23: Medial Epicondylitis

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CHAPTER 23

Medial Epicondylitis

Lyn D. Weiss, MD

Jay M. Weiss, MD

Synonyms

Tendinosis [1]

Medial epicondylitis

Pitcher’s elbow

Little Leaguer’s elbow

Golfer’s elbow

ICD-9 Code

726.31  Medial epicondylitis

ICD-10 Codes

M77.00  Medial epicondylitis, unspecified elbow

M77.01  Medial epicondylitis, right elbow

M77.02  Medial epicondylitis, left elbow

Definition

Epicondylitis is a general term used to describe inflammation, pain, or tenderness in the region of the medial or lateral epicondyle of the humerus. The actual nidus of pain and pathologic change has been debated. Medial epicondylitis implies an inflammatory lesion with degeneration at the origin of the flexor muscles (the medial epicondyle of the humerus). In medial epicondylitis, the tendon of the flexor muscle group is affected (flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, and palmaris longus).

Although the term epicondylitis implies an inflammatory process, inflammatory cells are not identified histologically. Instead, the condition may be secondary to failure of the musculotendinous attachment with resultant fibroplasia [2], termed tendinosis. Other postulated primary lesions include angiofibroblastic tendinosis, periostitis, and enthesitis [3]. In children, medial elbow pain may result from repetitive stress on the apophysis of the medial epicondyle ossification center (Little Leaguer’s elbow) [4]. Overall, the focus of injury appears to be the muscle origin. Symptoms may be related to failure of the repair process [5].

Repetitive stress has been implicated as a factor in this condition [6]. Poor throwing mechanics and excessive throwing have been implicated in Little Leaguer’s elbow. Repetitive wrist flexion, as in the trailing arm in a golf swing, can cause medial epicondylitis (hence, the term golfer’s elbow is frequently used for medial epicondylitis, regardless of etiology).

Symptoms

Patients usually report pain in the area just distal to the medial epicondyle. The patient may complain of pain radiating proximally or distally. Patients may also complain of pain with wrist or hand movement, such as gripping a doorknob, carrying a briefcase, or shaking hands. Patients occasionally report swelling as well.

Physical Examination

On examination, the hallmark of epicondylitis is tenderness over the flexor muscle origin (medial epicondylitis). The origin of the flexor muscles can be located one fingerbreadth below the medial epicondyle. With medial epicondylitis, pain is increased with resisted wrist flexion. There may be localized tenderness along the course of the radial nerve around the radial head. Motor and sensory findings are usually absent.

Functional Limitations

The patient may complain of an inability to lift or to carry objects on the affected side secondary to increased pain. Typing, using a computer mouse, or working on a keyboard may re-create the pain. Even handshaking or hand squeezing may be painful in medial epicondylitis. Athletic activities may cause pain, especially with an acute increase in repetition, poor technique, and equipment changes.

Diagnostic Studies

The diagnosis is usually made on clinical grounds. Magnetic resonance imaging, which is particularly useful for soft tissue definition, can be used to assess for tendinitis, tendinosis, degeneration, partial tears or complete tears, and detachment of the common flexor at the medial epicondyles [7]. Magnetic resonance imaging is rarely needed, however, except in recalcitrant epicondylitis, and it will not alter the treatment significantly in the early stages. The medial collateral ligament complexes can be evaluated for tears as well as for chronic degeneration and scarring. Ultrasonography has been used to diagnose medial epicondylitis [8,9]. Arthrography may be beneficial if capsular defects and associated ligament injuries are suspected. Barring evidence of trauma, early radiographs are of little help in this condition but may be useful in cases of resistant tendinitis and to rule out occult fractures, arthritis, and osteochondral loose body. Early radiographic studies (before commencing a rehabilitation program) may be considered in skeletally immature children with elbow pain to rule out growth plate disorders, osteochondritis dissecans, or ulnar collateral ligament tears [10].

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