Medial Epicondylitis (Golfer's Elbow)
Medial epicondylitis is a pathological condition affecting the common flexor tendon origin at the medial epicondyle of the elbow, characterized by pain at the medial aspect of the elbow and pain with resisted wrist flexion. 1
Epidemiology and Pathophysiology
- Medial epicondylitis affects approximately 1% of the general population, with higher prevalence (3.8% to 8.2%) in work-related complaints 2
- It is less common than lateral epicondylitis (tennis elbow), which occurs 7-10 times more frequently 3
- Most commonly affects individuals between 40-60 years of age, with equal distribution between men and women 2
- Results from repetitive eccentric loading of the flexor-pronator muscles, leading to microtrauma and degeneration of the common flexor tendon 4
- Often called "golfer's elbow," though it can result from various sports and occupational activities involving repetitive wrist flexion and forearm pronation 5
Clinical Presentation
- Patients typically present with an insidious onset of pain at the medial epicondyle 4
- Pain is exacerbated by activities involving wrist flexion and forearm pronation 6
- Diagnosis is primarily clinical, based on history of medial elbow pain and pain with resisted wrist flexion 1
- May occasionally result from an acute traumatic event, such as an avulsion of the common flexor tendon 4
Diagnostic Approach
- Physical examination should assess for:
- Plain radiographs are the most appropriate initial imaging study to rule out other causes of elbow pain and assess for bony abnormalities 1
- MRI may be considered if radiographs are normal or nonspecific and there is suspicion of tendon degeneration or tear 1
- T2-weighted MRI can show increased signal intensity in the common flexor tendon or a complete rupture 4
Treatment Options
First-Line 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 may be considered, though evidence for 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
- Stretching exercises for the wrist flexors 1
Second-Line Treatment
- Corticosteroid injections are more effective than NSAIDs in the acute phase and can provide short-term pain relief, though they do not change long-term outcomes 1
- Newer approaches include extracorporeal shock wave therapy and injectable blood derivatives 2
Surgical Management
- Indicated for debilitating pain that persists despite well-managed nonoperative treatment for at least 6 months 5
- Surgical technique involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin to the medial epicondyle 5
- High degree of subjective relief, though objective strength deficits may persist 5
- Most patients can return to preinjury levels of activity following surgical intervention 6
Clinical Pitfalls and Considerations
- Medial epicondylitis must be distinguished from other medial elbow pathologies that may coexist, particularly ulnar neuritis and ulnar collateral ligament injury 4
- Conservative treatment should be attempted first in all patients before considering surgical intervention 5
- Despite reports of high success rates with nonoperative treatment, symptoms frequently persist or recur 5
- Proper technique modification and equipment adjustment are important for prevention, especially in athletes and workers with repetitive wrist flexion activities 5