History

Fact Explanation
Pain of insidious onset on the medial aspect of the elbow; usually on the dominant side [1] The pain can range from mild discomfort to a severe ache. It is due to the initial inflammation, or a subsequent complication such as angio-fibroblastic degeneration, or tendinosis of the medial musculo-tendinous unit.
Pain radiating to the forearm [2] The affected musculo-tendinous unit is continuous with the flexor pronator muscles (i.e. Pronator teres and Flexor carpi radialis) of the forearm.
Worsening of pain with gripping and twisting movements [3] Occurs upon opening a jar, turning a door handle, lifting or throwing objects. The valgus stress transmits to the muscles attached during forearm pronation and wrist flexion. There may be associated micro tears as well.
Limited range of movements [4,5] Due to flexion contractures; relatively late presentation.
Weakness of grip [6] Occurs to pain on gripping.
Numbness and tingling of ring and little fingers [1] Concurrent ulnar neuritis.
References
  1. CICCOTTI,M.G, M.N.RAMANI. Medial epicondylitis.Techniques in hand & upper extremity surgery,2003 Dec,7(4),190-196.
  2. CICCOTTI,M.G. et al. Diagnosis and treatment of medial epicondylitis of the elbow,Clinics in Sports Medicine, 23 (2004), 693– 705.
  3. WALZ,D.M. et al. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics,2010 Jan,30(1),167-84.
  4. CICCOTTI,M.G, W.P.CHARLTON. Epicondylitis in the athlete,Clinics in Sports Medicine, 2001 Jan,20(1),77-93.
  5. JOBE F.W,M.G CICCOTTI. Lateral and medial epicondylitis of the elbow.The Journal of the American Academy of Orthopaedic Surgeons,1994,2,1–8.
  6. VICENZINO,B. et al. Initial effects of elbow taping on pain-free grip strength and pressure pain threshold. The Journal of orthopaedic and sports physical therapy,2003 Jul,33(7),400-7.

Examination

Fact Explanation
Point tenderness over the Pronator teres and Flexor carpi ulnaris origin at the medial epicondyle. [1] Initial Inflammation or subsequent pathologies.
Elbow flexion test. [2] Positive if there is co-existent ulnar neuritis.
Warmth and swelling over the medial epicondyle. [2] Underlying inflammatory process.
Tinel’s sign [2] Positive if there is co-existent ulnar neuritis.
Pain on flexion against resistance [2] Occurs in chronic cases due to development of flexion contractures.
References
  1. CICCOTTI,M.G, M.N.RAMANI. Medial epicondylitis.Techniques in hand & upper extremity surgery,2003 Dec,7(4),190-196.
  2. CICCOTTI,M.G. et al. Diagnosis and treatment of medial epicondylitis of the elbow,Clinics in Sports Medicine, 23 (2004), 693– 705.

Differential Diagnoses

Fact Explanation
Ulnar collateral ligament injury Is a common cause of medial elbow pain which mainly occurs during the acceleration phase of throwing due to a valgus force. It causes chronic pain and valgus instability. Important differential diagnosis that needs to be excluded. Occurrence is more common among athletes, similar to Golfer's elbow which may exist concurrently with injury to the ulnar collateral ligament. [1,2] A positive valgus stress test at 30 degrees and the milking test are positive.[3]
Ulnar neuritis Tingling and numbness of the little and ring fingers may occur during repetitive throwing which is relieved with rest.[1] Tinel's sign and the elbow flexion test are positive on examination.
Valgus extension overload Localized elbow pain in the postero-medial aspect of the Olecranon, which is present in both the acceleration and deceleration phases of throwing. Limited extension results from impinging osteophytes. [1]
Ulnar collateral ligament subluxation Is a rare condition that is caused by a congenital laxity of ligaments[4]
References
  1. RA'KERRY K. Elbow medial collateral ligament injuries.Current Reviews in Musculoskeletal Medicine,2008,1,197–204.
  2. GLOUSMAN R.E. et al. An electromyographic analysis of the elbow in normal and injured pitchers with medial collateral ligament insufficiency. Americal Journal of Sports Medicine,1992,20,311–317.
  3. CICCOTTI,M.G, M.N.RAMANI. Medial epicondylitis.Techniques in hand & upper extremity surgery,2003 Dec,7(4),190-196.
  4. XARCHAS,K.C. Ulnar Nerve Dislocation at the elbow:Review of the Literature and Report of three cases. The Open Orthopaedics Journal,2007,1,1-3

Investigations - for Diagnosis

Fact Explanation
Plain X-Ray of the elbow Usually no abnormalities are noted. Therefore imaging is not essential in the initial evaluation. But 20%-25% of patients with Golfer's elbow can have soft tissue calcification of the epicondyle.[1] In chronic cases (e.g. sportsmen); traction spurs and medial collateral ligament calcification may be seen.[2] Valgus instability is detected by valgus stress radiographs; medial joint line opening greater than 3 mm qualifies as positive.
Electromyography (EMG) Indicated in those with neurological symptoms. [3]
Magnetic resonance imaging (MRI) Intra-tendinous thickening and increased signal intensity is seen in tendonitis. A tendon tear is detected by a fluid signal intensity gap between the tendon and the epicondyle.[2] In addition, MRI arthrography is useful for evaluating rupture of the Ulnar collateral ligament.[2]
Ultra Sound Scan Tears appear as hypo-echoic areas. Will also detect calcifications.[2]
References
  1. CICCOTTI,M.G, W.P.CHARLTON. Epicondylitis in the athlete,Clinics in Sports Medicine, 2001 Jan,20(1),77-93.
  2. WALZ,D.M. et al. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics,2010 Jan,30(1),167-84.JOBE F.W,M.G CICCOTTI.
  3. CICCOTTI,M.G, M.N.RAMANI. Medial epicondylitis.Techniques in hand & upper extremity surgery,2003 Dec,7(4),190-196.

Investigations - Screening/Staging

Fact Explanation
MRI Mild tendinosis (low-grade partial tear) appears on MRI as tendon thickening and increased internal signal intensity. Less than 20% of the entire tendon thickness is affected. Moderate tendinosis (intermediate-grade partial tear) appears as partial-thickness tear with thinning and focal disruption that does not extend across the full thickness of the tendon. 20% - 80% of the entire tendon thickness is affected. Severe tendinosis (high grade partial tear or full-thickness tear) is a near-complete or complete tear, characterized as a fluid-filled gap separating the tendon from its origin at the lateral epicondyle. More than 80% of the tendon thickness is affected. [1]
Ultrasound Scan (USS) Mild tendinosis appears as a small linear hypo-echoic region at Extensor Carpi Radialis Brevis (ECRB) origin suggestive of a small partial thickness tear. Moderate tendinosis appears as a linear hypo-echoic region suggesting a partial thickness tendon tear surrounding heterogeneous echogenicity indicative of associated tendinitis (arrow). Severe tendinosis appears as a large hypo-echoic region at the tendon origin, a finding indicative of a near-full thickness tear with distal linear foci of calcium deposition and marked heterogeneity [1]
References
  1. WALZ,D.M. et al. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics,2010 Jan,30(1),167-84.

Management - General Measures

Fact Explanation
Avoiding offending activities To prevent exerting more force over the affected area. Of note however, complete immobilization or inactivity should be avoided, as this can lead to disuse atrophy and compromise later rehabilitation.[1]
Icing for 20 minutes, 3 to 4 times a day Local vasoconstrictive and analgesic effects. Best done after completing exercise, stretching, and strengthening.[1]
Elbow braces (e.g.: counter-force bracing and cock up wrist splints.) Counter-force bracing is used during activity that involve movements of the elbow and theoretically decreases the contraction forces.[2] Cock-up wrist splints maintain neutral position. [3]
References
  1. CICCOTTI,M.G, M.N.RAMANI. Medial epicondylitis.Techniques in hand & upper extremity surgery,2003 Dec,7(4),190-196.
  2. THURSTON, A.J. Conservative and surgical treatment of tennis elbow: a study of outcome.The Australian and New Zealand journal of surgery, 1998 Agu,68(8),568-72.
  3. PLANCHE,K.D,J.HALBRECHT,G.M.LOURIE. Medial and lateral epicondylitis in the athlete. Clinics in Sports Medicine,1996 Apr,15(2),283-305.

Management - Specific Treatments

Fact Explanation
Oral Non Steroidal Anti Inflammatory Drugs (NSAIDs) for 10-14 days Provides pain relief and anti inflammatory effect. [1] Since epicondylitis is considered a degenerative process, the beneficial effects of anti-inflammatory drugs is due to relieving pain caused by synovitis.[2,3] If the symptoms improve but without complete relief; a second course of medication can be started after a brief period of abstinence. Topical NSAID applications can be used in addition to oral drugs.
Local corticosteroid injection around the tendon insertion Steroid injections are efficacious in the short term. It provides significantly less pain at 6 weeks but no difference at 3 months and 1 year. [4,5]
Autologous blood injection or platelet-rich plasma (PRP) injection. This is a novel method of treatment for refractory cases of medial epicondylitis. It is thought to transform growth factor-b and basic fibroblast growth factor carried in the blood, which act as humoral mediators to induce the healing cascade.[6]
Extracorporeal shock wave therapy (ESWT) Provides relief by Increasing neo-vascularization, and modulate release of endogenous nitric oxide (NO) [7]
Elastic Therapeutic Tape Improves the contraction of the damaged muscle and uses the elasticity to create folds in the skin, resulting in areas of low pressure and areas of high pressure leading to a change in the flow of fluid under the skin, which will improve circulation of blood and lymph thereby reducing inflammatory reaction and pain. In addition, causes neurological suppression to reduce pain and increase range of motion of the joint.[8]
Guided rehabilitation program with stretching and progressive isometric muscle contraction. Achieving muscle strength greater than the pre-injury level is the goal, because of the risk of recurrent tension overload at pre-injury strength.[2]
Percutaneous epicondylar release Surgery is considered when non surgical options have failed to produce results for 3-6 years. [9] Percutaneous epicondylar release has a higher rate of success when compared to other surgical options. It is relatively simple to perform and is done as an outpatient procedure. [10]
Epicondylectomy This is an outpatient a procedure, performed under general or regional anesthesia. The principle is removal of the medial epicondyle to alleviate compression of the ulnar nerve. Medial epicondylectomy can also be used to treat cubital tunnel syndrome.[11]
References
  1. BASKURT,F,A.OZCAN,C.ALGUN Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis.Clinical rehabilitation,2003 Feb,17(1),96-100
  2. CICCOTTI,M.G, M.N.RAMANI. Medial epicondylitis.Techniques in hand & upper extremity surgery,2003 Dec,7(4),190-196.
  3. STANLEY,K.L, J.E.WEAVER. Pharmacologic management of pain and inflammation in athletes. Clinics of Sports Medicine,1998 April,17(2),375-92
  4. STAHL,S,T.KAUFMAN.The efficacy of an injection of steroids for medial epicondylitis: A prospective study of sixty elbows.The Journal of Bone & Joint Surgery,1997,79,1648–1652.
  5. VERHAAR,J.A.N. et al. Local corticosteroid injection versus cyriax-type physiotherapy for tennis elbows. The Journal of bone and joint surgery. British volume,1996 Jan,78(1),128-32.
  6. SURESH,S.P.S. Medial epicondylitis: is ultrasound guided autologous blood injection an effective treatment? British Journal of Sports Medicine,2006,40,935–939.
  7. MARIOTTO,S. et al.Extracorporeal shock wave therapy in inflammatory diseases: molecular mechanism that triggers anti-inflammatory action.Current medicinal chemistry,2009,16(19),2366-72.
  8. CHANG,H.Y. et al. Could Forearm Kinesio Taping Improve Strength, Force Sense, and Pain in Baseball Pitchers With Medial Epicondylitis? Clinical journal of sport medicine,2012,22,327–333.
  9. JOBE F.W,M.G CICCOTTI. Lateral and medial epicondylitis of the elbow.The Journal of the American Academy of Orthopaedic Surgeons,1994,2,1–8.
  10. NAZRAR,M.A. et al. Percutaneous Tennis Elbow Release Under Local Anaesthesia ,Open Orthop J. 2012, 6, 129–132.
  11. CICCOTTI,M.G. et al. Diagnosis and treatment of medial epicondylitis of the elbow,Clinics in Sports Medicine, 23 (2004), 693– 705.