What is Medial Epicondylitis?
Elbow pain is common, but if not taken care of properly it can turn into a chronic condition like medial epicondylitis, also known as “golfer’s elbow” or “pitcher’s elbow.” You don’t have to play the sport of golf or baseball to be a sufferer of this condition, in fact about 30% of all elbow epicondyle injuries are related to the medial (inside) elbow.
Repetitive movements elbow movements along with the wrist bent towards the palm plays a role in the cause of medial epicondylitis. What is not fully understood, is why in some people the fibers of the tendon break down causing irritation and pain yet for others this degenerative change does not occur. Some people have little to no symptoms with the same repetitive stressors, while others suffer from pain and irritation.
When standing in anatomical position, arms straight at the side and palms forward, the medial elbow is next to the body. The outside of the elbow is called the lateral elbow which an injury to that area of the elbow is called lateral epicondylitis, or tennis elbow.
Three bones make up the elbow joint, humerus (upper arm bone), ulna (larger forearm bone), and radius (smaller forearm bone). The bones of the elbow work together to flex (bend), extend (straighten), and rotate (supinate and pronate). At the end of the humerus, near the elbow, there are two bony prominences called epicondyle. You can feel the medial (inside elbow) epicondyle when your elbow is at your side.
The ulna is the second biggest bone within the elbow joint. It starts on the outside of the elbow and extends down to the wrist. The end of the ulna visable as it is the bony prominence that sticks out at your wrist.
The radius is the smallest of the elbow bones. It is on the inside (medial) side of the elbow and extends down to the wrist. The ulna and the radius together assist with the movement of rotation (supinate and pronation) of the forearm. Supination is rotating your forearm, so the palm is faced upward. Pronation is rotating your forearm, so the palm is faced down.
To hold the three bones together as well as allow for movement, we have muscles, tendons, and ligaments. Muscles are flexible and rich in blood supply, which means they not only help with movement, but they also tend to heal more quickly due to this rich blood supply when compared to other soft tissue.
Tendons connect muscle to bone. They are more fibrous than muscles and have less blood supply which means they are less flexible and when injured can sometimes be more stubborn to heal. Ligaments connect bone to bone. The job of the ligaments in the elbow is to make sure each of the three bones stays together, and there is no extra movement within the joint space. Ligaments are tough fibrous tissue which “stabilizes” our elbow joint, which also means they can take quite a long time to heal since there is less blood supply to the tissue compared to tendons and muscles.
Medial epicondylitis is when the tendons on the inside of the elbow are chronically irritated and may have degenerative (breaking down) changes occurring at the fibrous level. This degenerative change is called tendinosis.
Tendons are strong and meant to withstand tensile forces which mean both ends of the tendon can withstand pulling forces (one end on the muscle and the other end on the bone). With repeated forces and movements of the wrist and elbow, the added strain can irritate the tendons as well as the muscles. Without early intervention, for some this irritation and pain turns into tendinosis.
What causes medial epicondylitis?
Lateral epicondylitis is more common than medial epicondylitis; however, they both can be painful and debilitating. The most common age range for those who suffer from medial epicondylitis is between 20-60 years old.
Medial epicondylitis is caused by the repetitive elbow and wrist movements while the wrist is in a slightly flexed position. Irritation and pain is caused when degenerative changes start to occur in the fibrous tissue of the tendon.
Common causes of medial epicondylitis include repetitive movements with:
- Chainsaw work
- Chopping wood with an ax
- Hammering nails
- Pitching a baseball
- Spin serve in tennis
- Throwing a javelin
- Use of hand tools (e.g. screwdrivers)
Whether you are an athlete or not, the most common culprit to medial epicondyle is poor technique or style with the use of an improper tools or piece of equipment. Poor throwing mechanics, too tight of strings on a tennis racquet, or too heavy of a tool can all lead to overuse and strain of the elbow. If you couple poor technique with poor equipment and add in weak forearm muscles or poor flexibility, all that can lead to elbow pain.
Symptoms of Medial Epicondylitis
Symptoms include irritation and pain from the inside, medial, elbow and may run down the palm side of the forearm to the wrist. In severe cases, the hand may feel weak. Pain is common with firm gripping of objects especially if the wrist is slightly bent towards the palm.
How is medial epicondylitis diagnosed?
Medial epicondylitis can mimic an ulnar collateral ligament (UCL) injury (link to elbow pain). In fact, the UCL is a more common injury than medial epicondylitis. The UCL is the primary ligament on the inside of the elbow stabilizing the ulna bone with the humerus bone.
Just having medial elbow pain alone does not mean you have a medial epicondyle injury. A medical professional, such as a physical therapist (PT), occupational therapist (OT), or a physician can assess your elbow to determine the exact cause of symptoms.
Your health care provider will rule out cervical radiculopathy, a brachial plexus injury, or a UCL injury. Most medial epicondylitis cases are diagnosed with a simple physical exam. The exam will include a review of your medical history as well as asking questions about your hobbies, work activities, and sports.
Rarely are MRIs (magnetic resonance imaging) used for diagnosis. If an MRI is ordered, the physician may be looking to rule out other possible causes and conditions.
Treatment of Medial Epicondylitis
Treatment may vary depending on your age, how long you have suffered from symptoms, or the extent of your overall health. For acute mild medial elbow injuries, simply icing, resting, and gently stretching the elbow may be all you need.
Any acute injury is typically within the first one to three days of trauma or onset of symptoms. Apply ice to the area daily for about 15 mins at a time, 2-3 times per day, for up to three or four days, which will help reduce any swelling in the area.
Rest from the activities that irritate the elbow. If you can’t rest, it is advised to seek treatment from a physical or occupational therapist who may be able to provide you with a brace as well as to work with you on technique to minimize the stress on the tissue and painful area.
Gentle stretches of the elbow may help alleviate symptoms by reducing stiffness. Stretches should not aggravate the elbow symptoms before or after the stretch. Keep the stretch mild and tolerable.
If symptoms progress or are stubborn and just won’t go away, then seeking treatment from a physical or occupational therapy is highly recommended. Conservative treatment usually resolves symptoms with four to six weeks. The goal of rehabilitation is to manage symptoms and improve strength and mobility to return to functional activities, which is accomplished through soft tissue management and manual techniques. As well, your therapist will provide you with appropriate and graded stretches and strengthening exercises to avoid irritation. Furthermore, your therapist will instruct you on proper equipment, tools, and movement techniques to minimize the risk of the symptoms returning.
In rare cases, more than just conservative treatment is needed. Your physician may recommend an elbow injection if you are not tolerating PT or OT, or the symptoms are so severe they are impacting everyday activities, which is rarely needed, but there are cases where this is appropriate. If you are in PT or OT treatment, he or she may discuss this treatment with your physician. If you visit with your physician first, he or she will properly exam the elbow to determine the best treatment approach.
An injection is not a cure to the problem. It may minimize or eliminate your symptoms, but there is still a mechanical issue that caused the problem in the first place. PT or OT in conjunction with an injection, when needed, can have good and long-lasting effects.
If conservative care does not work, nor an injection, in a rare situation a surgeon will do either a tendon release or debridement surgery. A medial epicondyle release, tendon release, where the surgeon repairs the damaged tissue, removes any bone spurs, and assess the ulnar nerve to make sure that does not impinge. A surgical debridement is when the surgeon only cleans up or removes the damaged tissue.
Post-operative PT or OT treatment is likely. You will wear an elbow splint keeping your elbow bent at 90 degrees. For the first six weeks post-op, managing swelling, pain, and beginning gentle movements is the goal. Approximately six weeks post-operative, if healing is normal and symptoms are managed, then gentle strengthening of the elbow begins. Exercises will progress depending on tolerance.
Therapy is typically two to three months’ post-operation. Returning to higher level activity levels may be four to six months, or longer, after surgery.
Early intervention to elbow pain is the key to managing avoiding a costly injury in the future. The sooner you address your symptoms, the more likely conservative care will work for you.
As a consumer of health care, you have a choice in finding the right provider for you. Do your homework and search for a health care provider, like a physical or occupational therapist, with excellent outcomes, great customer reviews, and can provide you the care you need for a reasonable cost.
In most states, you can be seen by a PT first, without a physician’s order. To determine if your state has direct access, please visit the American Physical Therapy Association’s website Physical Therapy Direct Access By State.
To get started with conservative care today, you can find a highly qualified PT or OT in your area. There are many qualified PTs and OTs, so to find one near you, please click on the following link (FOTO PT database link). This link will help you find a PT or OT that has top national rankings for treating the elbow.