Medial epicondylitis, or golfer’s elbow, is a condition caused by repetitive microtrauma and gradual degradation of the flexor pronator mass. Originating at the medial epicondyle, the common tendon of the flexor carpi ulnaris, palmaris longus, pronator teres, flexor carpi radialis, and flexor digitorum superficialis is responsible for wrist flexion and forearm pronation. Those most commonly affected by the condition participate in a profession, activity, or sport where these motions are repetitive. Onset is often insidious and exacerbated by activity in the fourth to sixth decades of life, but can be acute with eccentric contraction of the muscles causing a strain or even rupture. The muscle mass also serves as a dynamic stabilizer to valgus stress at the elbow.¹

Physical examination is critical to evaluate the etiology of medial-sided elbow pain. Medial epicondylitis is exacerbated with flexion and pronation of the wrist. Patients often experience tenderness during palpation over the flexor pronator muscle mass just distal to the medial epicondyle. Evaluation for alternative or concomitant etiologies such as ulnar collateral ligament (UCL) tears, ulnar neuritis, or osteoarthritis is
imperative. Consideration should be given to medial epicondyle apophysitis or avulsion in the skeletally immature population.¹

Imaging is rarely helpful as radiographs are often normal. Ultrasonography may reveal diseased tendon but requires an experienced technician. MRI is the gold standard for soft-tissue evaluation although it is often unnecessary unless there is concern for rupture. A 2021 study demonstrated that abnormal signal in the common flexor tendon on MRI was only seen in 66% of clinically diagnosed cases of medial epicondylitis, and this finding was associated with persistent pain at follow-up.² Electromyography or nerve conduction studies can be performed if needed to evaluate for concomitant ulnar nerve pathology.

Management for most medial epicondylitis cases is nonsurgical, consisting of rest, ice, and nonsteroid anti-inflammatory drugs (NSAIDS). Physical therapy for strengthening with gradual progression to activity over the course of weeks to months is typical, with most cases resolving without further intervention. Recent focus has been on alternative nonsurgical modalities including injections (steroid, autologous whole blood, platelet-rich plasma [PRP]), splinting, kinesiology taping for counterforce brace treatment, and extracorporeal shock wave therapy.¹

Few recent studies are specific to medial epicondylitis, as most involve both medial and lateral tendinopathies. A 2020 meta-analysis evaluating PRP compared with corticosteroid for both medial and lateral elbow epicondylitis reported that corticosteroid may provide more pain relief within the first 3 months, but PRP may have better pain relief after 6 months. Neither provided functional benefit over the other.³ A 2019 study reported on ultrasound-guided tenotomy for common extensor, common flexor, and triceps tendinopathy. Overall, there was a 70% satisfaction rate. However, specific to the common flexors, no difference in pain or function was reported.⁴ A 2019 randomized controlled trial (RCT) compared PRP against lidocaine as tenotomy adjuvants for epicondylitis and found no difference in pain or function.⁵ A 2019 study compared PRP with ultrasound-guided percutaneous tenotomy for either medial or lateral epicondylitis. Again, there were no differences in pain or function in this mixed cohort.⁶ These findings suggest that PRP likely does not have a role in the management of this condition. Ultimately, medial epicondylitis is a self-limiting process best managed with activity modification, and its course is largely unaltered by treatment modalities based on the available evidence to date.

Surgical intervention is reserved for refractory chronic cases (longer than 6 months), or high-level athletes with rupture. In either case, the procedure entails débridement of the tendon with subsequent repair or reattachment with transosseous suture or anchor. Concomitant procedures may include microfracture of the epicondyle and ulnar nerve decompression or transposition. Postoperatively, range of motion starts after appropriate soft-tissue healing, followed by strengthening starting at 6 weeks, and return to sport-specific activity at 3 months.¹

Lateral epicondylitis, or tennis elbow, is more common than medial epicondylitis. It most often presents in middle-aged women but is common in both women and men. Pain occurs over the lateral aspect of the elbow near the origin of the long wrist extensors in the absence of elbow instability or nerve-related symptoms. Similar to medial epicondylitis, it is attributed to progressive microtrauma of the long wrist extensors with gradual degradation and fibrosis of the tendons. Specifically, the extensor carpi radialis brevis and extensor digitorum communis are affected and thought to be the source of symptoms.⁷ Aside from repetitive activity, few other risk factors are known, although a 2019 study identified an association between high total cholesterol levels and lateral epicondylitis.⁸ A 2019 study also found pain sensitization was associated with presenting Disabilities of the Arm, Shoulder and Hand (DASH) score, symptom duration, and DASH score after 1 year of nonsurgical management.⁹

Patients typically report pain over the dorsum of the forearm that is worse with wrist extension activities. Repetitive activities such as typing, writing, or sports may exacerbate symptoms. On examination, pain may be elicited with direct palpation over the origin of the wrist extensors at the lateral epicondyle as well as with resisted wrist extension in elbow extension. Evaluating for instability or nerve-related syndromes is critical to distinguish lateral epicondylitis from other diagnoses such as radial tunnel syndrome.⁷

Imaging is rarely helpful except in ruling out other causes of lateral elbow pain. Radiographs are often negative. MRI and ultrasonography may identify tendon degeneration with signal or concomitant ligamentous injuries (Figure 1). As such, the diagnosis of lateral epicondylitis is largely made on clinical examination and history. A 2020 study evaluated ultrasound changes in patients with chronic lateral epicondylitis, comparing the contralateral arm and healthy control patients. The affected arms exhibited greater tendon thickness, Doppler activity, and bone spurs. However, the differences were small and although they may help confirm
clinical suspicion, are not diagnostic. Importantly, there was no correlation with symptoms, outcomes, or duration.¹⁰

A number of treatment modalities have been proposed, although no one treatment has been shown to be most effective in the long term. Although some treatment modalities may alleviate symptoms for a period, it is not uncommon for symptoms to recur. Lateral epicondylitis is largely a self-limiting condition based on activity that may take 9 to 12 months to resolve, regardless of additional intervention. Therefore, initial treatment is primarily focused on activity modification, physical therapy, and gradual return to activity as tolerated. Various braces have been described such as counterforce brace treatment and wrist extension splinting. A 2019 RCT compared counterforce brace treatment with placebo brace treatment for lateral epicondylitis. Although both improved pain and function, counterforce brace treatment had better frequency of pain at rest at 6 and 12 weeks, pain at rest level at 2 weeks, and elbow function at 26 weeks so it may be beneficial in the short term.¹¹ Another 2019 RCT evaluated patients without a brace, with a forearm band, and with an elbow sleeve for lateral epicondylitis. Both braces improved pain and grip strength, with no significant difference between them. They each helped with proprioception, but at different degrees of flexion.¹² These findings suggest that brace treatment can reduce symptoms of lateral epicondylitis.

Injections into the muscle origin or proximal muscle tissue have been described including corticosteroid, PRP, autologous blood, prolotherapy, and saline. These have limited evidence-based success and potentially only short-term benefits. Steroid injections pose a risk of weakening the lateral collateral ligament complex and skin changes including thinning and depigmentation.⁷ Innovative injectable solutions are an active area of investigation. A 2019 study evaluated an injectable gel with cross-linked bioengineered recombinant human type 1 collagen combined with autologous PRP. In patients with chronic lateral epicondylitis, there was 59% reduction in the Patient-Rated Tennis Elbow Evaluation score at 6 months. They also noted improvement in the 12-item Short-Form Healthy Survey, grip strength, and ultrasonographic appearance of the tendon without any adverse effects.¹³ Although these results are promising, randomized studies should be performed before this treatment can be recommended.

A 2020 RCT of 119 patients with lateral epicondylitis receiving PRP, autologous blood, or saline found no significant differences in outcomes or grip strength.¹⁴ Interestingly, a 2020 meta-analysis reviewing 15 RCTs incorporating normal saline injection for lateral epicondylitis found significant improvement in pain, function, and outcome scores at minimum 6-month follow-up.¹⁵ This would indicate the physical injection, as opposed to what is injected, may be the significant intervention.

Extracorporeal shock wave therapy has been proposed although a 2020 meta-analysis found no clinical differences. In subgroup analysis, the study authors noted a greater effect in patients with symptoms over 6 months compared with 3 months. Even when effective, results did not last beyond 24 weeks.¹⁶ A 2019 RCT of 24 patients with lateral epicondylitis evaluated iontophoresis with dexamethasone and lidocaine compared with a control group. Although both groups improved, iontophoresis had greater improvement in pain and function.¹⁷

Percutaneous techniques have also been described. A previously mentioned 2019 study reported on ultrasound-guided tenotomy for a variety of pathologies. Specific to the common extensors, the study authors found significantly improved short-term and long-term pain, as well as physical function.⁴ A 2021 study reported on ultrasonic percutaneous tenotomy in 20 patients with minimum 7-year follow-up. Satisfaction was 100% with no recurrence of symptoms and a significant improvement in outcome scores.¹⁸ Another RCT of 101 patients undergoing dry needling compared with corticosteroid injection found that, at minimum 6-month follow-up, both groups improved though dry needling appeared slightly more effective based on the Patient-Rated Tennis Elbow Evaluation score.¹⁹

A 2019 meta-analysis reviewed all nonsurgical options for lateral epicondylitis. Over the short term, corticosteroid appeared to be most effective. Over the midterm, laser therapy and local botulinum toxin improved pain. Over the long term, extracorporeal shock wave therapy provided pain relief. Laser therapy was the only modality to improve grip strength. The study authors noted that these all have minimal effects on the course of lateral epicondylitis but are associated with adverse events. In patients treated with placebo, many improved between short-term and midterm follow-up.²⁰

Surgical intervention should be reserved for refractory cases. The procedure entails débriding the diseased portion of the tendon with or without reattachment to the origin. Débridement may be done either arthroscopically or open.⁷

Care should be taken not to violate the lateral collateral ligament complex and introduce iatrogenic instability. A 2021 study compared patients with lateral epicondylitis who underwent débridement with those who had concomitant lateral ulnar collateral ligament (LUCL) reconstruction for a suspected component of posterolateral rotatory instability (PLRI) in their clinical presentation. Both groups improved over time in visual analog scale score and Mayo Elbow Performance Score (MEPS).²¹ There is also the question of the involvement of the lateral capsule. A 2021 study evaluated arthroscopic lateral capsule resection with and without extensor carpi radialis brevis débridement. Both cohorts demonstrated similar improvement, leading to the conclusion that the lateral capsule may be a key factor.²² Ultimately, results of surgical intervention for lateral epicondylitis are mixed, and there is suspicion that patients improve primarily because it entails a period of enforced immobility and therapy.⁷

Distal biceps ruptures occur at a disproportionate rate in middle-aged men and are often the result of forced rapid eccentric elbow contraction.²³ A 2021 study of the demographics of distal biceps tears reported this disproportionate rate in men, as well as noting a bimodal occurrence in elite athletes and middle age. Prodromal symptoms were reported in 10% of cases.²⁴ Injuries are often labor related and accompanied by a pop with immediate weakness of elbow flexion and supination. Although often an acute event, tears may occur in a chronic setting secondary to degeneration, hypovascularity, or impingement. A number of risk factors for rupture have been reported, including obesity, smoking, anabolic steroids, statins, wild-type transthyretin cardiac amyloidosis, corticosteroid injection, chronic prednisone administration, and Cushing disease.²³ These all suggest that systemic metabolic factors increase the risk for tendon rupture.

Anatomically, the distal biceps has two insertion heads. Both insert on the more dorsal aspect of the bicipital tuberosity of the radius. The short head attaches distally, whereas the long head attaches posteriorly and deep. Of note, the bicipital aponeurosis, also called the lacterus fibrosus, is a band of connective tissues arising from the biceps distally and fans medially to attach on the forearm flexor/pronator mass as well as the ulna. Awareness of this structure is important because if it remains intact despite a distal biceps rupture, the examiner may mistakenly think that the distal biceps is intact.²³

Early detection of these injuries is critical as acute surgical intervention is favored. On examination, patients will have weakness with elbow flexion and forearm supination. There may also be swelling and bruising in the antecubital fossa, with an appreciable gap at the expected location of the tendon. Nerve injuries rarely accompany ruptures. Various tests have been described but in combination the hook test, passive forearm pronation, and biceps crease interval (ie, reverse Popeye deformity) have been shown to be most sensitive and specific.²³ If there is any uncertainty, MRI should be performed (Figure 2). Flexion-abduction-supination view has been advocated by some authors. A 2020 study found that it was no more specific or sensitive than standard MRI in detecting biceps pathology in patients without complete tears, though it was better at grading severity of injury.²⁵ Ultrasonography may also be valuable. A 2019 study found MRI to be more sensitive and specific than ultrasonography for distal biceps tears, although they were similar when only considering partial tears.²⁶

Nonsurgical treatment is reserved for low-demand patients, those with high risk, chronic ruptures with
acceptable deficiencies, and those with partial tears involving less than 50% of the tendon insertion.²³ Nonsurgical treatment can also be considered on the nondominant side where supination power is less important for activities of daily life. In a 2021 cadaver study, supination moment arm significantly decreased after 75% of the distal biceps tendon was detached suggesting this may be a cutoff for repair.²⁷ A 2020 MRI study of patients with partial distal biceps tears found that most (34%) were isolated partial long head ruptures though there was a greater likelihood of involvement of the short head in traumatic cases. Smoking was associated with atraumatic cases.²⁸ Numerous factors may play a role in treatment decision making. A 2021 retrospective review of 60 patients with distal bicep tears, both complete and incomplete, who were treated either surgically or nonsurgically had similar outcomes. This was a heterogenous population, but it demonstrated that individualized treatment decisions can yield similar results.²⁹

Surgical repair is typically favored for acute ruptures (less than 6 weeks) in appropriate candidates as failure to repair may lead to 30% flexion and 50% supination weakness. Numerous techniques have been described for repair with a focus around single versus dual incision approaches. Single incision is associated with a higher risk of nerve injury, whereas dual incision has a higher rate of heterotopic ossification. The arm should be supinated during the volar approach to avoid injury to posterior interosseous nerve (PIN).²³ A 2021 MRI study demonstrated that supination increases the distance of the PIN from the trajectory and start point of the guidewire for bicortical button fixation.³⁰ A 2019 study evaluating single incision cortical button fixation versus dual incision suture over bony bridge fixation found that single incision had a 20% greater supination torque at median 28 months follow-up.³¹ In cases of severe retraction, a 2020 study described a two-incision anterior technique. One incision was used to retrieve the tendon, whereas the other was used for reattachment with a cortical button. When compared with patients who underwent a single incision repair, there were no differences in strength (both were weaker with supination compared with contralateral side), motion, or outcomes.³² Concomitant repair of the biceps aponeurosis, if it is also torn, has been advocated as it may strengthen the repair up to 50% with faster return to activity.²³ A 2019 study comparing biceps repair with biceps and aponeurosis repair found a faster return to activity, but otherwise no differences.³³

A number of fixation techniques have been described including transosseous tunnels, suture anchor, suspensory cortical buttons, or interosseous screws. Biomechanically, suspensory cortical fixation appears to have the greatest strength, but there are no clear clinical differences.²³ A 2021 meta-analysis of biomechanical studies suggested that constructs with a cortical button had the greatest load to failure. Failure load improved with a locking stitch, but this also increased the odds of failure within the tissue.³⁴ Regarding unicortical compared with bicortical fixation, a 2020 cadaver study found no difference in strength of an intermedullary compared with a bicortical button.³⁵ Clinically, a 2019 study of distal biceps repairs with an intramedullary cortical button observed no differences in motion or strength compared with the contralateral side, with good to excellent outcome scores. Heterotopic ossification was observed in 46% of cases, but only one was symptomatic. There was one rerupture and one asymptomatic button migration.³⁶ Regarding other fixation methods, a 2019 cadaver study comparing all-suture anchors with titanium screw anchors found no difference in load to failure, stiffness, or mode of failure (anchor pullout).³⁷

Delayed surgical fixation is also more difficult as the tendon may retract and its course may fill with scar tissue. Chronic ruptures may be managed with nonanatomic repair to the brachialis or coronoid, anatomic repair (particularly if the bicipital aponeurosis is intact), and graft reconstruction. A 2020 study reported results of chronic distal biceps tears (longer than 4 weeks) treated with single-incision anatomic repair with a suture button in high flexion. As a result, patients’ initial flexion contractures ranged from 50° to 90° of flexion; however, at mean 26 months follow-up all had full motion, strength, and improved outcome scores.³⁸ A 2020 study comparing patients undergoing allograft reconstruction for chronic tears with primary repair found no differences in complications, range of motion, or outcome scores.³⁹ A 2019 study evaluated delayed primary repair, defined as over 21 days, to reconstruction with semitendinosus autograft. There were no differences in strength, motion, DASH score, or Single Assessment Numeric Evaluation. However, the primary repair did score better on the Patient-Rated Elbow Evaluation and MEPS, suggesting that primary repair is preferable if possible.⁴⁰

Regarding outcomes, a 2021 study of patients who underwent distal biceps repair reported 93% returned to sport. Delayed time to fixation, suture anchor compared with button, and dominant arm injury were associated with lower likelihood of returning to sport at the same or higher level. Single compared with double incision was associated with a longer time to return.⁴¹ A 2021 study of 35 National Football League players who
underwent distal biceps repair reported that 33 returned to sport, and there was no subsequent difference in length of career or performance compared with control patients.⁴² However, this is in contrast to another 2021 study of 25 National Football League players reporting 84% return to sport, with precipitous decline to 56% at 2 years. Compared with control patients, those with distal biceps repairs had shorter careers and played fewer games per season, but did not show differences in performance.⁴³

Rehabilitation involves a period of immobilization followed by passive range of motion. Active range of motion begins at 2 weeks with light strengthening at 6 weeks. A 2021 RCT evaluated early range of motion as tolerated compared with 6 weeks of splint immobilization following distal biceps repair. There were no significant findings of worse outcomes in the early mobilization group, indicating that this is a safe practice.⁴⁴ A 2020 systematic review of distal biceps repair reported average time to return to work was just over 14 weeks, with 89% returning to work.⁴⁵

Complications following distal biceps repair or reconstruction include nerve injury (lateral antebrachial cutaneous nerve [LABCN] and PIN most commonly), heterotopic ossification, synostosis, proximal radius fracture, rerupture, infection, stiffness, weakness, vascular injury, complex regional pain syndrome, and lateral epicondylitis.²³ A 2020 systematic review of 3,091 distal biceps repairs reported the overall complication rate to be 25%. This was divided into 4.6% major complications (ie, PIN, median nerve, rerupture, synostosis) and 20.4% minor complications (LABCN, superficial radial nerve, heterotopic ossification, infection). LABCN injury was the most common at 9% and was most often treated with cortical button fixation. Radioulnar synostosis was only seen in one dual incision case.⁴⁶ A retrospective review of 784 distal biceps repairs compared complications of single and dual incision techniques. LABCN was the most common complication and was significantly more frequent with single incision. However, dual incision was associated with a higher rate of PIN palsy, heterotopic bone, and revision surgery. The overall rerupture rate was 1.9%.⁴⁷

Distal triceps injuries are relatively uncommon. They typically occur with a discrete event such as a fall onto an outstretched hand, traumatic blow, or eccentric load while the muscle is contracting. Patients may feel a pop with subsequent ecchymosis and swelling about the olecranon. A palpable defect may be present. Passive range of motion is usually preserved though weakness with elbow extension may be appreciated.⁴⁸ A 2021 study compared distal triceps ruptures due to a fall as opposed to direct injury. Compared with direct injury, falls were more likely to be a partial tear, involve additional ligamentous injuries, and have bony involvement (fracture or contusion).⁴⁹ These injuries are most common in men and athletes, though risk factors include anabolic steroid use, weightlifting, local steroid injection, hyperparathyroidism, renal disease, Marfan syndrome, hypocalcemic tetany, osteogenesis imperfecta, olecranon bursitis, rheumatoid arthritis, and type 1 diabetes.⁴⁸

The triceps tendon is a confluence of the three muscle heads—lateral, long, and medial. The tendon inserts on the olecranon but has a lateral expansion that inserts on the anconeus fascia. The insertion is large so if there is a partial tear, or the lateral expansion remains intact, the patient may present with partially preserved extensor strength leading the examiner to falsely believe the tendon is intact. Injury can occur anywhere along the tendon and muscle, though avulsion typically occurs at the tendon-bone interface. Partial tears are most often on the medial side.⁴⁸

Radiographs are often normal, though enthesophytes may be appreciated. These may fracture and retract in cases of triceps rupture. MRI remains the gold standard for diagnosis though ultrasonography is equally effective with an experienced technician.⁴⁸

Treatment is largely dictated by tear width. A patient’s functional and medical status should also be considered. A previously mentioned 2019 study reported ultrasound-guided tenotomy for a variety of pathologies. Specific to the triceps, no improvement in short-term pain, long-term pain, or physical function was found.⁴ Partial tears less than 50% are typically managed nonsurgically, which entails a few weeks of immobilization at approximately 30° elbow flexion followed by progressive motion. Full-thickness tears and partial tears over 50% are often managed with surgical repair. Ideally this occurs within the first 2 to 3 weeks after injury. A number of techniques for fixation have been described, primarily with bone tunnels, suture anchor, or direct repair to a periosteal sleeve. If the lateral expansion is disrupted, it should be repaired as well to augment the construct. In chronic or revision cases, allografts with or without bone plugs, autografts, and anconeus rotation flaps have been described.⁴⁸