What is the treatment for medial epicondylitis?

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
• Progressive stretching exercises for wrist flexors should be incorporated into the rehabilitation program. 1

Adjunctive Therapies

• 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 acute phase. 1
• Counterforce bracing may improve function during daily activities, though evidence is limited. 2

Second-Line Interventions

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
• Consider corticosteroid injections when initial conservative measures fail to provide adequate pain control, but limit their use as they provide no long-term benefit. 3, 4

Other Modalities

• Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit and should not be prioritized. 1

Surgical Management

Indications

• Surgery should only be considered after failure of 6-12 months of appropriate conservative treatment. 1, 4
• Operative treatment is indicated for debilitating pain after exclusion of other pathologic causes that persists despite a well-managed nonoperative regimen. 3, 4

Surgical Technique and Outcomes

• The surgical technique involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin of the flexor pronator muscle group to the medial epicondyle. 3, 4
• Surgical success rates range from 63% to 100%, with a low complication rate of 4.3%. 5
• Return to work rates are 66.7%-100%, and return to sports rates are 81%-100%. 5
• Mean time to return to work is 2.8 months and to exercise is 4.8 months. 6
• Surgical treatment results in high subjective relief, though objective strength deficits may persist. 3, 4

Important Clinical Considerations

Differential Diagnosis

• Medial epicondylitis must be distinguished from cubital tunnel syndrome, ulnar collateral ligament injury, and other medial elbow pathologies that may coexist. 7
• The presence of bilateral symptomatic tendons should alert you to consider evaluation for rheumatic disease or rheumatologic referral. 1

Common Pitfalls

• Avoid premature surgical intervention before completing at least 6 months of conservative treatment, as the vast majority of patients respond to nonoperative management. 1, 7
• Do not rely on corticosteroid injections as a primary treatment strategy, as they only provide short-term relief without affecting long-term outcomes. 1
• Ensure complete immobilization is avoided during the rest phase, as this can lead to muscle atrophy and delayed recovery. 1