Diagnosis and treatment of medial epicondylitis of the elbow
Section snippets
Epidemiology and etiology
Medial epicondylitis occurs much less frequently than lateral epicondylitis, which has been diagnosed seven to ten times more often [5]. Although the syndrome has been identified in patients ranging from 12 to 80 years old, it predominantly occurs in the fourth and fifth decades. Male and female prevalence rates are reportedly equal. Seventy-five percent of patients are symptomatic in their dominant arms.
The majority of the literature on epicondylitis suggests that the disorder's primary
Biomechanics
The biomechanics of the medial elbow and the flexor-pronator musculature are most often described in terms of the baseball pitching mechanism. The acceleration phase of pitching—from the point at which the ball has virtually no forward velocity to the point of release—may produce peak angular velocity and extreme valgus forces greater than the tensile strength of the medial ligamentous and musculotendonous structures. The forces are initially transmitted to the flexor-pronator muscle group and
Anatomy
The flexor-pronator group comprises the musculotendonous structures of the medial elbow. From the radial to the ulnar aspects of the forearm, the musculature includes the pronator teres, the flexor carpi radialis, the palmaris longus, the flexor digitorum superficialis, and the flexor carpi ulnaris. The pronator teres and flexor carpi radialis both attach to the anterior aspect of the medial epicondyle. These tendons are stretched during the acceleration phases of throwing and swinging. Thus,
Pathophysiology
Since Morris' first description of epicondylitis in 1882, a vast amount of literature has been dedicated to the pathophysiology of this disorder. Early descriptions postulated an inflammatory process involving the radial humeral bursa, periosteum, synovium, and annular ligament [21], [22], [23], [24]. These theories, however, have recently been discounted by the histologic analysis of Nirschl and Pettrone [6], and Regan et al [25]. Their studies revealed that the normal collagen architecture is
Diagnosis
The diagnosis of medial epicondylitis requires a careful patient history and physical examination, and radiographic and imaging studies, to distinguish it from other possible etiologies of medial elbow discomfort, such as ulnar collateral ligament instability or ulnar neuritis.
Medial epicondylitis is characterized by pain of insidious onset along the medial elbow, which is worsened by resistance to forearm pronation and wrist flexion. Tenderness to palpation usually occurs over the pronator
Nonsurgical treatment
Nonsurgical treatment is the cornerstone of care for both medial and lateral epicondylitis. The objective of such conservative care is to relieve pain and reduce inflammation, allowing sufficient rehabilitation and return to activities. Although this treatment has been described as highly successful, there remains a lack of information concerning the long-term outcome of nonsurgical treatment. The available literature suggests that 5% to 15% of patients suffer recurring symptoms, but the
Surgical treatment
If a patient fails to respond to a disciplined, 3- to 6-month nonoperative program and all other possible pathologic causes for the pain of epicondylitis have been excluded, surgical treatment is recommended. In elite throwing athletes, operative treatment can be undertaken sooner if physical examination and imaging studies indicate tendon disruption. At this stage, nonoperative treatment will most likely prove insufficient to return the high-level athlete to peak performance.
Summary
Although limited literature exists on medial epicondylitis of the elbow, this disorder is an injury affecting many professionals and athletes at every level, especially throwing athletes. Care must be taken in diagnosing medial epicondylitis to distinguish it from other possible pathologies of the medial elbow, which may exist concurrently. The large majority of patients diagnosed with medial epicondylitis will respond to a well-structured, nonsurgical program; however, patients with persistent
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