Medial Epicondylitis

Abstract

Medial epicondylitis describes inflammation, pain, or tenderness in the region of the medial epicondyle of the humerus. Although epicondylitis implies an inflammatory process, inflammatory cells are not identified histologically. The syndrome is also known as golfer’s elbow, as it is commonly seen in overuse from repetitive wrist flexion in golf (especially with poor technique). Symptoms may include pain in the area just distal to the medial epicondyle, with radiation proximally or distally. On physical examination, there is usually pain over the flexor muscle origin. Pain is increased with resisted wrist flexion. The diagnosis is usually made clinically. Treatment is usually conservative, although surgery may be required in recalcitrant cases. The anatomy, symptoms, physical examination, functional limitations, diagnostic studies, and treatments (including potential disease and treatment complications) for medial epicondylitis will be discussed.

Keywords

Epicondylitis, golfer’s elbow, Little Leaguer’s elbow, medial epicondylitis, repetitive stress, tendinosis

Synonyms
Tendinosis Medial epicondylitis Pitcher’s elbow Little Leaguer’s elbow Golfer’s elbow
ICD-10 Codes
M77.00	Medial epicondylitis, unspecified elbow
M77.01	Medial epicondylitis, right elbow
M77.02	Medial epicondylitis, left elbow

Definition

Epicondylitis is a general term used to describe inflammation, pain, or tenderness in the region of the medial or lateral epicondyle of the humerus. The actual nidus of pain and pathologic change has been debated. Medial epicondylitis implies an inflammatory lesion with degeneration at the origin of the flexor muscles (the medial epicondyle of the humerus). In medial epicondylitis, the tendon of the flexor muscle group is affected (flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, and palmaris longus).

Although the term epicondylitis implies an inflammatory process, inflammatory cells are not identified histologically. Instead, the condition may be secondary to failure of the musculotendinous attachment with resultant fibroplasia, termed tendinosis . Other postulated primary lesions include angiofibroblastic tendinosis, periostitis, and enthesitis. In children, medial elbow pain may result from repetitive stress on the apophysis of the medial epicondyle’s ossification center (Little Leaguer’s elbow). Overall the focus of injury appears to be the muscle origin. Symptoms may be related to failure of the repair process.

Repetitive stress has been implicated as a factor in this condition. Poor throwing mechanics and excessive throwing have been implicated in Little Leaguer’s elbow. Repetitive wrist flexion, as in the trailing arm in a golf swing, can cause medial epicondylitis (hence, the term golfer’s elbow is frequently used for medial epicondylitis regardless of etiology).

Symptoms

Patients usually report pain in the area just distal to the medial epicondyle. They may complain of pain radiating proximally or distally. Patients may also complain of pain with wrist or hand movement, such as gripping a doorknob, carrying a briefcase, or shaking hands. They occasionally report swelling as well. Throwing athletes may complain of symptoms during the late cocking or early acceleration phases. Patients who spend a lot of time with their forearms supinated (professional slalom water-skiers), may be at increased risk of developing medial epicondylitis.

Physical Examination

On examination, the hallmark of epicondylitis is tenderness over the flexor muscle’s origin (medial epicondylitis). The origin of the flexor muscles can be located one fingerbreadth below the medial epicondyle. With medial epicondylitis, pain is increased with resisted wrist flexion. There may be localized tenderness along the course of the radial nerve around the radial head. Motor and sensory findings are usually absent.

Functional Limitations

The patient may complain of an inability to lift or to carry objects on the affected side secondary to increased pain. Typing, using a computer mouse, or working on a keyboard may recreate the pain. Even handshaking or hand squeezing may be painful in medial epicondylitis. Athletic activities may cause pain, especially with an acute increase in repetition, poor technique, and equipment changes.

Diagnostic Studies

The diagnosis is usually made on clinical grounds. Magnetic resonance imaging (MRI), which is particularly useful for soft tissue definition, can be used to assess for tendinitis, tendinosis, degeneration, partial tears or complete tears, and detachment of the common flexor at the medial epicondyles. MRI is rarely needed, however, except in recalcitrant epicondylitis, and it will not alter the treatment significantly in the early stages. The medial collateral ligament complexes can be evaluated for tears as well as for chronic degeneration and scarring. Ultrasonography has been used to diagnose medial epicondylitis. Arthrography may be beneficial if capsular defects and associated ligament injuries are suspected. Barring evidence of trauma, early radiographs are of little help in this condition but may be useful in cases of resistant tendinitis and to rule out occult fractures, arthritis, and osteochondral loose bodies. Early radiographic studies (before commencing a rehabilitation program) may be considered in skeletally immature children with elbow pain to rule out growth plate disorders, osteochondritis dissecans, or tears of the ulnar collateral ligament.

Differential Diagnosis