© ISAKOS 2017
Gian Luigi Canata, Pieter d’Hooghe and Kenneth J. Hunt (eds.)Muscle and Tendon Injuries10.1007/978-3-662-54184-5_2121. Medial and Lateral Epicondylitis
(1)
Orthopaedic and Arthroscopic Department, New Sassuolo Hospital, via F. Ruini, 2, 41049 Sassuolo, Modena, Italy
Keywords
Medial epicondylitisLateral epicondylitisExtensor carpi radialis brevisFlexor carpi radialisPronator teres21.1 Epitrochleitis
The medial epicondylitis, or “golfer’s elbow,” is a painful syndrome that affects the medial compartment of the elbow often with pain irradiation to the forearm and ipsilateral wrist, caused usually by a functional overload of flexor-pronator muscles of the forearm that anatomically have a common tendon that inserts on the medial epicondyle (Plancher et al. 1996).
The common tendon is on the anteroinferior surface of the epicondyle just proximal to the anterior bundle of the medial collateral ligament.
Despite the name given to this pathology, it is not exclusive of golfers, but it is a disorder related to specific work tasks and to particular sports including golf.
Tennis players and other athletes who use repetitively the flexion-extension of the wrist and fingers can develop this painful syndrome too.
In particular, the type of racket grip and rotator effects given to the ball is responsible of a medial painful syndrome much more common now than in the past.
Sports that can frequently determine this disease are, therefore, golf, tennis, throwing sports, and weight lifting (Plancher et al. 1996).
Common daily activities requiring continuous flexion-extension movements of the elbow and wrist can cause medial epicondylitis like drawing, hammering, chopping wood, using a computer, cooking, and screwing.
The involved muscles are usually the flexor carpi radialis and pronator teres and less frequently palmaris longus, the flexor carpi ulnaris, and the flexor digitorum superficialis.
Repeated microtrauma causes microtears and weakening of the flexor carpi radialis or the pronator teres near their common origin on the medial epicondyle characterized by fibroblastic tendinosis with proliferation of vascular granulation tissue. The histology of the tendon becomes abnormal and can ultimately lead to avulsion of the flexor-pronator origin (Kraushaar and Nirschl 1999). The process becomes chronic with a failed healing response.
Usually it affects people over 35 years (Kraushaar and Nirschl 1999) old.
If not well treated, it can cause chronic elbow pain and joint stiffness.
Medial epicondylitis can be classified (Gabel and Morrey 1995) into three types: type I (isolated medial epicondylitis), type IIA (medial epicondylitis with minimum or medium ulnar neuropathy), and type IIB (medial epicondylitis with moderate or severe ulnar neuropathy).
21.1.1 Physical Examination
Patients typically present with chronic medial elbow pain. They may complain of weak grasp, difficulty in bending the fingers, and paresthesias in the fourth and fifth finger.
The onset can be insidious with increasing symptoms or acute.
The diagnosis of medial epicondylitis can be difficult because of the differential diagnosis including several disorders such as compression of the anterior interosseous nerve, arthritis, arthrofibrosis, cervical radiculopathy, cubital tunnel syndrome, loose bodies, medial epicondyle avulsion, osteophytes, synovitis, medial collateral ligament instability, and extension valgus overload (Dlabach and Baker 2001).
A complete history, physical examination, and additional diagnostic studies are necessary to make the correct diagnosis.
Physical examination shows tenderness at the origin of the flexor-pronator mass on the medial epicondyle increased by resisted wrist flexion and pronation.
The point of maximum tenderness is approximately 5 mm distal and anterior to the midpoint of the medial epicondyle (Dlabach and Baker 2001).
Physical examination of the ulnar nerve and valgus stress tests should be negative to confirm the diagnosis of isolated medial epicondylitis.
The ulnar collateral ligament must be examined to rule out instability or partial tear. Pain along the ulnar collateral ligament with valgus stress tested between 30° and 80° of flexion is an indication of instability.
The medial epicondylitis can occur as a secondary phenomenon with ulnar collateral ligament injury. In this case the principal cause of the disease which needs to be treated remains.
A complete neurologic examination of the cervical spine, shoulder, and wrist should be performed. Radiographic examination, including anteroposterior, lateral, and axial views, may show other causes of medial-sided pain as fractures, osteoarthritis, or ossification.
Imaging techniques such as MRI or ultrasound are performed to complete diagnosis.
Ultrasound (Lin 2012) study of the elbow is increasingly used in the absence of radiation exposure and easily accessible and reduces costs. Furthermore, it allows a dynamic assessment of the joint compared to other imaging studies.
Most of the typical pathologic findings of medial epicondylitis are usually found in the aforementioned muscles. The common tendon of flexion-pronator mass can show hypoechogenicity, loss of normal fibrillar structure, increased caliber, partial- or full-thickness tears, calcification, and hyperemia (seen with Doppler examination).
Ultrasound examination especially during valgus stress tests may be very helpful in assessing possible injury of the ulnar collateral ligament.
Young patients may develop lesions caused by valgus overuse, which, occurring on immature skeleton, may generate osteochondritis dissecans of the lateral humeral condyle and epicondyle fragmentation or injury of the ulnar collateral ligament that can be diagnosed by ultrasounds.
Electromyography and nerve conduction studies are indicated in patients with abnormal neurological findings during physical examination.
21.1.2 Treatment
The medial epicondylitis management is initially based on the nonoperative treatment.
The goal is to diminish pain and inflammation with:
Resting from sports or from activities that cause pain
Local cryotherapy for 15–20 min 3–4 times daily for 3 weeks
The use of oral nonsteroidal anti-inflammatory drugs
Stretching exercises
Reducing the workload at the elbow while protecting the elbow with an elastic bandage and keeping wrist stiff during all activities in which weights are lifted
If this therapy is not successful in diminishing the symptoms, 1–2 injections of corticosteroids can be taken into account.
A gradual return to sports and work activities is possible when the patient does not complain of pain and starts practicing with the typical movements of his activities.
Patients with persistent symptoms after 6–12 months of nonoperative management should be considered candidate for surgical treatment (Gerard and Gabel 2001; Ciccotti 1999; Baker and Cummings 1998).
Treatments include percutaneous release (Baumgard and Schwartz 1982) and open debridement with or without common tendon detachment (Nirschl 1992; Vangsness and Jobe 1991).
The majority of surgical techniques for the medial epicondylitis are open procedures.
The procedure described by Nirschl (1992) consists of excising the pathologic tissue of the common tendon of the flexor-pronator mass leaving intact the normal tissue.
Vangsness and Jobe (1991) prefer to detach the origin of the flexion-pronator mass, remove the pathologic tissue, and reattach the origin of the flexor-pronator mass tendon.
With these procedures, the ulnar nerve is decompressed and transposed in patients with ulnar nerve symptoms.
21.1.3 Surgical Technique
Brachial plexus block or general anesthesia is usually performed for this surgery.
The patient is placed supine on the operating table. The involved extremity is exsanguinated and the tourniquet inflated.
A curved skin incision is performed just posterior to the medial epicondyle. The cutaneous nerves and the ulnar nerve are identified and protected during surgery.
The common tendon of flexor-pronator mass is exposed and the pathologic tissue identified and removed, leaving the normal tissue intact.
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