What is the treatment for medial epicondylitis (golf elbow)?

Treatment of Medial Epicondylitis (Golfer's Elbow)

Start with relative rest, activity modification, ice application, and eccentric strengthening exercises—this conservative approach resolves symptoms in approximately 80% of patients within 3-6 months and should be the foundation of treatment. 1

First-Line Conservative Management

Activity Modification and Rest

• Relative rest prevents ongoing tendon damage while avoiding complete immobilization that leads to muscle atrophy. 1
• Continue activities that don't worsen pain, but modify or temporarily stop those that aggravate symptoms. 2
• Recognize that medial epicondylitis is a degenerative tendinopathy ("tendinosis"), not an inflammatory condition, despite the misleading "-itis" suffix. 1

Exercise-Based Rehabilitation

• Eccentric strengthening exercises are the cornerstone of treatment, promoting tendon healing and increasing strength. 1, 2
• Stretching exercises for the wrist flexors should be incorporated into the rehabilitation program. 2
• Tensile loading stimulates collagen production and guides proper alignment of newly formed collagen fibers. 2
• Begin progressive exercises at 2-8 weeks as pain allows. 2

Pain Management

• Cryotherapy applied for 10-minute periods through a wet towel provides effective short-term pain relief. 1, 2
• NSAIDs (oral or topical) effectively relieve acute pain but do not alter long-term outcomes. 1, 2
• Topical NSAIDs reduce pain while avoiding gastrointestinal side effects of oral formulations. 2

Bracing and Support

• Counterforce bracing helps reinforce, unload, and protect the medial epicondyle during activity. 2
• These braces may improve function during daily activities, though evidence is limited. 3

Second-Line Interventions

Corticosteroid Injections

• Use corticosteroid injections judiciously for short-term relief only—they are more effective than NSAIDs in the acute phase but do not change long-term outcomes. 1, 2, 3
• Critical caveat: Corticosteroids may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture. 2
• Reserve for patients with severe pain that limits participation in rehabilitation exercises. 1

Additional Modalities

• Deep transverse friction massage can reduce pain. 2, 3
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak. 2
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research. 2
• Manual joint mobilization combined with exercise therapy is more effective than exercise alone. 3

Surgical Management

Reserve surgery for patients who fail 6-12 months of well-managed conservative treatment. 2

• Surgical intervention is needed in approximately 12% of medial epicondylitis cases (compared to under 4% for lateral epicondylitis). 4
• Surgery typically involves excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 2
• Open release of the common flexor origin yields good results with high patient satisfaction and reliable return to preinjury activity levels. 5, 4

Treatment Timeline Algorithm

Initial Phase (0-4 weeks):

• Rest, activity modification, ice application, NSAIDs, and bracing. 2

Rehabilitation Phase (2-8 weeks):

• Progressive eccentric strengthening exercises, stretching, and continued bracing as needed. 2

Persistent Symptoms:

• Consider corticosteroid injection or other second-line modalities. 2

Refractory Cases (>6-12 months):

• Surgical consultation. 2

Critical Pitfalls to Avoid

• Never rely heavily on corticosteroid injections—they may weaken tendons and cause rupture. 2
• Avoid complete immobilization, which leads to muscle atrophy and deconditioning. 2
• Recognize that medial epicondylitis is predominantly work-related (90% of cases) rather than sport-related, affecting patients over 40 years of age most commonly. 6, 4
• Distinguish medial epicondylitis from concurrent pathologies including ulnar collateral ligament injury, ulnar nerve compression at the cubital tunnel, and intra-articular elbow disorders. 5, 7