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Medial epicondylitis


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Updated: 28 January 2016
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Title: Medial epicondylitis

Medial epicondylitis, also known as golfer's
elbow, baseball elbow, suitcase elbow, or
forehand tennis elbow, is characterized by pain
from the elbow to the wrist on the inside (medial
side) of the elbow. The pain is caused by damage
to the tendons that bend the wrist toward the
palm. A tendon is a tough cord of tissue that
connects muscles to bones.
The group of muscles at the front of the forearm
are commonly called the forearm flexors . These
muscles act to flex the wrist and fingers (i.e.
bend them forwards) and have a common bony
attachment at the inner aspect of the elbow
called the medial epicondyle. The forearm flexors
attach to the medial epicondyle via the flexor
During contraction of the forearm flexors,
tension is placed through the flexor
tendon at its attachment to the medial
epicondyle. When this tension is excessive
due to too much repetition or high force,
damage to the tendon occurs. Golfers elbow
is a condition whereby there is damage, with
subsequent inflammation and degeneration to the
flexor tendon at its bony attachment to the
inner elbow. This is usually due to
gradual wear and tear associated with
overuse, however, it may also occur
traumatically due to a specific incident.
Medial epicondylitis accounts for only 10-20 of
all epicondylitis diagnoses, wich is 1-3 within
the general population this condition is often
found in the dominant elbow of a golfer. Tennis
players who hit their forehand with a heavy
topspin are also at increased risk for developing
medial epicondylitis. Although this condition can
occur at any age, it is commonly seen in patients
between the ages of 40 and 60.
Contrary to what the name suggests, you do not
have to play golf to develop this condition. In
fact, golfers elbow is more commonly seen in
non-golf players than in golf players. Smoking,
obesity, age 45 to 54, repetitive movement for at
least two hours daily, and forceful activity
(managing physical loads over 20 kg) appear to be
risk factors in the general population for the
development of epicondylitis
Patients typically develop Golfers Elbow due to
activities involving repetitive wrist flexion
against resistance or forceful or repetitive
gripping of the hand. These activities may
include sports or manual work such as
  • golf (especially those who continually take
    divots out of the ground)
  • tennis (especially those players who put a lot
    of top spin on the ball)
  • squash
  • badminton
  • water skiing
  • gymnastics
  • body building or weight lifting
  • carpentry
  • hammering
  • painting
  • chopping wood
  • bricklaying
  • repetitive use of a screwdriver
  • sewing
  • knitting
  • working at a computer

It is also common for patients to develop this
condition following a sudden increase in
activities that place stress on the forearm
flexors (such as involvement in a golf tournament
over consecutive days) or due to a change in
these activities (such as using a new technique
or clubs, or hitting the ball too hard). In golf
players, golfers elbow is often associated with
poor swing technique. Occasionally, this
condition may develop suddenly. This is usually
due to a forceful movement involving a heavy
lifting or gripping force through the arm. In
golf, this may occur when mis-timing a shot and
taking a divot out of hard ground. A history of
wrist, elbow, shoulder or neck injury may
increase the likeli- hood of a patient developing
this condition.
The symptoms associated with golfers elbow
usually develop gradually over a period of time.
Initially, symptoms may present as an ache
following an aggravating or unaccustomed
activity. This may often be felt first thing in
the morning. Patients with this condition usually
experience localized elbow pain 1-2cm down from
the bony lump on the inner aspect of the elbow ,
that increases on firmly touching this region.
Occasionally, the pain may radiate into the
forearm. In less severe cases of this condition,
patients may only experience a minor ache. In
more severe cases, the pain may be quite
incapacitating and can keep the patient awake at
night. Usually pain is experienced as an ache
that increases to a sharper pain with activity.
Occasionally, golfers elbow can be associated
with neck, shoulder or upper back pain on the
same side. In longstanding cases muscle weakness
and reduced grip strength may also be present.
  • Patients with this condition often experience an
    increase in pain during everyday activities such
  • picking up a cup
  • turning a door knob
  • opening a jar
  • shaking hands
  • carrying groceries or turning the steering wheel
    of a car.
  • Elbow stiffness may also be experienced and is
    typically worse first thing in the morning.

Your doctor will first take a detailed medical
history. You will need to answer questions about
your pain, how your pain affects you, your
regular activities, and past injuries to your
elbow. The physical exam is often most helpful in
diagnosing tennis elbow. Your doctor may position
your wrist and arm so you feel a stretch on the
forearm muscles and tendons. This is usually
painful with tennis elbow. There are also other
tests for wrist and forearm strength that can be
used to detect tennis elbow. You may need to get
X-rays of your elbow. The X-rays mostly help your
doctor rule out other problems with the elbow
joint. The X-ray may show if there are calcium
deposits on the lateral epicondyle at the
connection of the extensor tendon.
Tennis elbow symptoms are very similar to a
condition called radial tunnel syndrome. This
condition is caused by pressure on the radial
nerve as it crosses the elbow. If your pain does
not respond to treatments for tennis elbow, your
doctor may suggest tests to rule out problems
with the radial nerve. When the diagnosis is not
clear, your doctor may order other special tests.
A magnetic resonance imaging (MRI) scan is a
special imaging test that uses magnetic waves to
create pictures of the elbow in slices. The MRI
scan shows tendons as well as bones. Ultrasound
tests use high-frequency sound waves to generate
an image of the tissues below the skin. As the
small ultrasound device is rubbed over the sore
area, an image appears on a screen. This type of
test can sometimes show problems with collagen
  • Modification of Activity
  • General activities which make the pain worse
    should be avoided or at least cut back. For Golf
    players this may mean playing less golf. Use of
    the arm and hand within the limits of pain is
    recommended. In general, the patient can do
    anything that doesn't hurt. While continued
    activity in the presence of mild discomfort is
    not harmful, severe pain will only prolong the
    necessary recovery time and should be avoided.
  • 2. Ice
  • Cold therapy is very helpful for this condition
    to limit pain and to decrease inflammation. It is
    recommended that the area be iced 2 to 3 times a
    day, especially after any activity such as sports
    or work. Ice can be applied with an ice bag or
    the area can be rubbed or massaged with an ice
    cube (ice massage). The ice should be applied for
    20 to 30 minutes each time.
  • Medication
  • Oral nonsteroidal anti-inflammatory drugs are
    very helpful in controlling the pain and
    inflammation of Golfers elbow. These medications
    are aspirin-like medicines which include
    ibuprofen (Motrin, Advil, Nuprin, Medipren,
    etc.), and other prescription medications
    (Naprosyn, Indocin, Feldene, Relafen, etc.). We
    recommend the medicine be taken daily for at
    least four to six weeks when treating severe
    cases. For less severe cases these medicines may
    be taken only when needed. All of these
    medications can have side effects and should be
    used under the direction of a physician.
  • 4. Stretching and Strengthening Exercises
  • Stretching and strengthening of the involved
    muscle and tendon unit is one of the mainstays of
    treatment for this condition. A gentle stretching
    program is started through a range of motion at
    the elbow and wrist. This is combined with a
    program of muscle strengthening. A simple home
    program can be demonstrated by your physician in
    the office. In more severe cases, a referral to a
    physical therapist can be made for a supervised

  • Straps
  • Golfers elbow straps are found to be helpful by
    some patients. There are several different models
    available and they are designed to be worn 2-3
    centimeters from the elbow. This is intended to
    take the stress off the tendon where it attaches
    to the bone. The strap is to be worn during
    sports and during work. These straps should not
    be used as a sole means of treatment, but should
    supplement muscular stretching and strengthening
  • 6. Wrist braces
  • These are worn on the wrist to keep the wrist
    bent forwards, taking the stress off of the
    muscles as they attach at the elbow. Although not
    utilized routinely, some physicians utilize them
    when the pain is severe and when other measures
    have failed. They are primarily to be used at
    night while sleeping but they can be used during
    the day as well.
  • Cortisone shots
  • These are considered when the measures above have
    not worked and the pain is severe. The cortisone
    is injected into the area of the inflamed tendons
    in order to decrease the inflammation. After the
    shot, most physicians recommend that the patient
    return to using ice and anti-inflammatory
    medication. Sometimes the shot is curative and
    sometimes more than one shot is necessary.
  • 8. Extracorporeal shock wave therapy
  • Shock wave therapy sends sound waves to the
    elbow. These sound waves create "microtrauma"
    that promote the body's natural healing
    processes. Shock wave therapy is considered
    experimental by many doctors, but some sources
    show it can be effective.
  • With appropriate management, most minor cases of
    golfers elbow that have not been present for long
    can usually recover within a few weeks. In more
    severe and chronic cases recovery can be a
    lengthy process and may take up to 6 months in
    those who have had their condition for a long
    period of time. Early physiotherapy intervention
    is therefore vital to hasten recovery.

SURGICAL TREATMENT Sometimes nonsurgical
treatment fails to stop the pain or help patients
regain use of the elbow. In these cases, surgery
may be necessary. Tendon Debridement When
problems are caused by tendonosis, surgeons may
choose to take out (debride) only the affected
tissues within the tendon. In these cases, the
surgeon cleans up the tendon, removing only the
damaged tissue.
Tendon Release A commonly used surgery for
golfer's elbow is called a medial epicondyle
release. This surgery takes tension off the
flexor tendon. The surgeon begins by making an
incision along the arm over the medial
epicondyle. Soft tissues are gently moved aside
so the surgeon can see the point where the flexor
tendon attaches to the medial epicondyle. The
flexor tendon is then cut where it connects to
the medial epicondyle. The surgeon splits the
tendon and takes out any extra scar tissue. Any
bone spurs found on the medial epicondyle are
removed. (Bone spurs are pointed bumps that can
grow on the surface of the bones.) Some surgeons
suture the loose end of the tendon to the nearby
fascia tissue. (Fascia tissue covers the muscles
and organs throughout your body.) Your surgeon
will look at the ulnar nerve, to make sure that
it is not being pinched. If the nerve looks fine,
the skin is then stitched together.
This surgery can usually be done on an outpatient
basis, which means that you don't have to stay
overnight in the hospital. It can be done using a
general anesthetic or a regional anesthetic. A
general anesthetic puts you to sleep. A regional
anesthetic blocks only certain nerves for several
hours. For surgery on the elbow, you would most
likely get an axillary block to numb your arm.