Medial epicondylitis
From Medical-Wiki
Medial epicondylitis (ME) is also called golfer's elbow. This injury is caused by overuse of the flexor-pronator muscles. It is not as common as lateral epicondylitis. Physical load factors, smoking, obesity, repetitive movements, and forceful activities are associated with an increased incidence of medial epicondylitis. [1]
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Structures involved in golfer's elbow
The pronator teres, flexor carpi radialis, and palmaris longus are the muscles primarily responsible for pronation and flexion. These muscles attach at the on the anterior medial epicondyle. The flexor carpi ulnaris and flexor digitorum may also be involved, but their involvement is less common.
Pathophysiology of medial epicondylitis
Recent research has suggested that the mechanism of injury for both lateral and medial overuse syndromes involves more granulation tissue, fibrovascular and fibrocartilaginous tissue, tendon microfragmentation, calcification, and necrosis than an acute inflammatory reaction. It appears that the inflammatory reaction is in the muscle and surrounding soft tissue, not in the tendon. Consequently the term "tendinosis" is now used more commonly than "tendonitis."
It is repetitive stress at the attachment of the flexor-pronator muscles that create this tendinosis. However, one factor playing a role in medial tendinosis that does not come into play in lateral tendinosis is an ulnar neuropraxia created by pressure in or around the medial epicondylar groove. This is a significant factor in perhaps 50% of medial epicondylitis cases.
Clinical presentation of medial epicondylitis
Patients with medial epicondylitis will typically present with pain over the medial epicondyle made worse with wrist flexion and forearm pronation. Like lateral epicondylitis, patients may have pain even when simply shaking hands. Those patients with a neuropraxia may also complain of intermettant numbness or tingling radiating into their fourth and fifth fingers. Sometimes, there is a history of an acute injury, e.g. throwing a curve ball, hitting a hard serve in tennis, or hitting a particularly jolting golf shot.
Physical examination will reveal tenderness over the anterior aspect of the medial epicondyle. Sometimes, this tenderness will extend toward the proximal flexor-pronator muscle mass just distal to the epicondyle. Pain is usually seen with resisted wrist flexion or resisted forearm pronation. Range of motion is usually unaffected. Those patients a neuropraxia may demonstrate decreased sensation in the ulnar nerve distribution, a positive elbow-flexion test, and a positive Tinel sign. In more severe cases, decreased sensation is associated with intrinsic weakness; intrinsic muscle atrophy may be noted. [2]
Diagnostic studies for golfer's elbow
Since medial epicondylitis is not as common as lateral epicondylitis, there are occasions when visualizing modalities are necessary. X-rays are useful to rule out arthiritis or loose bodies. MRI may visualize pathology characteristic of chronic ME. MRI will also visualize the medial collateral ligament and ulnar nerve.
There are few studies that adequately evaluate the modalities used to treat ME. As with LE, watchful waiting, ultrasonography, iontophoresis with nonsteroidal anti-inflammatory drugs. topical nonsteroidal anti-inflammatory drugs, inelastic, nonarticular, proximal forearm straps, i.e. tennis elbow braces, and progressive resistance exercises all appear to have some effect in improving the condition. Basically, all treatment is an effort to reduce the stress on the point of tendinous attachment—even the activities of daily life. [3]
The modality that appears to offer the most dramatic improvement is local injection of corticosteroids. However, even this has not been subject to rigorous studies. Also, injection of the medial epicondyle must be done carefully because of the ulnar nerve. [4]
There are federal guidelines outlining what modalities are considered appropriate, what are considered poorly studied, and those with no evidence to support their use. [5]
