracorporeal shockwave therapy
Extracorporeal shockwave therapy

Complete immobilization is usually not recommended as it eliminates the stresses necessary for maturation of new collagen tissue.

Once the acute phase has passed, the focus switches to restoring range of motion and correcting any imbalances of flexibility and strength.

The strengthening program of medial epicondylitis physiotherapy initially includes multi-angle isometrics, and then concentric and eccentric exercises of the flexor–pronator muscles.

Splinting or the use of a counterforce brace may be a useful adjunct.

Golfer’s Elbow Stretches

The function of the long wrist flexors is flexion of the elbow, pronation of the forearm, and flexion of the wrist.

The patient sits on a chair, with the involved arm elevated approximately 60 degrees. The elbow is slightly flexed, the forearm supinated, and the wrist extended. The patient brings the wrist and fingers into as much extension as possible using the uninvolved hand. While holding the wrist in maximal extension, the clinician very slowly extends the patient’s elbow. As soon as pain or muscle guarding occurs, the motion is stopped and the elbow is brought slightly back into more flexion. If the pain disappears after a few seconds, the elbow can be brought further into extension.

Golfer's Elbow physical therapy exercises
Golfer’s Elbow Physical Therapy Exercises

Operative Treatment

Operative Treatment of Golfer’s elbow is indicated if conservative treatment failed.

It includes open debridement of PT/FCR and reattachment of flexor-pronator complex.

Medial Epicondylitis surgical Treatment
Medial Epicondylitis Surgical Treatment

References

  1. Jobe FW, Ciccotti MG. Lateral and Medial Epicondylitis of the Elbow. J Am Acad Orthop Surg. 1994 Jan;2(1):1-8. doi: 10.5435/00124635-199401000-00001. PMID: 10708988.
  2. Davidson PA, Pink M, Perry J, et al: Functional anatomy of the flexor pronator muscle group in relation to the medial collateral ligament of the elbow. Am J Sports Med 23:245–250, 1995.
  3. Nirschl RP: Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin Sports Med 7:289–308, 1988.
  4. Krischek O, Hopf C, Nafe B, et al: Shock-wave therapy for tennis and golfer’s elbow –1 year follow-up. Arch Orthop Trauma Surg 119:62–66, 1999.
  5. Glousman RE, Barron J, Jobe FW, et al: An electromyographic analysis of the elbow in normal and injured pitchers with medial collateral ligament insufficiency. Am J Sports Med 20:311–317, 1992.
  6. Bauer M, Jonsson K, Jesefsson PO, et al: Osteochondritis dissecans of the elbow: a long-term follow-up study. Clin Orthop 284:156–162, 1992.
  7. Balasubramaniam P, Prathap K: The effect of injection of hydrocortisone into rabbit calcaneal tendons. J Bone Joint Surg 54:729–736, 1972.
  8. Baumgard SH, Schwartz DR: Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med 10:233–238, 1982.
  9. Barry NN, McGuire JL: Overuse syndromes in adult athletes. Rheum Dis Clin North Am 22:515–530, 1996.