Understanding and Managing Medial Epicondylitis (Golfer’s Elbow)

Introduction

Medial epicondylitis, commonly referred to as golfer’s elbow, is a common musculoskeletal condition characterized by pain and dysfunction in the medial aspect of the elbow. This condition primarily affects the tendons that attach to the medial epicondyle of the humerus, particularly the common flexor tendon (CFT). Despite being known as golfer's elbow, it can occur in anyone who engages in activities involving repetitive wrist flexion and forearm pronation. This article provides an in-depth review of the pathology, epidemiology, diagnosis, differential diagnosis, and management strategies for medial epicondylitis, supported by current medical literature.

Pathology

Medial epicondylitis involves the degeneration of the flexor-pronator tendon, which comprises the pronator teres (PT), flexor carpi radialis (FCR), palmaris longus (PL), flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS) muscles. The CFT is approximately 3 cm long and crosses the ulnohumeral joint medially, attaching to the medial humeral epicondyle anteriorly and proximally to the anterior bundle of the ulnar collateral ligament (UCL). The fibers of the CFT run parallel to those of the UCL, providing dynamic stability to the elbow joint.

The primary mechanism of injury is repetitive eccentric loading of the muscles involved in wrist flexion and forearm pronation, combined with valgus overload at the elbow. This mechanism is particularly evident in athletes who perform overhead throwing motions, such as baseball pitchers, where the medial elbow undergoes significant strain. Over time, this repetitive stress leads to microtrauma and degeneration of the tendon.

Histopathologic examination reveals a staged process of pathologic tendon change. Initially, repetitive trauma results in peritendinous inflammation. Continued injury leads to angiofibroblastic hyperplasia, characterized by the invasion of vascular and fibroblastic elements into the tendon. Eventually, the normal tendon structure is replaced by angiofibroblastic hyperplasia, resulting in structural breakdown, irreparable fibrosis, or calcification.

Epidemiology

Medial epicondylitis affects approximately 0.4% to 1% of the general population, with higher prevalence rates in certain occupational settings. The condition is most prevalent among individuals aged 40 to 60 years, coinciding with the peak working years. Both men and women are equally affected, and the dominant arm is more frequently involved.

Risk factors include repetitive wrist flexion, forearm pronation, and activities that place valgus stress on the elbow. Professions such as carpentry, plumbing, and manual labor are particularly prone to developing this condition. Additionally, athletes involved in sports like golf, tennis, and baseball are at increased risk due to the repetitive strain on the forearm muscles and the valgus stress on the elbow during the late cocking and early acceleration phases of throwing.

Diagnosis

The diagnosis of medial epicondylitis is primarily clinical, based on patient history and physical examination. Patients typically present with persistent medial-sided elbow pain that is exacerbated by activities involving wrist flexion and forearm pronation.

Physical Examination

1. Tenderness: Palpation over the medial epicondyle and slightly distal to it reveals tenderness.
2. Pain with Resisted Wrist Flexion: Patients experience pain when asked to flex their wrist against resistance while the elbow is fully extended.
3. Pain with Passive Wrist Extension: Passive stretching of the wrist flexors by extending the wrist while the elbow is extended also elicits pain.
4. Grip Strength: Decreased grip strength compared to the contralateral side may be observed.
5. Elbow Range of Motion: Patients may present with normal passive and active range of motion, although some may develop an elbow flexion contracture secondary to pain and guarding.

Imaging Studies

While medial epicondylitis is primarily diagnosed clinically, imaging studies can be useful in atypical cases or when there is a lack of response to initial treatments.

1. X-rays: Generally used to rule out other conditions such as arthritis or fractures. Up to 25% of radiographs may show evidence of calcification of the CFT or UCL.
2. Ultrasound: Can detect tendon tears, hypoechoic areas, and increased blood flow associated with tendinosis. Ultrasound allows for dynamic examination, which may improve specificity and sensitivity.
3. MRI: Provides detailed images of the soft tissues, revealing degenerative changes, partial tears, and the extent of tendon involvement. On T2-weighted sequences, intermediate to high signal intensity at the CFT, especially in the setting of peritendinous edema, is indicative of medial epicondylitis.

Differential Diagnosis

When diagnosing medial epicondylitis, it is crucial to consider other conditions that can present with similar symptoms:

1. Ulnar Neuritis: Compression or irritation of the ulnar nerve, often associated with medial epicondylitis. Symptoms include numbness and tingling in the ulnar distribution of the hand, and a positive Tinel sign at the elbow.
2. Medial Collateral Ligament (MCL) Injury: Valgus instability of the elbow due to injury to the MCL, which may occur concurrently with medial epicondylitis. Valgus stress tests and the milking maneuver can help identify MCL involvement.
3. Osteochondral Lesions: Damage to the cartilage and bone in the elbow joint can present with similar pain. This is often accompanied by joint swelling, stiffness, and mechanical symptoms like clicking or locking.
4. Flexor-Pronator Mass Tear: Partial or complete tear of the flexor-pronator muscles can mimic medial epicondylitis. MRI can help differentiate between these conditions.
5. Cervical Radiculopathy: Nerve root compression in the cervical spine can mimic elbow pain. Symptoms often include neck pain, paresthesia, and weakness in the arm.

Management

Non-Surgical Treatments

1. Rest and Activity Modification: Reducing activities that exacerbate symptoms is the first step. This may involve modifications in occupational tasks or sports techniques.
2. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): These can help manage pain and reduce inflammation. Studies show that NSAIDs are effective in the short-term management of pain associated with medial epicondylitis.
3. Physical Therapy: Focuses on stretching and strengthening exercises for the forearm muscles. Eccentric exercises, in particular, have shown efficacy in promoting tendon healing and reducing symptoms.
   • Stretching: Stretching the wrist flexors helps reduce tension on the tendons.
   • Eccentric Strengthening: Exercises that emphasize controlled lengthening of the muscle can improve tendon health.
   • Manual Therapy: Techniques such as massage and mobilization can help reduce pain and improve function.
4. Bracing: Using a counterforce brace or wrist splint can help reduce strain on the affected tendons. Counterforce braces redistribute the load away from the CFT origin, while wrist splints immobilize the wrist to allow rest.
5. Injections:
   • Corticosteroid Injections: Provide short-term pain relief but may weaken the tendon if used repeatedly. Studies have shown that corticosteroid injections can provide significant short-term pain relief, but their long-term effectiveness is not superior to other treatments.
   • Platelet-Rich Plasma (PRP) Injections: Aim to promote healing by delivering growth factors to the affected area. Emerging evidence suggests PRP may be more effective than corticosteroids in the long term. A randomized controlled trial demonstrated that PRP injections resulted in significant pain reduction and functional improvement at six months compared to corticosteroid injections.
   • Autologous Blood Injections: Use the patient's blood to promote a healing response. This technique involves injecting autologous blood into the degenerated tendon to stimulate a healing response.
6. Extracorporeal Shock Wave Therapy (ESWT): Involves applying shock waves to the affected area to promote healing. Results are mixed, with some studies showing benefit and others not. ESWT is thought to work by inducing microtrauma, which promotes healing through neovascularization and the release of growth factors. A Cochrane review concluded that ESWT provided only marginal benefits over placebo, suggesting that its use should be considered on a case-by-case basis.

Surgical Treatments

Surgery is considered for patients who do not respond to at least six months of conservative treatment. The goal is to remove the degenerated tendon tissue and stimulate a healing response.

1. Open Surgery: Involves making an incision over the medial epicondyle, excising the degenerated tissue, and decorticating the epicondyle to promote healing.
   • Procedure: A 3-5 cm incision is made over the medial epicondyle. The surgeon identifies and excises the degenerative CFT. The underlying bone may be decorticated to stimulate healing, and the remaining tendon is reattached.
   • Effectiveness: Open surgery has shown good to excellent results in approximately 80-90% of patients. Studies report a high success rate with open débridement and reattachment, with patients returning to their previous levels of activity.
   • Postoperative Care: Typically involves immobilization in a splint for 1-2 weeks, followed by gradual physical therapy to restore motion and strength.
2. Percutaneous Techniques: These involve making small punctures in the skin and using specialized instruments to release the tendon.
• Procedure: Under ultrasound guidance, small incisions are made to release the degenerated portion of the CFT.
• Effectiveness: Percutaneous techniques offer a minimally invasive alternative with success rates similar to open methods.
• Postoperative Care: Similar to other surgical methods, but with a potentially shorter recovery time due to the minimally invasive nature.

Rehabilitation and Long-Term Management

Rehabilitation plays a crucial role in the recovery process, regardless of the treatment method used. A well-structured rehabilitation program includes:

1. Early Mobilization: Gentle range-of-motion exercises to prevent stiffness and promote blood flow.
2. Gradual Strengthening: Progressive strengthening exercises to restore muscle balance and function. Focus is on both concentric and eccentric exercises.
3. Functional Training: Activities designed to simulate daily tasks and sports-specific movements to ensure a safe return to normal activities.
4. Education: Teaching patients about ergonomics, proper techniques, and preventive measures to avoid recurrence.

Conclusion

Medial epicondylitis, or golfer’s elbow, is a common condition that can significantly impact daily activities and quality of life. While the majority of cases can be managed effectively with non-surgical treatments, a subset of patients may require surgical intervention. Understanding the pathology and various management options allows healthcare providers to tailor treatments to individual patient needs, optimizing outcomes and promoting recovery.

By staying abreast of the latest research and treatment modalities, clinicians can offer evidence-based care that improves the quality of life for those suffering from medial epicondylitis.

References

1. Amin, Nirav H., Neil S. Kumar, and Mark S. Schickendantz. "Medial epicondylitis: evaluation and management." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 23.6 (2015): 348-355.