Medial Epicondylitis, or golfer’s elbow, is similar to Lateral Epicondylitis, or tennis elbow, in that it is also a painful condition where the tendons of the forearm become degenerative at their attachment site on the inside of the elbow. The site of pain is the Flexor Pronator Mass (FPM), which is on the medial condyle side of the humerus. The FPM is a group of tendons and muscles that help flex the wrist. The group includes the following muscles: pronator teres, flexor carpi radialis, Palmaris longus and sometimes the flexor carpi ulnaris and flexor digitorum superficialis. Most people who get golfer’s elbow are in their 30s-60s and it is usually their dominant arm. Medial epicondylitis occurs less often than lateral epicondylitis, however, a person can have both lateral and medial epicondylitis at the same time.
You don’t have to play golf to get golfer’s elbow. Typically, this condition is caused by overuse activities that cause repetitive stress on the Flexor Pronator Mass (FPM) attachment site on the inside (medial side) of the elbow. Any sudden change in activity level or intensity, incorrect grip or grip size in racquet sports and sports like golf, prolonged hammering or use of a screwdriver, or lifting heavy objects can increase the strain on the FPM and cause microscopic tearing of the tendon. As in lateral epicondylitis, the blood supply to this area of the elbow is very poor and thus, a healing response is often slow and limited. Even with a slightly irritated tendon early on, light daily activities such as opening doors, lifting a laptop case or purse and shaking hands become enough to perpetuate the irritation. When the inflammation becomes severe, any motion of the wrist or fingers can cause agony. Trauma from a direct blow to the inside of the elbow can sometimes create a tear of the FPM. The degenerative, torn or completely ruptured tendon causes severe pain, which is what brings patients into the office to be seen for relief.
Signs and Symptoms
In most cases, the symptoms of medial epicondylitis develop gradually. There is usually no specific injury (unless there is a direct blow to the inside of the elbow) and the pain begins as mild and slowly worsens over the ensuing weeks and months. Most people experience burning pain on the medial side of their elbow. Weakness with gripping or twisting of the wrist and can also accompany pain. Numbness in the ring and small fingers can indicate ulnar nerve entrapment at the elbow near the irritated FPM.
A detailed history of the patient’s occupation and activities, examination of the arm with special tests and x-rays will help diagnose the condition. Dr. Viola prefers to follow the diagnosis with an MRI to quantify the level of tendon injury and possible nerve entrapment, which will give patients more definitive treatment options.
Many patients who visit the clinic have already tried conservative measures such as anti-inflammatory pain medications, ice, physical therapy, stretching, activity modification and rest without much improvement. The longer the duration of symptoms, usually the slower the recovery. At this point, it is important to obtain an MRI to quantify the level of Flexor Pronator Mass injury. Just injecting the tendon with steroid to ease the pain without this vital information can cause further tendon damage if the tendon is severely degenerative. If an MRI does show that the level of tendon tearing and degeneration is moderate to severe and symptoms are severe, surgery is recommended to debride the diseased tendon, which is unlikely to heal on its own, and then to repair the tendon. Because this site in the elbow has a very poor blood supply and is therefore slow to heal, Dr. Viola will often us PRP (platelet rich plasma, see below) in conjunction with debridement and repair to further improve the healing response. If there was severely damaged tendon and thus a repair of the FPM performed, a long-arm splint is worn for six weeks post-operatively to protect the repair, but range of motion exercises are started immediately. If only debridement and no repair are performed surgically, no splint is needed post-operatively and a more aggressive motion program is initiated.
If the level of tendon tearing is mild to moderate, as shown on MRI, a PRP injection without surgery is often appropriate to help the tendon heal faster on its own. Introduction of PRP, derived from your own blood, into the damaged tissue induces platelets to release concentrated healing proteins and growth factors. The FPM attachment site at the elbow has a poor blood supply, so the PRP helps initiate a regenerative healing response at the cellular level. After the injection, the arms is sore, but patients are allowed full range of motion and advised to slowly increase their arm level of activity and strengthening as pain improves.
Only in very special circumstances will Dr. Viola perform a steroid injection into the tendon attachment site for mild cases of medial epicondylitis, which can help relieve the symptoms of pain. Although they are potent anti-inflammatory medications, steroids inhibit tendon healing, weaken tendons and can even cause tendon rupture, which is a devastating consequence. Also, extreme care must be taken to avoid injury to the ulnar nerve when injecting the tendon because of its very close proximity to the FPM attachment site.
Modification of daily activities such as not reaching forward and lifting and lighter gripping is recommended to limit the aggravating factors causing further tendon pain.
Physical or Occupational Therapy Hand Therapy can provide stretching and strengthening exercises, custom splinting and education about activity modification and body mechanics. Massage, ultrasound or heat treatments can be pain relieving.
Over the counter pain relievers such as NSAIDs and Acetaminophen can help relieve the pain of the aggravated elbow and wrist. However, NSAIDs are NOT recommended long term or after PRP injections and surgery because they counteract the body’s mechanism of healing after these procedures.
Prevention of medial epicondylitis can be helped with proper technique in performing sports and activities that involve repetitive wrist flexion and forearm pronation.
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