Joseph E. Robison and Peter J. Evans
DEFINITION
Medial epicondylitis involves tendinosis at the origin of the flexor–pronator mass.
It is commonly referred to as “golfer's elbow,” although there is a stronger association with racquet sports and manual labor.4
ANATOMY
The common flexor–pronator origin is primarily on the anterior aspect of the medial epicondyle.
The common flexor–pronator origin includes the humeral head of the pronator teres, the flexor carpi radialis (FCR), the flexor carpi ulnaris, and a small portion of the flexor digitorum superficialis.
The palmaris longus also shares the origin, although this is not likely to be clinically relevant.
PATHOGENESIS
Epicondylitis results from repetitive microtrauma followed by an incomplete reparative response that results in tendinosis, a pathologic state in which the degenerative tendon cannot heal itself effectively.
Epicondylitis can be seen with medial collateral ligament instability whereby myotendinous overload occurs in an attempt to dynamically stabilize the ulnohumeral joint. In this scenario, ulnar neuropathy often is part of a trio of pathology.
NATURAL HISTORY
Most patients improve with conservative treatment.
However, a greater percentage of patients with medial epicondylitis go on to surgical treatment when compared to patients with lateral epicondylitis.3
PATIENT HISTORY AND PHYSICAL FINDINGS
Patients commonly complain of forearm pain rather than elbow pain. At times the inflammation is significant enough to cause irritation of the ulnar nerve as it enters the flexor carpi ulnaris, causing ulnar nerve symptoms (eg, local irritability and distal numbness and tingling).
Onset usually is insidious, but the patient may recall an inciting event.
Medial epicondylitis can be present simultaneously with lateral epicondylitis.
Examination methods include the following:
Palpation of the medial epicondyle for tenderness, a universal finding in medial epicondylitis
Resisted pronation is highly sensitive for medial epicondylitis.1
A decreased ROM suggests intra-articular pathology such as arthritis.
If resisted wrist flexion reproduced symptoms, it supports a diagnosis of medial epicondylitis.
Tap the ulnar nerve in the cubital tunnel and along its path into the ECU. Presence of a tingling sensation locally prompts further nerve investigation.
Flex patient's elbow maximally, then compress the ulnar nerve just proximal to the cubital tunnel. Presence of hand numbness or tingling prompts further nerve investigation.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain radiographs may show calcifications at the flexorpronator origin.
MRI will reliably demonstrate increased intratendon signal on T2-weighted sequences. Most will also show increased intratendon signal and/or tendon thickening on T1-weighted sequences.
A small percentage of patients may show increased T2 signal in the medial epicondyle or anconeus edema.2
Periosteal reaction is not commonly seen on MRI.2
Electrophysiologic testing (electromyography and nerve conduction studies) are warranted if patients have ulnar nerve symptoms, but with mild ulnar neuropathy these tests have a very low sensitivity.
DIFFERENTIAL DIAGNOSIS
Pronator syndrome
Medial collateral ligament injury
Ulnar neuropathy
Arthritis
Cervical radiculopathy
Malingering
NONOPERATIVE MANAGEMENT
Appropriate initial treatment includes avoidance of painful activities and symptomatic relief with nonsteroidal antiinflammatory drugs and ice.
Daytime wrist bracing for exertional activities
Physical or occupational therapy to supervise and instruct on stretching and strengthening protocol for patients not otherwise inclined to comply with those instructions
Although corticosteroid injection at the medial epicondyle has been shown to provide temporary symptomatic relief, it does not affect the natural history.5 Repeat injections should be avoided to avoid tendon weakening and rupture.
Ulnar nerve injury has been reported with injection, so careful attention should be paid to the location of the nerve and whether or not it is subluxed.
SURGICAL MANAGEMENT
A minority of patients fail nonoperative management.
Careful patient selection will ensure an excellent outcome with surgical management.
Preoperative Planning
Be prepared to address concurrent ulnar nerve pathology. If necessary, ulnar nerve decompression should be performed in situ, using subcutaneous or submuscular transposition.
In thin patients, and especially those who have lifestyles in which the inner elbow is struck frequently, we prefer submuscular transposition with flexor pronator lengthening, which definitively treats epicondylitis as well.
Be prepared to address flexor pronator tears or avulsion. These typically will present more abruptly, with acute or chronic pain, ecchymosis, and swelling.
It will be necessary to débride the ruptured degenerative tissue (FIG 1) and repair it by retensioning it close to the origin and closing the gap with healthier medial and lateral portions of the flexor pronator origin down to the medial epicondyle (as shown in Tech Fig 2D).
Positioning
The patient is placed in the supine position.
The arm is externally rotated at the shoulder and padding is placed under the elbow.
The arm should rest in a position allowing ready access to the medial aspect of the elbow without requiring constant holding by an assistant.
Approach
The elbow should be examined after the administration of anesthesia to ensure stability, and the result documented in the operative note.
The goal of surgery is to débride the degenerative tissue at the flexor–pronator origin and create an environment conducive to proper healing of the tendon.
FIG 1 • The common flexors can be seen ruptured and retracted distal to the medial epicondyle.
TECHNIQUES
MEDIAL EPICONDYLAR FASCIECTOMY AND PARTIAL OSTECTOMY
Incision and Dissection
A 3- to 5-cm incision through the skin only is made beginning just proximal to and in the center of the medial epicondyle and extending distally along the axis of the forearm (TECH FIG 1A).
Blunt dissection with scissors is carried through the subcutaneous tissues, taking care to preserve medial antebrachial cutaneous nerve branches, which commonly cross the field (TECH FIG 1B).
The subcutaneous tissues are gently swept away, exposing the fascia of the flexor–pronator mass.
The ulnar nerve is palpated, and the elbow is put through a range of motion to check for ulnar nerve subluxation. The result is documented in the operative note.
The fascia overlying the interval between the pronator and FCR is then incised in line with the fibers to expose the tendon origin (TECH FIG 1C). The exact location can be altered depending on clinical examination and the point of maximal tenderness.
TECH FIG 1 • A. A 3- to 5-cm incision is started just proximal to the medial epicondyle. B. The medial antebrachial cutaneous nerve is identified and protected. C. The interval between the FCR and common flexors is used and split in line with the fibers. D. The FCR is elevated, and the deeper degenerative tendon of the FCR and pronator is identified.
The pronator is reflected anteriorly and the FCR posteriorly, exposing the abnormal, deeper tendon tissue (TECH FIG 1D).
Fasciectomy and Partial Ostectomy
The abnormal tissue is excised. It can be identified by its grayish, unorganized mucoid appearance. Abnormal tissue will scrape away with a no. 15 blade, but normal tendon will remain attached (ie, Nirschl scratch test).
The pathologic tissue is débrided to margins showing an organized, tendinous appearance.
The area of excision usually is 1 to 1.5 cm long and 3 to 5 mm wide (TECH FIG 2A).
A rongeur is used to roughen the anterior portion of the medial epicondyle to a bleeding surface without removing cortical bone (TECH FIG 2B,C).
The defect in the tendon is closed with a running absorbable suture, using 0 or 1-0 suture material with a tapered needle (TECH FIG 2D).
The subdermal layer is closed with buried, interrupted absorbable sutures, followed by a subcuticular skin closure and Steri-strips (TECH FIG 2E).
TECH FIG 2 • A. Degenerative tissue is excised. The remaining healthy tendon is stable and cannot be scraped away with a no. 15 blade. B. The anterior portion of the medial epicondyle is scraped or rongeured to remove any remaining degenerative tendon. C. The bony cortex is not violated, however. D. The muscle interval is closed with a running size 0 Vicryl suture and tied with inverted knots. E. Skin closure is done with a running 3-0 Prolene suture.
POSTOPERATIVE CARE
Postoperatively, the patient is placed in a soft dressing and a removable cock-up wrist brace.
The elbow is not immobilized, and gentle ROM is allowed immediately.
The dressing is removed in 3 to 5 days. The patient may perform activities of daily living as tolerated with the wrist brace, removing the wrist brace several times daily for ROM.
Exertion is avoided.
A strengthening program is initiated in 6 weeks with a counterforce brace.
All restrictions are removed at 3 months, but impact activities are not allowed until 4 to 6 months postoperatively. Return of full, pain-free activity can take 6 to 24 months.
OUTCOMES
Over 85% of all patients will have return to full activities with no pain or only mild, occasional pain. Among high-level athletes, 75% to 85% will return to their previous level. In patients with mild or no ulnar nerve symptoms, the success rate is greater than 95%.1,6
In patients with more than moderate ulnar nerve symptoms, there is a trend toward less favorable and less predictable outcomes, although a satisfactory result still is possible.
It is uncommon for a patient to have absolutely no improvement in pain after surgery, even if the subjective outcome is unsatisfactory. Such a result should prompt consideration of incorrect diagnosis or the possibility of secondary gain issues.
COMPLICATIONS
Medial antebrachial cutaneous nerve injury
Grip weakness
Weakness with wrist flexion or pronation
Hematoma
Infection
Ulnar nerve injury
Medial collateral ligament injury
REFERENCES
1. Gabel GT, Morrey BF. Operative treatment of medial epicondylitis. Influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am 1995;77A:1065–1069.
2. Martin CE, Schweitzer ME. MR imaging of epicondylitis. Skeletal Radiol 1998;27:133–138.
3. O'Dwyer KJ, Howie CR. Medial epicondylitis of the elbow. Int Orthop 1995;19:69–71.
4. Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow: A prospective analysis. Am J Sports Med 1995;23:214–221.
5. Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis: A prospective study of sixty elbows. J Bone Joint Surg Am 1997;79:1648–1652.
6. Vangsness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis: Results in 35 elbows. J Bone Joint Surg Br 1991;73:409–411.