Medial epicondylitis (golfer’s tendonitis)

Certain factors increase the risk of developing this condition. Sports that involve repetitive flexion of the wrist and pronation of the forearm, such as golf, baseball pitching, javelin throwing, bowling, weightlifting and racket sports like tennis, put individuals at higher risk. In addition, certain occupations involving heavy manual work and exposure to constant elbow vibration (e.g. plumbers, carpenters, construction workers) can also contribute to the development of medial epicondylitis. This condition can also occur post-traumatically, following injury to the medial region of the elbow.

Medial epicondylitis involves repetitive stress and microtrauma at the insertion of the flexor and pronator tendons, leading to tissue damage and inflammation. All the muscles of the common flexor tendon are affected, with the exception of the palmaris longus. The development of medial epicondylitis generally progresses in three distinct stages: the initial stage involves peritendinous inflammation, characterized by increased blood flow and infiltration of inflammatory cells into the affected area. This inflammatory response can cause pain, swelling and tenderness. In the next stage, angiofibroblastic hyperplasia occurs, leading to the proliferation of blood vessels and fibroblasts. This hyperplasia contributes to thickening and degenerative changes in the affected tendon. Increased vascularization and fibrous tissue can further contribute to pain and impaired function. As the disease progresses, degradation, fibrosis and calcification can occur in the affected tendon. This last stage is characterized by the degeneration and rupture of tendon fibers, as well as the formation of fibrous tissue and areas of calcification. These structural changes can lead to additional pain, functional limitations and reduced tendon strength.

Medial epicondylitis can be associated with a variety of conditions that may contribute to or coexist with it. A common condition is ulnar neuropathy, where inflammation and swelling around the medial epicondyle can affect the neighboring ulnar nerve. This can lead to symptoms such as numbness, tingling or weakness in the ulnar distribution of the hand and forearm. Another associated condition, to be considered particularly in throwing athletes, is injury to the ulnar collateral ligament. This ligament is crucial for elbow stability during throwing movements. In the case of medial epicondylitis, it is important to assess its integrity, as damage to it can lead to recurrent or persistent symptoms. Other pathologies of occupational origin may be associated, with around 84% of these occurring in the workplace, the most common including carpal tunnel syndrome, lateral epicondylitis and rotator cuff tendonitis. These pathologies can result from repetitive movements or overuse of the wrist, forearm and shoulder, leading to increased tension on the medial epicondyle.

The history may reveal a potential cause, such as acute elbow trauma resulting in avulsion of the common flexor tendon. Repetitive use of the elbow, repetitive gripping and repetitive valgus stress are also common contributors. Patients may also report numbness or tingling in the fourth and fifth fingers (ulnar nerve territory). Symptoms usually have an insidious onset and involve pain in the medial epicondyle. Pain tends to worsen with wrist and forearm movements, as well as with grasping. On physical examination, tenderness is usually localized 5-10 mm distal and anterior to the medial epicondyle. If inflammation is present, there may be soft-tissue swelling and warmth. The provocation test consists of pronating the forearm and flexing the wrist against resistance. It is important to carry out a thorough examination to identify any associated conditions. In athletes, for example, assessment of valgus instability is crucial. Ulnar neuritis should also be considered, and can be assessed by tests such as two-point discrimination in the ulnar distribution, evaluation of the hypothenar mass and inspection for Tinel’s sign along the length of the ulnar nerve. In chronic cases, it is possible to visualize contracture on elbow flexion.

Imaging plays a crucial role in the evaluation of medial epicondylitis. X-rays are often the initial imaging modality, and although they are generally unremarkable, in 25% of cases they may show calcification of the common flexor tendon or ulnar collateral ligament. Posteromedial osteophytes or degenerative changes may also be observed. In some centers, stress radiography is used to assess valgus instability. Ultrasound is a useful tool, enabling dynamic examination with real-time visualization of affected structures. It can reveal hypoechoic or anechoic areas corresponding to focal degeneration in the tendon. MRI is considered the gold standard. It is indicated when it is necessary to assess concomitant pathologies, such as ulnar collateral ligament lesions in throwing athletes, or when the source of medial elbow pain is unclear. Possible findings in medial epicondylitis include tendinosis (inflammation of the tendon) or rupture of the common flexor tendon, characterized radiologically by increased signal intensity on T2-weighted images and the presence of peritendinous edema. It can also identify lesions of the ulnar collateral ligament and osteochondral lesions. Electromyography (EMG) and nerve conduction studies (NCS) can be used in cases of suspected ulnar nerve compression based on patient history and physical examination findings. These tests can further assess the integrity and function of the ulnar nerve.

In the majority of cases, a conservative approach is recommended as the first line of defence, due to the less predictable success of surgical interventions compared to lateral epicondylitis. A prolonged trial of non-operative measures is therefore appropriate. Initial management consists of rest, ice application and activity modification, which may involve abstaining from throwing for a period of 6 to 12 weeks. Physiotherapy focusing on passive stretching exercises can help improve flexibility and relieve symptoms. Wearing orthoses and kinesiology bands is also beneficial. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used to relieve pain and inflammation. Corticosteroid injections into the peritendinous tissue should be limited, as they can lead to complications such as skin depigmentation (particularly in dark-skinned people), subcutaneous atrophy, tendon weakening and even ulnar nerve damage. Although there are no definitive recommendations for extracorporeal shockwave therapy in medial epicondylitis, it has shown potential benefits: it promotes angiogenesis, tendon healing and short-term pain relief. Acupuncture is also an alternative treatment option, although its efficacy is not firmly established.

Surgical intervention is considered in compliant patients who have not responded to at least 6 months of conservative management, or when symptoms are severe and have a significant impact on the patient’s quality of life. It is crucial to establish a clear diagnosis before proceeding with surgery. It involves open debridement of the tendons of the round pronator and flexor carpi radialis muscles, followed by reattachment of the flexor and pronator muscles at the medial epicondyle. Results are generally favourable, with around 80% of patients achieving good to excellent results. However, it is important to note that results may be less favourable compared to lateral epicondylitis. The presence of preoperative ulnar nerve symptoms can have a negative impact on results, and may require additional management or intervention.

Rehabilitation after surgical treatment generally involves a structured approach to optimize recovery and regain functional ability. Initially, a short period of immobilization in a sling for around 1-2 weeks is recommended to allow proper healing and minimize stress on the surgically-treated area. During this immobilization phase, it is important to avoid palmar flexion of the wrist to prevent excessive stress on the flexor-pronator group. After the initial immobilization period, range-of-motion exercises can be started, usually around the 2-week mark. These exercises focus on gradually restoring full range of motion to the elbow and wrist. It is important to progress these exercises in a controlled manner, ensuring that the patient experiences no excessive discomfort or pain. Around 6 to 8 weeks after surgery, the rehabilitation program can move on to strengthening exercises. These exercises specifically target the muscles involved in the flexor-pronator group to improve their strength and endurance. The program must be tailored to the individual’s specific needs, progressing progressively in intensity and resistance. The time frame for resuming sporting activities after surgical treatment of medial epicondylitis may vary according to various factors such as the patient’s progress, the severity of the initial condition and the specific requirements of the sport. Generally speaking, athletes can expect to return to sport between 3 and 6 months after surgery. It is important to note that return to sport should be gradual, with the emphasis on proper technique, progressive training and close monitoring for any symptoms or signs of overuse.

Although complications following surgical treatment are relatively rare, it’s important to be aware of the potential risks. One possible complication is neuropathy of the medial cutaneous nerve of the forearm, which can occur following its avulsion or sectioning during surgery. If this injury is noticed intraoperatively, a possible management option is to transpose the nerve into the brachial muscle to protect it from further damage and facilitate proper healing. Another potential complication is injury to the ulnar nerve, which passes in the immediate vicinity of the medial epicondyle. General complications such as infection are also possible.

Prognosis varies according to several factors, including severity and duration of symptoms, compliance and individual patient characteristics. In general, medial epicondylitis has been less studied than lateral epicondylitis, which may contribute to a slightly less predictable prognosis. Available research suggests that outcomes are generally favourable, with the majority of patients showing significant improvement in symptoms and functional abilities. However, it should be noted that treatment success rates tend to be slightly lower than for lateral epicondylitis.