Scott Duncan
Medial epicondylitis is a confusing and poorly understood condition. It is frequently referred to as “golfer's elbow.” There have been few studies with proper design methodology or power to scientifically delineate definitive treatment requirements. Medial epicondylitis is perhaps the most common cause of medial elbow pain. The term epicondylitis is really a misnomer because there is minimal histologic evidence of inflammatory disease. It most likely is a tendinosis, i.e., a degenerative condition of the tendon. This tendinosis appears to be a failure of tendon healing in the face of continual microtrauma. The diagnosis can be difficult and may be found in conjunction with ulnar neuropathy at the elbow.
Pathogenesis
Etiology
The etiology of medial epicondylitis suggests that there is a repetitive overuse or stressing of the flexor pronator mass musculature resulting in microtrauma. Degenerative changes involving the musculotendinous unit of the medial epicondyle appear to be brought about by a chronic repetitive concentric and eccentric loading of the flexor pronator musculature. These repetitive eccentric and concentric contractions load the muscle and tendon, causing microtrauma. These microtears fail to heal and can build up over time. The degenerative changes are usually seen in the pronator teres as well as the flexor carpi radialis muscles. A single traumatic event such as a direct blow or sudden-overload eccentric contraction can result in the development of epicondylitis; however, the repetitive overuse theory is usually attributed as the main cause. Activities that require repetitive forearm pronation as well as wrist flexion have been associated with causing medial epicondylitis.
Medial epicondylitis has been related to sports such as golf, tennis, baseball, racquetball, bowling, football, archery, javelin throwing, and weight lifting. However, this is not just an athletic-type injury; some occupations require significant physical activity. For example, butchers, carpenters, and plumbers are at potential risk because of the repetitive forearm pronation and wrist flexion involved with their occupations. It is thought that overload from extrinsic valgus stresses and intrinsic muscular contractions can predispose the flexor pronator mass musculature to injury and accumulative microdegenerative trauma involving the pronator teres, flexor carpi radialis, and occasionally the flexor carpi ulnaris. Most commonly what is seen is a microtear in the interface between the pronator teres and the flexor carpi radialis origins with subsequent development of fibrotic granulation tissue.
Epidemiology
Medial epicondylar tendinosis occurs much less frequently than its lateral counterpart, lateral epicondylitis. The predominant age groups affected are fourth and fifth decades although almost any age group can potentially be affected. However, it has not been described in children. Male and female prevalence appears to be equal in most studies. Other studies have suggested a 2:1 male-to-female ratio. Approximately 75% of patients are usually symptomatic in their dominant extremity. Approximately 30% of patients describe the pain being associated with an acute injury. Most patients, roughly 70% of cases, describe a much more insidious onset of their symptoms. Almost half of all cases will have some ulnar nerve symptoms associated with them. Other conditions commonly seen in patients with medial epicondylitis include an approximately 30% rate of prior history of lateral epicondylitis, a 25% rate of history of carpal tunnel syndrome, and a 20% rate of prior rotator cuff tendinosis. In younger patients other causes of epicondylar pain should be ruled out prior to considering this degenerative condition more commonly seen in middle-aged adults. Other literature has suggested no predilection for the dominant hand or between genders.
Pathophysiology
Early descriptions of medial and lateral epicondylitis were posed and postulated in inflammatory conditions that involved bursa, periosteum, synovium, and ligaments. The recent literature has discounted these theories, and the
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histologic analysis of Nirschl and Pettrone has demonstrated normal collagen and architecture disrupted by fibroblastic immature vascular response as well as an incomplete reparative process. Importantly, there is a lack of acute and chronic inflammatory cellular architecture. In the very early stages of medial epicondylitis, there may be some inflammatory or synovitis-type patterns present. However, more definitively in the later stages there is evidence of microtearing with tendon degeneration, with or without calcification, and failure to complete a neovascular healing response. The pathologic tissue appears grossly friable and has a gray to tannish color.
Nirschl and Pettrone have coined the term “angiofibroblastic hyperplasia” to describe such structural changes. Nirschl has described four stages of epicondylar tendinosis. In stage one there is generalized inflammation that can recede. In stage two the injury is noted to have pathologic tissue changes of the angiofibroblastic type. Stage three is noted to have degeneration that results in structural failure. Finally, stage four can include components of stages two and three but is also accompanied by marked fibrosis or calcifications. The exact pathophysiology of medial epicondylitis has not yet been established. It is agreed that the injury results from microtearing of the tendon origin at the epicondyle with failure of the usual reparative processes to mount a response. The subsequent tendon tearing and degeneration changes the usual musculotendinous biomechanics of the elbow, resulting in the pain and dysfunction seen clinically.
Classification
Gable and Morrey have described a classification for medial epicondylitis based on the presence and severity of concomitant ulnar neuropathy at the elbow. In their classification system, type 1A includes patients without any associated ulnar nerve symptoms. Type 1B has mild ulnar nerve signs or symptoms. In the type 2 medial epicondylitis patient, there are moderate or severe ulnar nerve symptoms with objective deficits noted on the physical exam as well as denervation noted on electromyography.
Diagnosis
History and Physical Examination
Clinical Features
A patient who presents with medial epicondylitis can come from various situations. Some are from the workplace and have an environment that is consistent with repetitive activity. Others relate it to being problematic with their athletic endeavors. When obtaining the history, it is useful to divide patients based on the manner of onset, provocative activities, localization of pain, and severity of discomfort. Other specific characteristics to specifically ask about include onset of pain with the date, time, and activity being performed. For example, a golfer may recall a missed hit striking the ground with the club that resulted in a sudden deceleration, or the tennis player or racquetball player may remember a specific extra-hard hit or serve that resulted in pain about the medial aspect of the elbow. Is the patient able to localize the pain with one specific finger to the medial epicondylar region or is he or she vague in where the symptoms are located? Are symptoms better with rest and reproduced with certain provocative activities? Do they have other areas of significant pain about the upper extremity or neck or is it again specifically localized to the medial epicondylar region? Is worker's compensation or other potential secondary gain involved? Do they describe numbness and tingling in an anatomic or in a nonanatomic distribution?
The textbook case of medial epicondylitis should be mechanically based in that the pain is exacerbated or reproduced by the stress and strain of the wrist flexors and forearm pronators on the medial side. Otherwise other conditions need to be considered (Table 54-1). The most important injuries to exclude when evaluating a patient with medial epicondylitis involve, again, the amount of ulnar nerve involvement and any type of injury to the medial collateral ligament. In overhead throwing athletes, this can be a challenging differential. One technique for trying to differentiate medial tendon injury from medial collateral ligament insufficiency is by placing a valgus force to a slightly flexed elbow with the wrist in volar flexion and the forearm pronated. This test usually does not elicit pain or demonstrate laxity if the diagnosis is medial epicondylitis only. Other considerations to think about are lower cervical radiculopathies involving C7 through T1 that may cause radiating pain along the medial aspect of the upper extremity.
Ideally the physical exam should be done with the patient relaxed and sitting. The patient frequently is able to help identify the tenderest spot. Classic findings consist of exquisite and repeatable localization of medial epicondylar tenderness with palpation. Some patients may have maximal tenderness just distal to the epicondylar region in the proximal flexor pronator mass. The medial pain can be exacerbated with resisted pronation and flexion of the wrist. The usual physical exam shows some tenderness over the anterior aspect of the medial epicondyle. More than 90% of patients will have pain with resisted pronation and more than 70% pain with resisted wrist flexion. Wrist and elbow range of motion are typically normal. Local injection of lidocaine or Marcaine results in near complete obliteration of the discomfort.
Of course the ulnar nerve needs to be evaluated including the Tinel sign over the ulnar nerve in the region of the elbow, an elbow flexion test, ulnar nerve compression test, and
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checking the ulnar nerve for subluxation about the medial epicondyle (Table 54-2) Distally, function of the ulnar nerve needs to be assessed with two-point discrimination in intrinsic strength and dorsal cutaneous nerve status. Other things to check for include the cervical spine to rule out a radiculopathy. The skin about the elbow should be inspected. Palpation about the biceps insertion, brachialis, and lacertus needs to be performed. The triceps insertion and olecranon should also be palpated. Kurvers and Verhaar have noted that in their patient series, approximately 20% of patients with medial epicondylitis for >12 months had flexion contractors ranging from 10 to 25 degrees. Furthermore, 15% of their patient population had decreased active supination range of motion by 5 to 15 degrees. Occasionally local swelling and warmth may be present.
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TABLE 54-1 Medial Elbow Pain Differential Diagnosis |
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TABLE 54-2 Ulnar Nerve Transposition Indications in Patients with Medial Epicondylitis |
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Radiographic Features
The radiographs of elbows affected with medial epicondylitis are usually normal. Approximately 20% to 25% of patients, however, may have some soft tissue calcification in the proximity of the medial epicondyle. Other patients, especially throwing athletes, may have ulnar-sided traction spurs and medial collateral ligament calcifications. Radiographs are also useful to rule out associated conditions such as osteoarthritis as well as medial instability with valgus stress views (if medial instability is suspected). An MRI arthrogram can be helpful in differentiating medial collateral ligament injury from medial epicondylitis. Other findings potentially seen on radiographs are loose bodies, radiocapitellar and ulnar trochlear arthritis, olecranon or coronoid impingement. In trying to differentiate calcification to the medial tendon from the medial collateral ligament, it should be noted that the calcifications in the medial tendon are usually relatively superficial whereas those in the medial collateral ligament are deep to the flexor pronator mass.
Other Studies
Electrodiagnostic evaluation of the ulnar nerve is useful in cases where ulnar neuropathy is suspected clinically. This can be used to document the severity of axonal changes. This can also be used to show nerve conduction slowing in an absolute or relative fashion compared with other nerves or the other side. The author's preference is to obtain electrodiagnostic studies with nerve conduction velocities as well as electromyographic analysis. Surgical outcome can be compromised by failing to address the ulnar neuropathy (Table 54-2). In obtaining the MRI, make sure that the facility to be used has the appropriate coils and imaging protocols as well as technical knowledge to adequately evaluate the elbow; otherwise the study will be for naught.
Diagnostic Workup
Algorithm
The reader is referred to Figure 54-1 for the work-through algorithm in evaluating the patient and proceeding with study intervention and treatment options.
Anatomy
The anatomy of the medial epicondyle consists of the flexor pronator origin; this is at the anterior medial epicondyle. The pronator teres originates in part from the superior interior medial epicondyle; however, its main origin is from an intramuscular tendon otherwise known as the medial conjoint tendon. In going from the radial to ulnar aspect of the forearm, the musculature includes the pronator teres, the flexor carpi radialis, the palmaris longus, the flexor digitorum superficialis, and the flexor carpi ulnaris. The pronator teres and flexor carpi radialis tendon and muscles are most afflicted with the alteration of stretching and acceleration during throwing and swinging.
The critical lesion of medial epicondylitis comes from the medial conjoint tendon and its associated pronator teres and flexor carpi radialis origins. The medial conjoint tendon serves as the landmark for the surgical excision of the pathology as well as a way to identify and avoid the anterior oblique ligament. Medial conjoint tendon arises from the anterior inferior epicondyle with an oblique parasagittal orientation that traverses approximately 12 cm into the proximal forearm. Any surgical dissection and elevation off the medial epicondyle posterior to the medial conjoint tendon will violate the anterior oblique ligament of the medial collateral ligament.
Professional throwing athletes can develop hypertrophy of the flexor pronator mass resulting in a flexion contracture. Frequently 50% of these individuals will have some type of flexion contracture and 30% will have an increased valgus angle compared with their contralateral extremity. Of note, though, is that these features have never been correlated with the recurrence of medial epicondylitis. The ulnar nerve transverses posteromedially about the medial epicondyle. Also, the medial antebrachial cutaneous nerve passes in this zone. Occasionally the triceps can snap over the medial epicondyle causing pain that is not related to medial epicondylitis, and this is known as a snapping triceps syndrome.
Treatment
Nonoperative Options
Nonoperative treatment works for most cases of medial epicondylitis. The purpose of this nonsurgical care is to relieve pain and allow sufficient rehabilitation so that the
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patient can return to the previous activities. Current literature suggests that roughly 5% to 15% of patients suffer recurring episodes of medial epicondylitis. However, this may represent incomplete rehabilitation or premature termination of the rehabilitative program. The initial nonoperative treatment usually consists of rest, ice, nonsteroid anti-inflammatories, local modalities, splinting, and cortisone injections. The author's preference for cortisone injection consists of a water-soluble corticosteroid mixed with 2 mL of half percent plain bupivacaine.
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Figure 54-1 Algorithm for patient evaluation and treatment. MCL, medial collateral ligament OA; osteoarthritis; NSAIDs, nonsteroidal anti-inflammatory drugs; MRI, magnetic resonance imaging; EMG/NCV, electromyogram/nerve conduction velocity. |
The injection can be both therapeutic and diagnostic. The bupivacaine should substantially reduce the pain and this should last for several hours. If the patient does not notice any relief from the symptoms or minimal relief from the symptoms, then it is unlikely the diagnosis is epicondylitis, assuming the injection was placed in the proper location.
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Most cases of medial epicondylitis do benefit from the initial injection, and this can last several months. However, repeat injections tend to have a decreasing benefit. When performing an injection about the medial aspect of the elbow for medial epicondylitis, care needs to be taken to make sure the ulnar nerve is palpated and that the needle is directed away from the cubital tunnel. I prefer to do the injection with the elbow extended and the thumb of my nondominant hand over the cubital tunnel.
A commercial wrist splint can help a patient whose pain is of sudden onset and severe. Usually a cock-up wrist splint resting the wrist at approximately 10 degrees of extension is adequate. In combination with the previously mentioned items, a 2-week course of oral nonsteroid anti-inflammatories may also be helpful. A medial counterforce brace can also be helpful for some patients, and the pad of the brace needs to be anteromedial on the flexor pronator mass but not medial or posterior medial over the ulnar nerve. If ulnar nerve symptoms are exacerbated, the brace should be discontinued.
If symptoms are improved at 6 to 8 weeks, a conditioning program can be initiated. This part of the rehabilitation starts with wrist flexor and forearm pronator stretching and progressive isometric exercises. Provocative activities, however, need to be avoided until predisease strength is restored. Eccentric and concentric resistive exercises are added once the flexibility, strength, and endurance of the patient have improved adequately to tolerate the program. Success rates of this combined approach range between 70% and 90%. The use of modalities such as ultrasound and iontophoresis may help some patients with their symptoms. However, there is no strong evidence in the literature to support widespread use of one modality over another, and no studies have shown modalities to provide prolonged long-term benefit.
Surgical Indications
If after one or two injections that provided temporary relief of the patient's symptoms the patient finds recurrence of the symptoms inhibiting function of daily activities, then these patients can be considered for surgical intervention. Patients with continued minor or intermittent symptoms whose hobbies such as tennis or golf are bothered but are not incapacitated in their activities of daily living are marginal candidates for surgery. Contraindications to surgery would be those patients who medically could not tolerate the surgery. The other candidate obviously would be those patients who received no benefit, even temporary, from an injection and are not able to demonstrate or localize the pain to the medial epicondyle.
Patients need to understand that not everyone benefits from surgery and it is rare for anyone to achieve 100% improvement. Certainly strenuous or provocative activities that brought the symptoms on before can still bring the symptoms on postoperatively. A rough rule to give patients in counseling them about surgery is that 80% of patients see 80% improvement in their symptoms. The author prefers to try a minimum of 6 months of nonoperative treatment prior to considering surgical intervention. Some authors recommend MRI or MRI arthrogram as part of the preoperative planning to rule out any concomitant pathology, to evaluate the condition of the tendons prior to surgery, and to help focus on where the pathology may be present. However, by no means is MRI mandated; this is a diagnosis that is made clinically and not by imaging studies.
Surgical Technique
Various procedures have been described such as percutaneous epicondylar release and epicondylectomy; however, the standard surgical treatment at this time consists of debridement of the degenerative nidus in the tendon. This can be summarized as excising the pathologic portion of the tendon, trying to enhance local vascularity to promote healing, performing stout reattachment of any elevated tissues to the medial epicondyle, repairing any tissue defects, and surgically decompressing the ulnar nerve and reconstructing the ulnar collateral ligament if needed. Nirschl and Pettrone have performed a debridement of abnormal tendon tissue through a longitudinal split of the medial tendon complex. The diseased tendon can be identified and excised in an elliptical fashion. The tendon origin is not disrupted.
Vangsness and Jobe described a technique that provided a greater exposure of the flexor origin and facilitated a complete debridement. They used a curvilinear incision at the medial elbow centered at the medial epicondyle. The interval between the pronator teres and flexor carpi radialis is then identified. The medial tendon is incised along the interval in the common flexor origin and is reflected directly off the epicondyle with sharp dissection. The medial collateral ligament is exposed but not disturbed. Any diseased and abnormal tissue is sharply excised, and the epicondyle is prepared with a rongeur to remove fibrous tissue. Small holes can be drilled in the medial epicondyle that create a vascular bed. Care needs to be taken to avoid entrapping any soft tissue around the drill. The common flexor origin is then reattached to the bleeding bone surface with interrupted stitches. Morrey describes his type 1A cases as requiring epicondylar debridement only, whereas type 1B cases require debridement with or without cubital tunnel decompression or transposition. Finally, his type 2 cases receive debridement with submuscular transposition of the ulnar nerve.
Technique
A 5-cm oblique incision is made just anterior to the medial epicondyle. I usually apply a sterile tourniquet and use an arm board. The medial antebrachial cutaneous nerve and its branches are identified. The incision may be easily enlarged if ulnar nerve transposition is to be considered. The common flexor pronator origin is found along with the ulnar nerve, which is protected. Usually an incision to the pronator teres and flexor carpi radialis interval is developed longitudinally (Fig. 54-2). This exposes the medial conjoint tendon. Again, care must be taken along the posterior aspect of the medial conjoint tendon because that is where the anterior oblique ligament lies. The degenerative tissue is then debrided with a rongeur as seen in Figure 54-3. The flexor pronator fascia is then repaired back to the retained rim
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of fascia at its original position or in a slightly lengthened position but not by more than >1 cm. The flexor pronator origin can be reattached to the bleeding bony surface with either interrupted sutures or through drill holes or with the attached adjacent flexor pronator origin (Fig. 54-4).
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Figure 54-2 Anatomy and exposure of the medial epicondyle. Note the medial conjoint tendon, anterior oblique ligament, and medial antebrachial cutaneous nerve branches. |
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Figure 54-3 Note reflection of forearm flexors and debridement of degenerative tissue with a rongeur. |
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Figure 54-4 The common flexor tendon is then reattached with interrupted sutures, creating a secure closure. |
Rehabilitation
The patient is then placed in a posterior plaster splint that is applied to the elbow and wrist with the elbow at 90 degrees of flexion and the forearm in neutral rotation. At approximately 10 days postoperatively, the splint is removed and any skin sutures are removed. At this point gentle passive and active nonresistive range of motion exercises are begun for the hand, wrist, and elbow. Gentle isometric exercises are usually begun at 3 to 4 weeks postoperatively. Finally at 6 weeks, more aggressive resistant wrist flexion and forearm pronation are begun. Finally the progressive strengthening program is initiated. A gradual careful return is encouraged. Total body and extremity conditioning is encouraged throughout the entire rehabilitative process. The average return for most patients to their regular activities is 3 to 6 months postoperatively. However, in some series this has been anywhere in the range from 3 to 24 months.
Complications
Potential complications associated with this surgery include injury to branches of the medial antebrachial cutaneous
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nerve with subsequent neuromas around the incision site. Other complications involve injury to the ulnar nerve. Ulnar neuritis after surgery is not uncommon for a short period of time. Scarring along the cubital tunnel can lead to ulnar nerve symptoms developing postoperatively. Medial collateral ligament injury can destabilize the elbow and result in new symptoms that were not present preoperatively. Excessive release and debridement of flexor fascia without careful repair can lead to permanent flexor weakness. After surgery hematoma formation can result, causing discomfort. Patients should be warned about numbness around the incision area as well as potential numbness in the forearm. The other potential complication of course relates to failure to obtain improvement in the patient's preoperative symptoms.
Results and Outcome
Surgical results appear to correlate with the class of medial epicondylitis. Types 1A and 1B have roughly ≥90% good or excellent results as reported in two studies and have slightly lower rates in another two studies. Two thirds of patients can take ≤6 months to obtain the good to excellent level, whereas the remaining third may take up to ≤2 years. Type 2 with its associated ulnar nerve neuropathy has a poorer prognosis. The results of type 2 medial epicondylitis are related to the failure of the ulnar neuropathy to respond to the surgical treatment. Cubital tunnel release alone as treatment for type 2 medial epicondylitis has been shown to be suboptimal. Vangness and Jobe have reported the results of their surgical intervention with 86% of patients having no limitation in use of the elbow. In their study, isokinetic and grip-strength testing revealed no significant functional loss. Gabel and Morrey have reported similar success rates after surgical treatment of medial epicondylitis, but again found ulnar neuropathy to be correlated with a poor prognosis. Using Nirschl debridement technique Ollivierre et al. analyzed 50 cases of intractable medial epicondylitis and found partial or complete pain relief in all patients. Yet, one quarter of these patients were not able to return to painfree participation after surgery.
Summary
Medial epicondylitis will continue to remain an enigmatic and problematic disease until surgeons have a better understanding of the failure of the reparative mechanisms by which this degenerative condition occurs. Nonoperative management remains the mainstay of treatment, but surgical intervention is warranted in those patients who fail nonoperative treatment and can no longer tolerate the effect of their symptoms on their activities of daily living. Most patients will have improvement in their symptoms after surgery.
Suggested Readings
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Hotchkiss RN. Epicondylitis—lateral and medial. A problem-oriented approach. Hand Clin. 2000;16:505–508.
Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg. 1994;2:1–8.
Kurvers H, Verhaar J. The results of operative treatment of medial epicondylitis. J Bone Joint Surg Am. 1995;77:1374–1379.
Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61:832–839.
Ollivierre CO, Nirschl RP, Pettrone FA. Resection and repair for medial tennis elbow. A prospective analysis. Am J Sports Med. 1995;23(2):214–221.
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.
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