Medial Epicondylitis
Introduction and prevalence
Medial epicondylitis, commonly called the golfer's elbow, is tendinosis of the wrist flexors and pronators attaching to the medial epicondyle of the humerus. Medial epicondylitis accounts for about 10% of all epicondylitis cases and is one tenth as common as lateral epicondylitis. The total prevalence of medial epicondylitis is less than 1% .
Etiology and Pathophysiology
Medial epicondylitis results from repetitive strain caused by activities involving gripping under load, forearm pronation, and wrist flexion, which is prevalent in athletes such as baseball pitchers, javelin throwers, golfers, tennis players, bowlers, rock climbers, archers, and weightlifters. Degenerative changes from overuse are characterized by findings such as angiofibroblastic hyperplasia or tendinosis, along with fibrosis and calcification, most commonly affecting the pronator teres and flexor carpi radialis tendons.
Clinical presentation
Common presentation is pain in the medial aspect of the elbow, exacerbated with activities such as gripping, throwing, and forearm flexion/pronation, worst in the morning, and associated numbness in the distribution of the ulnar nerve in the hand. Obtaining a history of activities and profession is necessary.
Physical examination
Tenderness around the medial epicondyle is a common finding. The pain is generally worsened by resisted wrist flexion and pronation when the elbow is flexed at 90°. In addition, Tinel's sign at the medial elbow in flexion, within the cubital tunnel, along with a careful neurological examination, including sensory and motor testing, of the upper extremity should be conducted.
Investigations
Diagnosis is usually clinical, however if any clinical ambiguity, plain radiograph can be used to assess calcification in the flexor-pronator tendons or traction osteophytes, along with other bony abnormalities. On MRI, thickened common flexor tendon sheath and increased T2 signal intensity are suggestive of medial epicondylitis. On ultrasound, focal, hypoechoic changes in the common flexor tendon, thickening of the tendon sheath, partial or full-thickness tears, and cortical irregularities at the medial epicondyle can be assessed.
Management
Management is usually conservative and includes cessation of offending activities, analgesics, NSAIDs (oral and topical), guided physiotherapy, and bracing. Therapy focuses on achieving a full range of motion without pain, followed by stretching and progressive isometric exercises. For bracing, the strap should be positioned approximately 2 cm below the medial epicondyle and a nighttime volar wrist splint can prevent stress caused by sleeping positioning. Kinesiology tape is an alternative to traditional bracing methods. Corticosteroid injections are useful for short-term symptom relief. Treatments such as prolotherapy, platelet-rich plasma, autologous blood, and botulinum toxin injections may also be effective, however, these have mostly been studied in the context of later epicondylitis. Extracorporeal shock wave therapy, massage, transcutaneous electrical stimulation, iontophoresis, phonophoresis, and ultrasonography, may be beneficial, although evidence of their effectiveness is very limited.