Treatment of Bilateral Medial Epicondylitis
Begin with relative rest, activity modification, eccentric strengthening exercises, and cryotherapy, as 80-90% of patients recover with conservative management within 3-6 months. 1, 2
Initial Conservative Management (First-Line Treatment)
Activity Modification and Rest
- Reduce repetitive wrist flexion and forearm pronation activities that load the damaged common flexor tendon, but avoid complete immobilization to prevent muscle atrophy 1
- Continue activities that do not reproduce pain, as tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
- Most patients can expect recovery within 3-6 months with appropriate conservative treatment 1, 2
Eccentric Strengthening Exercises
- Eccentric exercise is the cornerstone of rehabilitation and may reverse degenerative changes in the tendon 1
- This approach has proven beneficial in multiple tendinopathies and should be initiated early 1
Cryotherapy
- Apply ice through a wet towel for 10-minute periods for acute pain relief 1
- Ice reduces tissue metabolism and may slow the release of blood and proteins from surrounding vasculature 1
Pain Management
- NSAIDs provide short-term pain relief but do not alter long-term outcomes 1
- Topical NSAIDs are effective alternatives that eliminate the increased risk of gastrointestinal hemorrhage associated with systemic NSAIDs 1
- NSAIDs are recommended for short-term use only, not as a long-term solution 1
Second-Line Interventions (If Conservative Treatment Fails After 4-12 Weeks)
Corticosteroid Injections
- Local corticosteroid injections are more effective than oral NSAIDs for acute-phase pain relief but do not change long-term outcomes 1
- Use judiciously for short-term relief only, as they provide no benefit to ultimate recovery 1
- Be aware of potential complications including skin atrophy, infection, and tendon weakening 3
Additional Physical Therapy Modalities
- Deep transverse friction massage may reduce pain 4
- Progressive stretching exercises for wrist flexors 4
- Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit 1
Surgical Management (Reserved for Refractory Cases)
Indications for Surgery
- Surgery should only be considered after failure of 6-12 months of appropriate conservative treatment 1, 3
- Surgical success rates range from 63% to 100%, with low complication rates of 4.3% 5
- Return to work rates are excellent, ranging from 66.7% to 100% 5
Surgical Techniques
- Open release of the common flexor origin is the most studied technique, with good results in most cases 6, 5
- Arthroscopic and percutaneous techniques are alternatives, though no technique has proven superior 5
- Surgery for medial epicondylitis is needed in approximately 12% of cases, compared to under 4% for lateral epicondylitis 6
Important Clinical Considerations
Bilateral Presentation
- The presence of bilateral symptomatic tendons should alert you to consider evaluation for rheumatic disease or rheumatologic referral 1
- While most medial epicondylitis cases are work-related (90%), bilateral presentation is less common and warrants broader differential consideration 6