What is the recommended treatment for a patient with persistent bilateral medial epicondylitis (golfer's elbow) of 1 year's duration?

Management of Persistent Bilateral Medial Epicondylitis (Golfer's Elbow)

For persistent bilateral medial epicondylitis of 1 year's duration, a comprehensive treatment approach should include conservative measures first (rest, physical therapy, NSAIDs, bracing), followed by corticosteroid injections for short-term relief, and consideration of surgery only after 6 months of failed conservative management.

Initial Diagnostic Approach

• Plain radiographs of the elbow are the most appropriate initial imaging study to rule out other causes of elbow pain and assess for any bony abnormalities 1
• MRI may be considered if radiographs are normal or nonspecific and there is suspicion of tendon degeneration or tear 1
• Diagnosis is primarily clinical, based on history of pain at the medial epicondyle and pain with resisted wrist flexion 1, 2

First-Line Treatment Options

Conservative Management

• Relative rest and activity modification to reduce repetitive loading of the damaged tendon 1
• Eccentric strengthening exercises to promote tendon healing and increase strength 1
• Cryotherapy (ice application) for 10-minute periods to provide acute pain relief 1
• NSAIDs for short-term pain relief, though they do not affect long-term outcomes 1
• Counterforce bracing/orthotics, though evidence for their effectiveness is limited 1

Physical Therapy

• Deep transverse friction massage to reduce pain 1
• Progressive strengthening exercises focusing on the flexor-pronator muscle group 1, 3
• Stretching exercises for the wrist flexors 1, 4

Second-Line Treatment Options

Corticosteroid Injections

• More effective than NSAIDs in the acute phase of epicondylosis 1
• Provide short-term pain relief but do not change long-term outcomes 1, 5
• Should be considered when conservative measures fail to provide adequate relief 3

Other Injection Therapies

• Blood derivatives (platelet-rich plasma) may be considered, though evidence is still emerging 2
• Extracorporeal shock wave therapy has shown mixed benefits for elbow tendinopathy 1, 2

Surgical Management

• Indicated only after failure of well-managed conservative treatment for at least 6 months 3, 6
• Involves excision of pathologic tendon tissue, repair of the resulting defect, and reattachment of the origin to the medial epicondyle 3, 6
• High degree of subjective relief, though objective strength deficits may persist 3
• Surgical treatment should be considered in elite athletes and patients with persistent symptoms despite appropriate conservative management 6, 4

Important Considerations

• Medial epicondylitis affects men and women equally and is most common after 40 years of age 1, 2
• The condition is degenerative (tendinosis) rather than inflammatory, despite the "-itis" terminology 5
• Evaluate for concomitant pathologies such as ulnar neuritis and ulnar collateral ligament injury 6
• Bilateral involvement may suggest occupational factors that need to be addressed to prevent recurrence 2, 3

Treatment Algorithm

1. Begin with 4-6 weeks of conservative management (rest, ice, NSAIDs, bracing, physical therapy) 1, 3
2. If symptoms persist, consider corticosteroid injection for short-term relief 1, 5
3. Continue rehabilitation with eccentric strengthening program for 3-6 months 1
4. Consider alternative therapies like extracorporeal shock wave therapy or blood derivative injections if available 2
5. If symptoms persist beyond 6 months despite appropriate conservative management, surgical consultation is warranted 3, 6