What is Medial Epicondylitis?

    Medial epicondylitis of the elbow, commonly referred to as ‘‘golfer’s elbow,’’ is characterized by pathologic changes to the musculotendonous origin at the medial epicondyle. 

    Medial epicondylitis (ME) is an elbow overuse condition characterized by flexor-pronator group (FPG) muscle damage, tendinopathy, muscular stiffness, and inflammation. The suffix "-itis" refers exclusively to the condition's acute inflammatory phase. When the disorder becomes chronic, the inflammation subsides and degenerative processes take over, making the suffix "-osis" more suitable. The phrase "medial elbow tendinopathy" refers to both the acute, inflammatory phase of the ailment as well as the chronic, degenerative phase. 




Causes:

    The majority of the research on epicondylitis contends that overuse or repeated stress on the flexor-pronator muscle is the primary cause of the condition. Chronic repeated concentric and eccentric contractile stress of the flexor-pronator group causes degenerative alterations in the musculotendonous area of the medial epicondyle. Although greater widespread rips can develop in the palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris, these alterations are most frequently observed in the pronator teres and the flexor carpi radialis muscles. A single traumatic incident, such as a direct hit or a rapid, very eccentric contraction, may cause epicondylitis to develop even when recurrent usage has been established as the major cause. 
    Activities requiring repeated forearm pronation and wrist flexion have been linked to medial epicondylitis. Although it is most common in baseball pitchers as a result of intense valgus forces on the medial elbow during the late cocking and acceleration phases of throwing, it has also been linked to golf, tennis, bowling, racquetball, football, archery, weightlifting, and javelin throwing. However, this illness is not entirely athletic in nature, since it is also connected with jobs such as carpentry, plumbing, and meat cutting, all of which demand repeated forearm, wrist, and hand motions.

Diagnosis:

    Medial epicondylitis is characterized by pain that develops gradually throughout the medial elbow and gets worse by resistance to forearm pronation and wrist flexion. Tenderness on palpation is most common across the pronator teres and flexor carpi radialis, and is greatest 5 mm to 10 mm distal and anterior to the midpoint of the medial epicondyle. The intensity of pain varies, but it is usually present and intense during the offending action. Local swelling and warmth are also possible.

Diagnostic Test:

Medial Epicondylitis Test

  • The patient can be seated or standing for this test
  • The physician palpate the medial epicondyle and supports the elbow with one hand, while the other hand passively supinate the patient forearm and fully extends the elbow, wrist and fingers.
Result: If the sudden pain or discomfort is reproduced along the medial aspect of the elbow in the region of the medial epicondyle, then this test is consider positive.

Reverse Cozen Test:

  • The patient is seated
  • The examiner palpate the medial epicondyle with one hand while the other hand rests on the wrist of the patient's supinated forearm. 
  • The patient attempts to flex the extended hand against the resistance of the examiner's hand on the wrist.
Result: Acute, Stabbing pain over the medial epicondyle suggests medial epicondylitis.


Treatment:

Soft tissue Mobilization:

Cross frictional massage: help to break down the scar tissue.

Electrotherapy:

    Electrotherapy modalities (also known as electrophysical agents) are methods of physical therapy that aim to reduce pain and enhance function by introducing more energy into the body (electrical, sound, light, magnetic, or thermal). Lowlevel laser treatment, therapeutic ultrasound, interferential current, and transcutaneous electrical nerve stimulation (TENS) are all electrotherapy techniques used to treat the medial epicondylitis.

Theraputic Exercises:

Exercises to stretch and strengthen the muscles attached to the injured tendon will help with the healing process. Stretches and exercises should be avoided if they are painful. The following exercises can be done every other day until your symptoms subside. Continue to use the exercises as a warm-up before tennis, golf or other gripping activities.

Resisted Wrist Flexion

With tubing wrapped around the hand and the opposite end secured under foot, keep the palm facing up and bend the wrist and hand upward as far as you can. Hold one count and lower slowly 3 counts. Repeat 10 to 20 times, two times per day. This exercise can also be done with a dumbbell.




Resisted Wrist Extension

With tubing wrapped around the hand and the opposite end secured under foot, keep the palm facing down and bend the wrist and hand upward as far as you can. Hold 1 count and lower slowly 3 counts. Repeat 10 to 20 times, two times per day. This exercise can also be done with a dumbbell.




Resisted Forearm Supination and Pronation 
Holding a dumbbell, with the forearm supported on your thigh, slowly turn the palm facing up and then slowly turn the palm facing down. Make sure to hold the elbow still and only move the forearm. Repeat 10 to 20 times each way, one to two times per day.


Stretches:

Wrist Flexor Stretch

Hold the arm with the elbow straight and the palm facing up. Grasp the involved hand at the fingers and stretch the wrist backward, until a stretch is felt on the inside of the forearm. Hold 15 seconds, repeat 3 to 5 times, 2 to 3 times per day.

Wrist Extensor Stretch

Hold the arm with the elbow straight and the palm facing down. Push downward on the back of the involved hand until a stretch is felt in the muscles on the outside of the forearm. Hold 15 seconds, repeat 3 to 5 times, 2 to 3 times per day.


Kinesotaping:





Protocol designing idea:

please note that it is important to consult with a qualified physiotherapist or healthcare professional for a personalized treatment plan. They will be able to assess your specific condition and provide appropriate guidance. Here is a general weekly protocol for medial epicondylitis:

Week 1:

  1. Assessment and Evaluation:
    • Initial assessment of the patient's symptoms, medical history, and any relevant factors.
    • Evaluation of pain level, range of motion, strength, and functional limitations.
  2. Pain Management:
    • Ice therapy: Apply ice packs wrapped in a thin cloth to the affected area for 15-20 minutes, 3-4 times a day to reduce pain and inflammation.
    • Non-steroidal anti-inflammatory drugs (NSAIDs): Over-the-counter NSAIDs may be recommended for pain relief. Consult with a healthcare professional for appropriate dosage and duration.
  3. Rest and Immobilization:
    • Avoid activities that exacerbate pain and put stress on the elbow.
    • Consider using a brace or splint to provide support and limit movement.
  4. Gentle Range of Motion Exercises:
    • Passive range of motion exercises: Gently move the affected elbow joint through its full range of motion, without applying any resistance.

Week 2:

  1. Pain Management and Inflammation Control:
    • Continue with ice therapy and NSAIDs as needed.
  2. Stretching Exercises:
    • Wrist flexor stretch: Extend the affected arm in front of you, palm facing up. Use your other hand to gently pull the fingers backward until a stretch is felt in the forearm. Hold for 30 seconds and repeat 3-4 times on each side.
    • Forearm pronation and supination: Hold a light dumbbell or a can of soup and slowly rotate your forearm, turning your palm up and down. Perform 2 sets of 10-15 repetitions.
  3. Strengthening Exercises:
    • Eccentric wrist flexion exercise: Hold a light dumbbell or a resistance band and rest your forearm on a table, palm facing downward. Slowly lower the weight or resist the band's pull as you flex your wrist. Return to the starting position with your unaffected hand. Perform 2 sets of 10-15 repetitions.
    • Pronation and supination strengthening: Use a hammer or a weighted object, hold it at one end, and rotate your forearm, turning your palm up and down. Perform 2 sets of 10-15 repetitions.

Week 3:

  1. Pain Management and Inflammation Control:
    • Continue with ice therapy and NSAIDs as needed.
  2. Progressive Strengthening Exercises:
    • Progress the intensity of eccentric wrist flexion exercise and pronation/supination exercises by gradually increasing the weight or resistance.
    • Gradually introduce wrist curls and extensions with light dumbbells or resistance bands, 2 sets of 10-15 repetitions.
  3. Functional Training:
    • Simulate specific activities or sports that may have caused the injury, gradually increasing the intensity and complexity as tolerated.
  4. Ergonomic Modifications:
    • Evaluate and modify work or sports equipment, if necessary, to reduce strain on the elbow.

Week 4 and Beyond:

  1. Progressive Strengthening:
    • Gradually increase the intensity, repetitions, or resistance of the strengthening exercises as tolerated, while monitoring pain levels.
  2. Functional and Sport-Specific Training:
    • Focus on specific activities or sports that the patient needs to return to, gradually increasing intensity and complexity under the guidance of a physiotherapist.
  3. Ongoing Pain Management:
    • Continue to manage pain and inflammation using ice therapy, NSAIDs (as advised by a healthcare professional), and other modalities such as heat therapy or ultrasound if recommended.

It is essential to progress gradually, listen to your body, and consult with a physiotherapist throughout the protocol to ensure proper management and recovery from medial epicondylitis.