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Elbow Pain – Medial and Lateral Epicondylitis

New understandings of golfer's elbow and tennis elbow have shifted treatment methods away from anti-inflammatories, steroids, and physical therapy to biological therapies aimed at tendon regeneration.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.

History/Pathogenesis

Elbow epicondylitis is a common chronic overuse injury that is typically associated with sports. Although the prevalence rates in specific sports may be significantly higher than others, athletes in general, as well as nonathletes, often experience epicondylitis-related pain. There are two types:

  • Medial epicondylitis (golfer’s elbow” or “little-league elbow") involves chronic pain at the medial epicondyle (bony origin of wrist flexors) caused by repetitive stress, leading to microtrauma of the forearm flexor and pronator muscles, as well as the wrist flexor muscles.
  • Lateral epicondylitis (“tennis elbow”) involves chronic pain at the lateral epicondyle (bony origin of wrist extensors) caused by repetitive stress, leading to microtrauma of primarily the extensor carpi radialis brevis and common extensor tendon.

Both injuries are induced by repetitive stress, however, research suggests that frequent eccentric overloads placed on the muscle may occur primary to epicondylitis. Additionally, literature shows that these injuries primarily occur during the fourth decade of life, which suggests a degenerative mechanism could be largely responsible. It is thought to occur, beginning with degeneration of the tendon, leading to calcification, fibrosis, vascular proliferation, and hyaline degeneration of associated muscles without inflammatory presence.

This new understanding of epicondylitis has shifted traditional treatment methods of anti-inflammatory drugs, steroids, and physical therapy to biological therapies (eg, platelet-rich plasma, stem cell therapy) aimed at tendon regeneration rather than pain reduction.1-13

Image: iStock (SARINYAPINNGAM)Golfer's elbow and tennis below are induced by repetitive stress on the joint.

Prevalence/Epidemiology

Lateral epicondylitis reportedly affects 1.3% of the general population, while medial epicondylitis affects only 0.4%, making tennis elbow the most common source of elbow pain related symptoms. Despite the name, tennis players only make up approximately 10% of the patients diagnosed with lateral epicondylitis. Reports show that epicondylitis is equally present in men and women, with the largest incidence between the ages of 45 and 54 years old.5-6,8,13-17

High Risk Activities

  • Medial epicondylitis risks include golf, overhead throwing activities (pitching, tennis serve, football), and occupations involving repetitive wrist flexion.
  • Lateral epicondylitis risks include racquet sports, playing piano, occupations involving repetitive wrist extension, radial deviation, and/or forearm supination.

Additional Risk Factors for the General Population

  • Age–risk greatly increases after age 40
  • Smoking
  • Obesity
  • Repetitive movement for at least two hours daily
  • Inexperienced athletes performing with improper form (Risk is infrequent in advanced athletes.)

 

Signs/Symptoms

Medial epicondylitis: Pain in medial elbow accentuated during later cocking of throwing motions; pain with resisted wrist flexion, pronation, and forearm motions. Mild weakness is often noted for grasping activities.

Lateral epicondylitis: Pain at lateral elbow; pain with wrist and forearm motions; and pain with gripping/lifting objects (eg, screwdriver, making fist, shaking hands). Pain radiates from dorsum of the forearm to the fingers.

Related Conditions: Medial epicondylitis can mimic Panner’s disease (osteochondritis and/or osteochondrosis of the capitellum).

Physical Exam

Medial epicondylitis: Look for increased carrying angle (greater than 10° in males and 15° in females); pain with point tenderness over the tip of the medial epicondyle extending distally 1 to 2 inches along the common flexor origin (usually pronator teres [PT] and flexor carpi radialis [FCR]); pain/weakness of wrist flexors and pronators with elbow extended; and possible loss of full extension of elbow (flexion contracture consistent with avulsion fracture). Assess for ulnar collateral ligament stability and pain/weakness with resisted wrist flexion.

Lateral epicondylitis: Look for localized tenderness just anterior and distal to the lateral epicondyle; and pain/weakness to resisted wrist extension (especially with extended elbow) and/or middle finger extension. Pathoanatomic changes occur primarily in the extensor carpi radialis brevis (ECRB) and secondarily at the extensor digitorum communis (EDC). It is important to rule out C6/C7 radiculopathy, especially with paresthesias.

Diagnostic tests (medial and lateral)

  • If indicated, evaluate with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, or bone scan testing, or EMG/NCS testing.

Differential Diagnoses

Medial epicondylitis: lateral epicondylitis, chronic valgus instability or tears of the medial collateral ligament, intra-articular pathology or stress fracture, gout, cervical spine disease, and ulnar nerve entrapment.

Lateral epicondylitis: medial epicondylitis, intra-articular pathology or stress fracture, gout, cervical spine disease, and posterior interosseous nerve entrapment.

Acute Treatment

Medial epicondylitis: First-line treatment includes relative rest; analgesia through appropriate doses of NSAIDs and physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant and electrical stimulation.

If avulsion fracture with minimal displacement, apply posterior splint for 2 to 3 weeks then gradually progress range of motion (ROM) and strengthening. If displacement is greater than 5 mm, open reduction and internal fixation may be warranted.

Lateral epicondylitis: First-line treatment includes relative rest; equipment modifications (decrease racquet string tension for tennis players or improve ergonomics of work station); analgesia through appropriate doses of NSAIDs, physical modalities such as ice, ultrasound, iontophoresis, phonophoresis; counterforce bracing, and/or wrist splinting (especially at night); along with forearm stretching, and topical anesthetic skin refrigerant and electrical stimulation.

Long-Term Treatment/Rehab

Despite recent advancements in treatment methods, therapeutic treatment, rest, and bracing still remain as the first line of treatment. Therapy should focus on stretching and strengthening relevant muscles. Activity modification in both conditions is vital. The conditions are usually attributed to improper technique and/or biomechanics. Therefore, improvement upon these aspects is necessary before returning to activity in order to prevent reoccurrence. Recommend activity modification, stretch tight musculature, and strengthen weak musculature.

With young baseball players, it is critical to promote good throwing mechanics, limit the types of pitches thrown (especially breaking pitches such as the screwball), and keep a cap on the number of innings pitched per week (less than 10 is a safe recommendation based on the data).18-25 Advanced treatment methods (platelet-rich plasma, collagen-producing cell treatments, and stem cell treatments) have demonstrated positive results, but more research is needed to determine definitive efficacy.1,12

Prevention

To prevent injury and injury reoccurrence, clinicians should advise patients on:

  • proper biomechanics and technique, especially in those playing high incidence sports
  • proper warmup before beginning activity
  • avoiding overexertion and allowing time for rest and recovery
  • proper equipment (eg, racquets, clubs, grips).

Practical Takeaways 

  • Medial epicondylitis (golfer’s elbow/ little-league elbow) is chronic pain at the medial epicondyle (bony origin of wrist flexors) caused by repetitive stress, leading to microtrauma of the forearm flexor and pronator muscles, as well as the wrist flexor muscles.
  • The medial epicondylitis physical exam should look for increased carrying angle (greater than 10° in males, 15° in females); pain with point tenderness over the tip of the medial epicondyle extending distally 1 to 2 inches along the common flexor origin (usually PT and FCR); pain/weakness of wrist flexors and pronators with elbow extended and possible loss of full extension of elbow.
  • Acute treatment for medial epicondylitis includes relative rest; analgesia through appropriate doses of NSAIDs and physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerant, and electrical stimulation. Long-term treatment/rehab includes stretching and strengthening relevant muscles.
  • Lateral epicondylitis: (tennis elbow) is chronic pain at the lateral epicondyle (bony origin of wrist extensors) caused by repetitive stress, leading to microtrauma of primarily the extensor carpi radialis brevis and common extensor tendon.
  • The physical exam for lateral epicondylitis should look for localized tenderness just anterior and distal to the lateral epicondyle, pain/weakness to resisted wrist extension (especially with extended elbow) and/or middle finger extension. Pathoanatomic changes occur primarily in the ECRB and secondarily at the EDC. Rule out C6/C7 radiculopathy, especially with paresthesias.
  • Acute treatment for lateral epicondylitis includes relative rest; equipment modifications (decrease racquet string tension for tennis player or improve ergonomics of work station); analgesia through appropriate doses of NSAIDs, physical modalities such as ice, ultrasound, iontophoresis, phonophoresis; counterforce bracing, and/or wrist splinting (especially at night); along with forearm stretching, and topical anesthetic skin refrigerant and electrical stimulation. Long-term treatment/rehab includes stretching and strengthening relevant muscles.
Additional chronic overuse injuries in this primer:
Last updated on: May 29, 2020
Continue Reading:
Achilles Tendinopathy as a Chronic Overuse Injury
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