The Problem
Medial epicondylitis, popularly referred to as “golfer’s elbow”, is an overuse injury that results in microtears at the tendinous origin of the flexor-pronator mass of the elbow. The commonly affected muscles include the origin of the pronator teres, flexor carpi radialis and palmaris longus. Less commonly, the origin of the flexor carpi ulnaris is involved. Histologically, this disorder has been termed “angiofibroblastic tendinosis” to emphasize the fact that the etiology is more consistent with a degenerative process rather than acute inflammatory process. Other terms used to describe this condition include “tendinosis.”
Clinical Presentation
This disorder occurs in equal frequency amongst women and men, typically between the ages of 30 and 50 years of age. The dominant elbow appears to be affected more often than the non-dominant elbow. Patients present with insidious onset of medial elbow pain, mostly with activities that require repetitive forearm pronation and/or wrist flexion. It may also be encountered in overhead athletes that place a repetitive valgus load on the elbow, such as in swimming, tennis, and golf. These symptoms may also be encountered following similar elbow and forearm activities in normal, non-athletic occupations. Medial epicondylitis is far less common that lateral epicondylitis.
Diagnostic Workup
Typical clinical examination findings
Tenderness to palpation over the medial epicondyle. There may be exacerbation of the medial elbow/proximal medial forearm pain with resisted forearm pronation and resisted wrist flexion.
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Tenderness to palpation over the course of the ulnar nerve. It is essential to assess the function of the ulnar nerve. The examiner may also elicit a positive ulnar nerve Tinels sign at the level of the medial elbow. There may be exacerbation of the ulnar nerve-related pain with hyperflexion of the elbow.
Pain with valgus stress of the affected elbow. It is essential to assess the integrity of the medial ulnar collateral ligament. This can be achieved by using the valgus stress test, milking maneuver or moving valgus stress test.
There is typically full active range-of-motion of the elbow, although there may be pain at the extremes of elbow extension because of tension placed on the flexor- pronator mass.
Imaging findings
Standard radiographs of the elbow should be obtained, although they are typically no osseous findings present. On occasion, calcifications may be noted at the origin of the flexor-pronator mass at the lateral epicondyle. An MRI may be helpful in supporting the diagnosis, with increased signal on T2-weighted images; these findings are sensitive, but not specific for medial epicondylitis. The MRI may also help assess for damage to the medial ulnar collateral ligament or intra-articular chondral lesions. Ultrasound diagnosis may also be utilized, although it requires an operator skilled in its use and interpretation.
Special diagnostic tests
Given the concomitant ulnar nerve symptoms (~60%) found in conjunction with medial epicondylitis, an EMG/NCV study may be useful for baseline assessment of the ulnar nerve. This test should be reserved for those patients with symptomatic ulnar neuritis.
Non–Operative Management
Non-operative management can be categorized into three distinct phases. These include:
Phase 1: The goal of treatment in the early, symptomatic phase is to reduce the acute inflammation and minimize any offending activity. A course of anti-inflammatories is recommended unless there are any contraindications to their use. Local application of ice may also be beneficial for minimizing the inflammatory process. For more recalcitrant cases, a local injection of corticosteroids and a local anesthetic may be administered. Finally, a counterforce brace may be applied to reduce local muscular contractions.
Phase 2: This phase begins as the symptoms are improving and is centered around a formal physical therapy program. Therapy focuses initially on regaining full, painless elbow and forearm range-of motion. This involves progressive stretching of the involved musculature, as well as isometric strengthening exercises. As the patient’s flexibility, strength and endurance improve, resistive exercises including eccentric and concentric strengthening are incorporated. A gradual return to normal activities, including sporting activities, is emphasized through a maintenance program.
Phase 3: This phase is the maintenance phase. After the patient returns to their occupation, sport, or other activities, it is essential to modify any equipment or office furniture to prevent recurrence of symptoms. Patients should also carry out a home exercise program until satisfied with their clinical outcome.
Indications for Surgery
Surgical intervention is indicated for cases of recalcitrant medial epicondylitis that have failed to respond to appropriate non-operative management. Typically, the symptoms of pain and functional disability have persisted beyond 6 months. It is important to ascertain that the patient will adhere to post-operative restrictions and are willing to participate in a post-operative rehabilitation program. Surgical intervention is considered on a more expeditious manner in competitive, overhead athletes with diagnosed medial ulnar collateral ligament insufficiency and symptoms of medial epicondylitis.
Surgical Technique
In the holding area, the surgical site is verified with the patient and the consent is reviewed. The surgeon should then place their initials in a clearly visible manner over the surgical site. In the operating room, the patient is placed supine upon the flat table and the operative extremity is placed over a radiolucent hand table. A tourniquet is applied proximally on the arm and the extremity is prepped and draped in the usual sterile fashion. It is imperative to elicit and mark out the point of maximal tenderness on the skin to focus the surgeon’s attention during deep dissection.
General anesthesia (or regional anesthesia) is induced. The operative extremity is once again verified. Prophylactic antibiotics are administered. The bony landmarks are drawn onto the skin using an indelible marker; specifically, the medial epicondyle should be drawn out. The longitudinal incision begins 1 cm proximal and posterior to the medial epicondyle and curves distally for approximately 4-5 cm. The proximal limb of the incision parallels the medial epicondylar ridge. A full-thickness flap is retracted anteriorly to expose the fascia of the flexor-pronator mass. A longitudinal incision is made in the affected tendon origins starting at the medial epicondyle extending distally towards the area of maximal tenderness. These tissues are bluntly spread, exposing the degenerative tissue. The tissue is removed in an elliptical fashion so as not to disrupt the flexor-pronator origin. This tissue is then sent for pathologic examination. Multiple drill holes are placed in the anterior cortex of the medial epicondyle to enhance local vascularity and healing. The fascial defect is closed using absorbable sutures (i.e. #1 PDS).
If ulnar nerve symptoms were noted pre-operatively, the ulnar nerve is addressed at this time. In the case of nerve compression, which is most commonly found distal to the medial epicondyle, release of Osborne’s ligament (connection of ulnar and humeral heads of the flexor carpi ulnaris) is sufficient to remove the compression. In the setting of a subluxing or frankly dislocating ulnar nerve, anterior transposition of the nerve may be considered. This may be accomplished in a subcutaneous, submuscular or intramuscular fashion, depending on surgeon preference. Other reasons to consider nerve transposition include prior trauma with copious scar tissue or a prior malunion with valgus angulation of the distal humerus.
The subcutaneous tissue is closed with interrupted 3-0 Monocryl sutures followed by 4-0 Monocryl sutures in a subcuticular fashion. Steri Strips are applied, followed by a sterile dressing. The patient is placed in a splint at 90 degrees of elbow flexion and neutral rotation. This procedure is performed on an outpatient basis.
Pearls and Pitfalls of Technique
The incision should be made posterior to the medial epicondyle to avoid iatrogenic injury to the medial antebrachial cutaneous nerve. Thick flaps including the skin and subcutaneous tissue should be raised to further minimize this risk.
The fascial incision in the flexor-pronator mass should start from the medial epicondyle and extend distally. This avoids releasing the origin of this important dynamic elbow stabilizer.
Potential Complications
One potential complication of this procedure includes iatrogenic injury to the medial antebrachial cutaneous nerve, which may result in an area of numbness overlying the medial volar forearm. Similarly, transection of the medial antebrachial cutaneous nerve may result in formation of a neuroma and pain. Furthermore, injury to the ulnar nerve can also occur due to its proximity to the surgical site. A rare complication following the surgery is mild loss of elbow extension. Cases of superficial wound infections have been infrequently reported on.
Post–operative Rehabilitation
Immediate active range of motion of the wrist and digits is encouraged to reduce distal extremity swelling. The posterior splint is worn full-time for 48 hours following surgery. Thereafter, it is removed for hygiene and gentle range-of-motion exercises to the elbow. In most cases, the splint can be removed permanently after 1 week. The patient then begins on non-resistance elbow flexion/extension, forearm supination/pronation, wrist, flexion/extension. At 3 weeks following surgery, light resistive exercises are permitted, depending on patient comfort. A formal physiotherapy program may be initiated, based on patient progress. Unrestricted recreational and occupational activities are usually achieved by 4-6 months. During the period of resistive exercises, some authors recommend the use of a counterforce brace.
Outcomes/Evidence in the Literature
Olivierre, CO, Nirschl, RP, Pettrone, FA. “Resection and repair of medial tennis elbow: a prospective analysis”. Am J Sports Med. vol. 23. 1995. pp. 214-221. (A clinical report on 50 cases of recalcitrant medial epicondylitis treated with open resection of the degenerated tissue, found mostly in the flexor carpi ulnaris-pronator teres interval. The authors described the diseased tissue histologically as "angiofibroblastic tendinosis" and reported on the presence of "collagen degeneration." The majority of patients were able to return to prior recreational or occupational activities. All patients reported partial or complete pain relief. Dynanometer strength testing demonstrated improvement in all cases.)
Nirschl, RP, Ashman, ES. “Elbow tendinopathy: tennis elbow”. Clin Sports Med. vol. 22. 2003. pp. 813-836. (A comprehensive review of tendinosis of the medial and lateral side of the elbow, with emphasis on patient history, evaluation, non-operative treatment, operative intervention and expected outcomes.)
Gabel, GT, Morrey, BT. “Operative treatment of medial epicondylitis: the influence of concomitant ulnar neuropathy at the elbow”. J Bone Joint Surg Am. vol. 77. 1995. pp. 1065-1069. (A retrospective review of clinical outcomes following surgical treatment for medial epicondylitis in 26 patients (30 elbows). Using a variety of surgical techniques to debride the flexor-pronator mass, the authors reported 87% good to excellent results at a mean of 7 years following the operation. Ninety-six percent of elbows with no or mild ulnar neuritis achieved good to excellent results, while <50% of patients with moderate or severe ulnar neuritis achieved good to excellent results.)
Vangsness, C, Jobe, FW. “Surgical treatment of medial epicondylitis: results in 35 elbows”. J Bone Joint Surg Br. vol. 73. 1991. pp. 409-411. (A retrospective review of 35 elbows with recalcitrant medial epicondylitis who underwent surgical intervention consisting of elevation of the flexor-pronator mass, resection of the tendinosis tissue, followed by re-attachment of the tendons to the medial epicondyle. The authors reported 88% good to excellent results at a mean of 6 years following surgery. Fourteen percent of the patients required anterior submuscular ulnar nerve transposition, none of whom had any residual symptoms. Nineteen of twenty athletes returned to their same level of play.
Baumgard, SH, Schwartz, DR. “Percutaneous release of epicondylar muscles for humeral epicondylitis”. Am J Sports Med. vol. 10. 1982. pp. 233-236. (A small series of 6 patients who underwent percutaneous release of the medial flexor-pronator muscles from the medial epicondyle. Five patients reported an excellent result after the first procedure, with the final patient achieving an excellent result following a revision precutaneous release.)
Gong, HS, Chung, MS, Kang, ES, Oh, JH, Lee, YH, Baek, GH. “Musculofascial lengthening for the treatment of patients with medial epicondylitis and coexistent ulnar neuropathy”. J Bone Joint Surg Br. vol. 92. 2010. pp. 823-827. (A retrospective review of 19 patients who underwent a Z-lengthening of the flexor-pronator mass along with submuscular ulnar nerve transposition. There were five excellent and 14 good results, with a significant improvement in grip strength and in DASH score.)
Summary
Medial epicondylitis represents an overuse tendinopathy of the origin of the flexor-pronator mass. Successful management of this disorder requires an accurate diagnosis, primarily based on history and clinical examination. The majority of these cases can be treated non-operatively with a structured treatment protocol including pain control and physiotherapy. When non-operative management fails to result in a successful outcome, surgical management may be appropriate. It is important to address any concomitant pathology, specifically ulnar nerve compression. In general, successful outcomes can be expected following operative intervention, including a return to previous occupation and sporting activities.
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