Treatment of Medial Epicondylitis
Begin with relative rest, activity modification, and eccentric strengthening exercises, as 80-90% of patients recover with conservative management within 3-6 months. 1
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
Eccentric Exercise Program
- Eccentric exercise is the cornerstone of rehabilitation and may reverse degenerative changes in the tendon. 1
- This should be the foundation of your treatment approach, as it promotes tendon healing and increases strength. 2
Adjunctive Pain Management
- Apply ice through a wet towel for 10-minute periods for acute pain relief. 1
- NSAIDs provide short-term pain relief but do not alter long-term outcomes, so use them primarily for symptom control during the rehabilitation phase. 1
Second-Line Interventions (If Conservative Management Fails After 6-12 Weeks)
Corticosteroid Injections
- Local corticosteroid injections are more effective than oral NSAIDs for acute-phase pain relief but do not change long-term outcomes, so use them judiciously for short-term relief only. 1
- Reserve these for patients with significant pain that limits participation in eccentric exercise programs. 1
Physical Therapy Modalities
- Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit. 1
- Counterforce bracing may improve function during daily activities, though evidence is limited. 2
Surgical Management (After 6-12 Months of Failed Conservative Treatment)
Indications for Surgery
- Surgery should only be considered after failure of 6-12 months of appropriate conservative treatment. 1
- Most patients respond to nonsurgical management, with only 12% requiring operative intervention. 3, 4
Surgical Outcomes
- Surgical success rates range from 63% to 100%, with a low complication rate of 4.3%. 5
- Open release of the common flexor origin yields high patient satisfaction with 86% of patients having no limitation in elbow use. 6
- Mean return to work is 2.8 months and return to exercise is 4.8 months postoperatively. 7
- Three surgical techniques exist (open, arthroscopic, and percutaneous), with no clear superiority among approaches. 5
Critical Clinical Pitfall
If you encounter bilateral symptomatic medial epicondylitis, evaluate for rheumatic disease or consider rheumatologic referral, as bilateral presentation is uncommon and may indicate systemic pathology. 1
Differential Diagnosis Considerations
- Distinguish medial epicondylitis from cubital tunnel syndrome, ulnar collateral ligament injury, and medial elbow instability, which may coexist with or mimic this condition. 3
- Plain radiographs should be obtained initially to rule out osseous pathology, heterotopic ossification, or intra-articular bodies. 2