Treatment of Medial Epicondylitis
The primary treatment for medial epicondylitis consists of relative rest, eccentric strengthening exercises, and cryotherapy, with approximately 80% of patients recovering fully within 3-6 months using conservative management alone. 1
Understanding the Condition
Medial epicondylitis is a degenerative tendinopathy, not an inflammatory condition, and should be properly termed "tendinosis" or "tendinopathy" rather than "tendonitis." 1 This distinction matters because the pathology involves tendon degeneration at the common flexor origin, typically at the osteotendinous junction, rather than acute inflammation. 1
First-Line Conservative Treatment
Core Interventions (Strongly Recommended)
Relative rest and activity modification: Reduce repetitive wrist flexion and forearm pronation activities that load the damaged tendon. 2 This prevents further damage while promoting healing. 1
Eccentric strengthening exercises: These are the cornerstone of rehabilitation, promoting tendon healing and increasing strength in the flexor-pronator muscle group. 1, 2 Progressive strengthening should be implemented as tolerated. 2
Cryotherapy: Apply ice for 10-minute periods to provide acute pain relief. 2
Adjunctive Measures
NSAIDs: Use for short-term pain relief only; they provide acute symptom control but do not affect long-term outcomes or healing. 1, 2 These cannot be recommended over other analgesics. 1
Physical therapy: Deep transverse friction massage can reduce pain, and stretching exercises for wrist flexors provide additional benefit. 2
Counterforce bracing: May be considered, though evidence supporting effectiveness is limited. 2
Second-Line Treatment
Corticosteroid Injections
Use corticosteroid injections cautiously and only for short-term pain relief in the acute phase. 1, 2 While more effective than NSAIDs acutely, they do not change long-term outcomes and should be used with caution due to potential adverse effects on tendon integrity. 1, 2
Surgical Management
Reserve surgery exclusively for patients who fail conservative therapy after a minimum of 6 months. 3 Surgery is effective but should only be considered after exhausting nonoperative options. 1
Surgical Approach
The standard technique involves open release of the common flexor origin at the medial epicondyle, with excision of pathologic tendon tissue. 4, 5 Surgical success rates range from 63-100%, with return to work rates of 66.7-100%. 4 Approximately 12% of medial epicondylitis cases ultimately require surgery, compared to under 4% for lateral epicondylitis. 6
Important Caveat
Screen for coexistent ulnar neuritis before surgery, as it occurs in a substantial proportion of cases and significantly affects outcomes. 5 Patients with isolated medial epicondylitis have better surgical outcomes than those with concurrent ulnar nerve involvement (p < 0.01). 5 When ulnar neuritis is present, consider cubital tunnel release in addition to flexor origin release. 5
Clinical Pitfalls to Avoid
Do not mislabel this as "tendonitis": Most cases seen in primary care are chronic degenerative conditions, not acute inflammation. 1
Do not rely solely on imaging initially: Diagnosis is primarily clinical, based on medial epicondyle pain and pain with resisted wrist flexion. 2 Plain radiographs are appropriate initially only to rule out other pathology. 2
Do not rush to surgery: The vast majority (approximately 88%) of patients respond to conservative management. 6 A well-structured nonoperative program spanning at least 6 months should be exhausted first. 7, 3
Do not overlook occupational factors: 90% of cases are work-related rather than sports-related. 6 Address workplace ergonomics and technique modification as part of comprehensive management. 1