What is Medial Epicondylitis?

Epicondylitis, often a cause of elbow pain for athletes and regular people, typically impacts certain areas on the elbow called the medial and lateral epicondyles, especially the lateral epicondyle. Medial epicondylitis, also known as golfer’s elbow or thrower’s elbow, happens when the tendons connected to the inside of the elbow, usually due to overuse or repeated stress. This group of muscles includes specific muscles and tendons that help us flex our hand and rotate our forearm, with some being more commonly impacted. This part of the elbow also helps in stabilizing the elbow against certain movements.

Interestingly, despite its name suggesting inflammation, chronic cases of epicondylitis might more accurately describe the degeneration of tissues and the formation of a kind of scar tissue, called angiofibroblastic hyperplasia or tendinosis. This shows that there may not necessarily be a clear inflammatory process going on, although the early stages of the condition could still involve inflammation.

What Causes Medial Epicondylitis?

Medial epicondylitis, more commonly known as golfer’s or tennis elbow, usually happens because of constant strain from activities that require a lot of gripping, turning your forearm, and bending your wrist. This issue is often seen in athletes like baseball pitchers, javelin throwers, golfers, tennis players, bowlers, rock climbers, archers, and weightlifters. The highest numbers of cases are typically seen among golfers, tennis players, and pitchers.

The problem often starts when there is too much stress on the inside part of the elbow during critical parts of throwing or swinging a golf club, specifically just before and when you are about to hit the ball or ground. While it’s often associated with sports, golfer’s or tennis elbow can also affect people in the general population who do certain jobs like carpentry, utility work, butchering, and catering. Incorrect body movements, improper techniques or unsuitable equipment often contribute to the start of this issue.

Risk Factors and Frequency for Medial Epicondylitis

Epicondylitis is a common arm condition, but the type known as medial epicondylitis is much less common than another type known as lateral epicondylitis. Medial epicondylitis only accounts for about 10% of all epicondylitis cases. Studies show that in the United States military, there are about 5.6 cases per 1000 people each year. It commonly affects women more than men, as well as middle-aged people, particularly those in their 40s and 50s. This condition usually manifests in the dominant arm.

Epicondylitis is a common arm disorder that usually affects a person’s dominant arm.
Medial epicondylitis is a type of epicondylitis that is much less common than the type known as lateral epicondylitis.
About 10% of all epicondylitis cases are due to medial epicondylitis.
In the U.S. military, the incidence rate is 5.6 cases per 1,000 people annually.
The condition more often impacts women than men and is seen most often in people in their 40s and 50s.

Some factors that increase the risk of developing medial epicondylitis include smoking, having diabetes, being overweight, and engaging in activities that require constant wrist flexion or forearm turning for 2 or more hours daily. Most people with this condition experience a reduction in symptoms over time, with approximately 80% recovering within 1 to 3 years.

Signs and Symptoms of Medial Epicondylitis

Medial elbow pain, which gets worse when gripping, throwing, or moving the forearm, is a typical symptom experienced by patients. This pain usually decreases when the person rests and may suddenly appear following an injury or develop slowly over time. Some people may feel pain spreading to their forearm or wrist, and persistent cases may lead to reduced grip strength. It’s common for people to experience more severe pain in the morning. A detailed history of the patient’s social activities, especially those involving repeated elbow bending, wrist movement, and twisting, can help identify potential causes. Patients often report feelings of numbness in the hand relating to the ulnar nerve due to its location behind the medial epicondyle within the cubital tunnel.

The elbow may not present any visible signs like swelling or redness, especially in cases that have persisted for a long time. The tenderness can often be felt most 5 to 10 mm below the medial epicondyle at the flexor-pronator mass’s attachment site. The pain usually worsens with resistance to wrist flexion and pronation, with pronation being the strongest trigger. During these tests, the elbow should be bent at 90 degrees to identify the pronator teres specifically. If medial epicondylitis is left untreated, a flexion contracture could develop.

As patients with medial epicondylitis can also exhibit ulnar neuritis, a thorough neurological examination is needed. This would include testing hand and wrist sensation and movement, checking for Tinel’s sign at the medial elbow within the cubital tunnel, assessing for subluxation of the ulnar nerve out of the ulnar groove, performing the milking maneuver, and a valgus stress test to examine the stability of the ulnar collateral ligament.

Testing for Medial Epicondylitis

Diagnosing medial epicondylitis, often known as golfer’s elbow, usually involves reviewing your medical history and a physical exam by a doctor. In many cases, this is all that’s needed. However, if the symptoms aren’t clear-cut, certain imaging techniques might be used to confirm the diagnosis and rule out other conditions.

Plain radiographs, which are just a type of X-ray, could be used to spot calcium build-up in tendons or bony outgrowths known as “traction osteophytes”. They’re especially useful for patients who’ve had a sudden onset of pain due to an injury. Also, these X-rays are vital for spotting bone abnormalities in children, because their growth plates – the areas of growing tissue near the ends of the long bones – are more likely to get injured than tendons.

Magnetic Resonance Imaging (MRI) is considered the best method for diagnosing golfer’s elbow. On an MRI, a thickened common flexor tendon sheath (a layer of membrane around the tendon) and an increased intensity of some MRI signals can suggest medial epicondylitis. Additionally, MRIs can spot other potential issues inside the joint or with soft tissues, like loose bodies (small loose fragments of cartilage or bone), injuries to the ulnar collateral ligament (a ligament on the inner side of your elbow), or osteochondritis dissecans (a condition in which a fragment of bone comes loose).

Musculoskeletal ultrasound, a type of imaging test that uses sound waves to produce pictures of muscles, tendons, ligaments, and joints, is also very accurate (95.2% sensitive and 92% specific) for diagnosing golfer’s elbow. Common ultrasound findings that suggest golfer’s elbow include focal, hypoechoic (darker areas) changes in the common flexor tendon, thickening of the tendon sheath, partial or full-thickness tears, new blood vessel formation using Doppler ultrasound, and irregularities at the bump on the inside of the elbow (the medial epicondyle). A nice thing about ultrasound is that it allows for real-time imaging to check for sliding of the ulnar nerve and instability of the collateral ligament.

If your doctor thinks you might have ulnar neuritis (a condition where the ulnar nerve gets inflamed) or neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness), they may use electromyography (a diagnostic procedure to assess the health of muscles and the nerve cells that control them) and nerve conduction studies (tests that measure how well and how fast the nerves can send electrical signals) to help with the diagnosis.

Treatment Options for Medial Epicondylitis

Medial epicondylitis, often called ‘golfer’s elbow’, is usually treated without surgery. The treatment process can be divided into three stages.

Starting with the first phase, avoidance of actions or exercises that cause pain is recommended along with treatments that relieve pain. Next, in the second phase, a guided physiotherapy and recovery program begins. The final stage involves changing any previous activities that caused the issue.

Non-Surgical Treatment

To initially alleviate the pain, you can apply ice, particularly after any strain, and take pain-relieving medications such as acetaminophen and non-steroidal anti-inflammatories. You can also use topical medications applied directly on the skin. Wearing a brace can also help. This would be either an elbow strap, positioned about an inch below the elbow to reduce tendon strain, or a night-time wrist splint to prevent stress from sleeping positions. Kinesiology tape is another option. While specific research on its effectiveness for golfer’s elbow is lacking, it has shown promise in treating tennis elbow.

A key part of treatment is active involvement in physical therapy. The therapy focuses on getting full movement back without pain, then moving onto stretching and gradually increasing resistance exercises. As things improve, these exercises should be more difficult than before the injury. Once repeated exercises can be done comfortably, you can start getting back into sports or work-specific activities. The therapy ends with exercises to maintain flexibility and strength, reducing the likelihood of the injury happening again. To prevent future issues, adjustments to any sporting or work equipment and changes to techniques are recommended. For example, if you play tennis, using a larger racquet grip, loosening the strings, and improving the serve and forehand techniques can all help.

Supplemental Therapies

Corticosteroid injections can provide temporary relief for up to 6 weeks, but longer-term benefits have not been found. Other treatments, such as prolotherapy, platelet-rich plasma, autologous blood, and botulinum toxin injections may also be effective, but more research is needed to confirm their use in golfer’s elbow. Take note that care is required with injections due to nearby nerves, and ultrasound is suggested to guide the needle.

Experimental Treatments

Other treatments that may offer benefits include shock wave therapy, massage, electric stimulation through the skin, iontophoresis, phonophoresis, and ultrasound. However, science has not yet fully proven the effectiveness of these methods.

Surgical Treatment

If the non-surgical treatments aren’t working after 6 to 12 months, surgery may be needed. The surgery consists of cleaning out the degenerated tendon, releasing the tendon at the elbow, and drilling into the elbow to increase blood flow. If there is pressure or squeezing on the ulnar nerve, that can be addressed as well. After the operation, rest and wearing a brace are recommended, with therapy starting 7 to 10 days later to improve the range of motion. Gentle resistance exercises can begin 3 to 4 weeks after surgery, with a more demanding strengthening program starting between 6 and 12 weeks. A slow return to sports activities can start between 3 and 6 months after the surgery.

When a doctor is trying to diagnose medial epicondylitis (golfer’s elbow), they need to consider other conditions that cause similar symptoms. These could be:

Ulnar neuropathy (a condition affecting the ulnar nerve)
Cervical radiculopathy (a nerve problem causing pain and loss of sensation in the arm)
Ulnar (medial) collateral ligament sprain or tear
Valgus extension overload syndrome (a common elbow injury in athletes)
Posteromedial elbow impingement (obstruction or interference at the joint)
Synovial plica (fold of synovial membrane in the elbow)
Synovitis (inflammation of the synovial membrane)
Elbow bursitis (inflammation of the small sacs in the elbow joint)
Rheumatoid arthritis (a chronic inflammatory disorder)
Osteoarthritis (a type of joint disease that affects mostly old people)
Osteochondritis dissecans (bone damage from reduced blood flow)
Occult fracture (a fracture not detected by normal X-ray)
Myofascial pain complex (pain in certain muscle groups)
Shingles (a painful skin rash with blisters)

A doctor will need to conduct necessary tests to be sure of the diagnosis.

What to expect with Medial Epicondylitis

The outlook for people with medial epicondylitis (commonly known as golfer’s elbow) is usually good. Many find relief through various treatments such as physical therapy, non-opiate pain relievers (safer alternatives to opioids that manage pain), and wearing braces. However, it can be less predictable to treat than lateral epicondylitis (tennis elbow).

If the initial treatments don’t work, other methods might be effective. These include corticosteroid injections (anti-inflammatory medicine), prolotherapy (injecting an irritant solution into the damaged ligament to stimulate healing), or platelet-rich plasma injections (injecting a concentration of a patient’s own platelets to accelerate the healing of injured tendons).

Surgery might be an option if other conservative treatments have not been successful. However, it’s worth noting that patients with both golfer’s elbow and ulnar neuritis (inflammation of the ulnar nerve) may face a less favorable outcome.

Possible Complications When Diagnosed with Medial Epicondylitis

After successful treatment, most people can go back to their regular duties and activities. However, even though complications are not common, some might still experience ongoing pain or symptoms that keep coming back. If a patient requires surgery, there’s a small chance of complications like harm to certain nerves (medial antebrachial cutaneous nerve or ulnar nerve) or an infection. For those hard-to-treat cases that end up needing a surgical procedure, while pain is expected to be less, about one in five patients might not be able to achieve the same high level of athletic performance they had before.

Common Side Effects:

Persistent or recurring pain
Potential nerve injury (Medial antebrachial cutaneous nerve or ulnar nerve)
Infection
Reduced athletic performance for some patients (Approximately 20%)

Preventing Medial Epicondylitis

It’s important to make patients aware of the significance of starting rehabilitation as soon as possible and the need to change or avoid recurring activities that might worsen their condition. When making treatment plans, it’s also key to ensure that patients comprehend and have realistic expectations. Additionally, it is crucial to provide patients with guidance and examples for exercises and stretches they can do at home. This can greatly help minimize the chance of their symptoms coming back.

Frequently asked questions

Medial epicondylitis, also known as golfer's elbow or thrower's elbow, is the inflammation or degeneration of the tendons connected to the inside of the elbow. It is typically caused by overuse or repeated stress and affects the muscles and tendons that help flex the hand and rotate the forearm.

About 10% of all epicondylitis cases are due to medial epicondylitis.

Signs and symptoms of Medial Epicondylitis include: - Medial elbow pain that worsens when gripping, throwing, or moving the forearm. - Pain that decreases when resting and may suddenly appear following an injury or develop slowly over time. - Pain spreading to the forearm or wrist. - Reduced grip strength in persistent cases. - More severe pain in the morning. - Numbness in the hand related to the ulnar nerve. - Tenderness felt below the medial epicondyle at the flexor-pronator mass's attachment site. - Pain worsening with resistance to wrist flexion and pronation, with pronation being the strongest trigger. - Possible development of a flexion contracture if left untreated. - Possible presence of ulnar neuritis, requiring a thorough neurological examination. - Testing hand and wrist sensation and movement. - Checking for Tinel's sign at the medial elbow within the cubital tunnel. - Assessing for subluxation of the ulnar nerve out of the ulnar groove. - Performing the milking maneuver. - Conducting a valgus stress test to examine the stability of the ulnar collateral ligament.

Medial Epicondylitis is usually caused by constant strain from activities that require a lot of gripping, turning your forearm, and bending your wrist. It can also be caused by incorrect body movements, improper techniques, or unsuitable equipment.

The other conditions that a doctor needs to rule out when diagnosing Medial Epicondylitis are: - Ulnar neuropathy (a condition affecting the ulnar nerve) - Cervical radiculopathy (a nerve problem causing pain and loss of sensation in the arm) - Ulnar (medial) collateral ligament sprain or tear - Valgus extension overload syndrome (a common elbow injury in athletes) - Posteromedial elbow impingement (obstruction or interference at the joint) - Synovial plica (fold of synovial membrane in the elbow) - Synovitis (inflammation of the synovial membrane) - Elbow bursitis (inflammation of the small sacs in the elbow joint) - Rheumatoid arthritis (a chronic inflammatory disorder) - Osteoarthritis (a type of joint disease that affects mostly old people) - Osteochondritis dissecans (bone damage from reduced blood flow) - Occult fracture (a fracture not detected by normal X-ray) - Myofascial pain complex (pain in certain muscle groups) - Shingles (a painful skin rash with blisters)

The types of tests that may be needed to diagnose medial epicondylitis (golfer's elbow) include: 1. Physical exam: A doctor will review your medical history and perform a physical examination to assess the symptoms and determine if they are consistent with golfer's elbow. 2. Imaging techniques: - Plain radiographs (X-rays): These can be used to identify calcium build-up in tendons or bony outgrowths called "traction osteophytes." They are particularly useful for sudden onset pain due to an injury and for detecting bone abnormalities in children. - Magnetic Resonance Imaging (MRI): Considered the best method for diagnosing golfer's elbow, an MRI can show a thickened common flexor tendon sheath, increased intensity of MRI signals, and other potential issues within the joint or soft tissues. - Musculoskeletal ultrasound: This imaging test uses sound waves to produce pictures of muscles, tendons, ligaments, and joints. It can accurately diagnose golfer's elbow by identifying specific ultrasound findings such as changes in the common flexor tendon, tendon sheath thickening, tears, and irregularities at the medial epicondyle. 3. Electromyography (EMG) and nerve conduction studies: These tests may be used if ulnar neuritis or neuropathy is suspected. EMG assesses the health of muscles and the nerve cells controlling them, while nerve conduction studies measure how well and how fast nerves can send electrical signals. It's important to note that not all of these tests may be necessary for every case of golfer's elbow. The specific tests ordered will depend on the individual's symptoms and the doctor's clinical judgment.

Medial epicondylitis, also known as golfer's elbow, is typically treated without surgery. The treatment process involves three stages. In the first phase, it is recommended to avoid actions or exercises that cause pain and use treatments to relieve pain. The second phase involves guided physiotherapy and a recovery program to regain full movement without pain, followed by stretching and gradually increasing resistance exercises. The final stage includes making changes to previous activities that caused the issue. Non-surgical treatments include applying ice, taking pain-relieving medications, using topical medications, wearing a brace, and considering kinesiology tape. Supplemental therapies and experimental treatments may also be considered. If non-surgical treatments are ineffective after 6 to 12 months, surgery may be necessary.

The side effects when treating Medial Epicondylitis include: - Persistent or recurring pain - Potential nerve injury (Medial antebrachial cutaneous nerve or ulnar nerve) - Infection - Reduced athletic performance for some patients (Approximately 20%)

The prognosis for Medial Epicondylitis, commonly known as golfer's elbow, is usually good. Most people with this condition experience a reduction in symptoms over time, with approximately 80% recovering within 1 to 3 years. Many find relief through various treatments such as physical therapy, non-opiate pain relievers, and wearing braces. If initial treatments don't work, other methods like corticosteroid injections, prolotherapy, or platelet-rich plasma injections may be effective. Surgery might be an option if conservative treatments have not been successful, although patients with both golfer's elbow and ulnar neuritis may face a less favorable outcome.

You should see an orthopedic doctor or a sports medicine specialist for Medial Epicondylitis.

Joint Muscle and Bone Overuse Tendinopathy