What is the recommended treatment for medial epicondylitis?

Treatment of Medial Epicondylitis

Begin with conservative management including relative rest, activity modification, NSAIDs for acute pain relief, ice application, and eccentric strengthening exercises, as approximately 80% of patients recover completely within 3-6 months with this approach. 1

Initial Conservative Treatment (First-Line for All Patients)

Activity Modification and Rest

• Implement relative rest by avoiding repetitive wrist flexion and forearm pronation movements that aggravate symptoms, while maintaining some activity to prevent muscular atrophy. 2, 1
• Modify gripping techniques and incorporate rest breaks during repetitive activities. 1
• Complete immobilization should be avoided as it leads to deconditioning. 2

Pain Management

• Apply ice through a wet towel for 10-minute periods to provide acute pain relief and reduce swelling. 2, 1
• Prescribe NSAIDs for short-term pain relief, though they do not alter long-term outcomes. 2, 1
• Topical NSAIDs eliminate gastrointestinal hemorrhage risk associated with systemic NSAIDs. 2

Physical Therapy Program

• Initiate eccentric strengthening exercises targeting the wrist flexors to promote tendon healing and increase strength. 2, 1
• Include stretching exercises for the wrist flexors. 2, 1
• Apply deep transverse friction massage to reduce pain. 2, 1
• Progress to a strengthening program focused on the affected muscle groups. 1

Adjunctive Therapies

• Consider counterforce bracing/orthoses to reduce tension on the tendon origin. 1
• Apply local heat (paraffin, warm compresses) before exercise sessions. 1
• Ultrasonography may provide complementary benefit. 1

Corticosteroid Injection (Second-Line)

If symptoms persist after 4-6 weeks of conservative treatment, consider local corticosteroid injection, which provides more effective acute pain relief than NSAIDs but does not change long-term outcomes. 2, 1

Injection Technique

• Infiltrate triamcinolone acetonide into the area of greatest tenderness at the medial epicondyle using strict aseptic technique. 3
• Dosing: 5-15 mg for the medial epicondyle area, with care to inject into the tendon sheath rather than the tendon substance. 3
• Avoid injecting into surrounding tissues as this may lead to subcutaneous fat atrophy. 3

Important Caveats

• Corticosteroid injections are indicated for acute nonspecific tenosynovitis and epicondylitis as adjunctive therapy. 3
• The benefit is primarily short-term pain control during the acute phase. 2

Surgical Intervention (Reserved for Refractory Cases)

Refer to orthopedic surgery if debilitating pain persists despite a well-managed conservative treatment trial of at least 6 months to 1 year. 2, 4, 5

Surgical Indications

• Failure of conservative management including rest, physical therapy, NSAIDs, and at least two corticosteroid injections over minimum 1 year. 6
• Debilitating pain that significantly limits work or activities after excluding other pathologic causes. 5

Surgical Outcomes

• Surgical success rates range from 63-100%, with return to work rates of 66.7-100% and return to sports rates of 81-100%. 7
• Mean time to return to work is 2.8 months and to exercise is 4.8 months. 6
• Surgical technique typically involves excision of pathologic tendon tissue and longitudinal tenotomies to release scarring and fibrosis. 2
• Open, arthroscopic, and percutaneous techniques all demonstrate favorable outcomes with low complication rates (4.3%). 7

Special Consideration

• Coexistent ulnar neuritis occurs in a significant proportion of medial epicondylitis cases and results in less favorable surgical outcomes, with persistent symptoms in many patients despite cubital tunnel release. 8
• Preoperative identification of ulnar nerve involvement is critical as isolated medial epicondylitis has better surgical outcomes than cases with coexistent ulnar neuritis. 8

Clinical Pitfalls to Avoid

• Do not proceed to surgery without a minimum 6-month trial of conservative management, as the majority of patients respond to non-operative treatment. 4, 5
• Distinguish medial epicondylitis from other medial elbow pathologies including ulnar collateral ligament injury, ulnar neuritis, and intra-articular pathology. 4
• Avoid complete immobilization which causes muscular atrophy and deconditioning. 2
• Do not rely on corticosteroid injections for long-term management as they only provide acute phase benefit. 2