EMDIAL EPICONDYLE SURGERY

Medial Epicondyle Surgery

J. Robert Giffin and James P. Bradley

Medial epicondylitis is much more rare than its lateral counterpart but the symptoms of localized pain and weakness are similar. It commonly occurs within the fourth and fifth decades, with roughly an equal distribution in both males and females. Although termed “golfer’s elbow,” medial epicondylitis occurs in a variety of overhead repetitive action sports (baseball, javelin throwing, swimming, gymnastics, fencing) and occupational activities (carpentry, meat cutting) that create valgus and flexion forces about the elbow. In most cases, nonoperative treatment (nonsteroidal anti-inflammatory drugs, steroid injections) along with a quality rehabilitative program (physical therapy modalities, stretching, exercise) will obviate the need for surgical intervention. In recalcitrant cases, however, surgical treatment of medial epicondylitis can result in high patient satisfaction with reliable pain relief. Some residual strength deficits may exist, but these do not seem to interfere with functional activities.

Indications

1. Persistent severe medial elbow pain unresponsive to a well-managed nonoperative program for a minimum of 3 to 6 months

2. Exclusion of other possible diagnosis (ulnar nerve neuropathy, medial collateral ligament instability and intraarticular pathology)

Contraindications

Inadequate trial of nonoperative treatment.

Mechanism of Injury

Although the definitive etiology of medial epicondylitis has not been determined, the bulk of the literature supports repetitive valgus stress or overuse as the major source of injury. However, cases have been reported in both athletes and workers following a single traumatic event.

Improper technique, inadequate warm-up, poor conditioning, and fatigue lead to inflammation and microtearing at the musclotendinous origin of the flexor pronator mass (Fig. 49–1). For example, a vertical downswing in golf will result in the player taking too deep (i.e., fat) of a divot, causing excessive tension on the common flexor origin at the medial epicondyle. A failed healing response within the tendons of pronator teres and flexor carpi radialis results in a chronic degenerative process (i.e., angiofibroblastic hyperplasia) and the insidious onset of symptoms.

Physical Examination

1. Tenderness near the origin of the forearm flexors, slightly distal and lateral to the medial epicondyle over the pronator teres and flexor carpi radialis.

2. Resisted wrist flexion and forearm pronation with the elbow extended exacerbates symptoms (i.e., pain and local tenderness).

3. Range of motion of the elbow and wrist are usually full; however, grip strength of the ipsilateral hand may be decreased.

4. If concomitant ulnar neuropathy exists, varying degrees of hypo- or paresthesia in the ring and small fingers, as well as Tinel’s sign at the cubital tunnel, may be present. Maximum elbow flexion with wrist extension for 3 minutes will produce pain and numbness if ulnar neuropathy is present.

5. Valgus stability of the elbow must be carefully assessed to rule out ulnar collateral ligament insufficiency (especially in throwers). Valgus stress testing with the wrist flexed and the forearm pronated will produce pain and laxity if the ulnar collateral ligament is insufficient.

Diagnostic Tests

1. Anteroposterior and lateral radiographs of the elbow are usually normal, but 20 to 25% of patients may have soft tissue calcification about the epicondyle.

2. Throwing athletes may have calcification within the ulnar collateral ligament or medial traction spurs, which may suggest concomitant instability.

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