What is the initial treatment plan for a patient with medial epicondylitis?

Initial Treatment Plan for Medial Epicondylitis

Begin with relative rest, activity modification, and eccentric strengthening exercises as the foundation of treatment, as 80-90% of patients recover with conservative management within 3-6 months. 1

First-Line Conservative Management

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
• These exercises should be initiated early and performed consistently throughout the treatment course. 1, 2

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for acute pain relief. 1
• Instruct patients to ice the elbow regularly, particularly after activities. 2

NSAIDs

• NSAIDs provide short-term pain relief but do not alter long-term outcomes. 1
• Use these medications for symptomatic relief during the acute phase only. 1

Additional Conservative Interventions

Manual Therapy Techniques

• Cross friction massage to the medial epicondyle area can be beneficial. 2
• Instrument-assisted fascial stripping over the pronator teres muscle may help address trigger points. 2
• Ischemic compression and active assisted compressions to trigger points in the pronator teres should be considered. 2
• Mobilizations of the carpals, specifically the scaphoid, may provide additional benefit. 2

Modalities of Uncertain Benefit

• Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit according to current evidence. 1

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. 1
• When performing injections, infiltrate the preparation into the area of greatest tenderness at the medial epicondyle. 3
• Use strict aseptic technique and avoid injecting into the tendon substance itself. 3
• Reserve corticosteroid injections for patients who have failed initial conservative measures and require short-term relief. 1

Imaging Considerations

When to Image

• Plain radiographs are the most appropriate initial imaging study if there is diagnostic uncertainty or to rule out other causes of medial elbow pain. 4
• MRI or ultrasound should be considered if symptoms persist despite appropriate conservative treatment or if surgical planning is needed. 4
• MRI demonstrates intermediate to high T2 signal within the common flexor tendon and paratendinous soft tissue edema in medial epicondylalgia. 4
• Sonoelastography has shown high sensitivity (95.2%) and specificity (92%) for detection of medial epicondylalgia. 4

Surgical Management

Indications for Surgery

• Surgery should only be considered after failure of 6-12 months of appropriate conservative treatment. 1
• Surgical treatment involves release of the attachment of the common flexor muscle at the medial epicondyle. 5, 6
• At operation, residual tears with incomplete healing are consistently found in the flexor origin, with microscopy showing reactive fibrous connective tissue. 5

Surgical Outcomes

• Surgical treatment shows excellent to good results in 94% of cases when conservative treatment fails. 7
• Mean time to return to work is 2.8 months and to exercise is 4.8 months post-operatively. 7
• Patients with isolated medial epicondylitis have better surgical outcomes than those with coexistent ulnar neuritis. 6

Critical Clinical Consideration

Bilateral Presentation Alert

• The presence of bilateral symptomatic tendons should alert you to consider evaluation for rheumatic disease or rheumatologic referral. 1
• Bilateral medial epicondylitis is uncommon and warrants investigation for systemic inflammatory conditions. 1

Common Pitfalls to Avoid

• Do not use complete immobilization, as this leads to muscle atrophy and delays recovery. 1
• Avoid relying solely on corticosteroid injections, as they provide only short-term relief without changing long-term outcomes. 1
• Do not proceed to surgery without an adequate trial of conservative management lasting at least 6 months. 1
• When coexistent ulnar neuritis is present, recognize that outcomes are less favorable and symptoms may persist despite treatment. 6