Medial Epicondylitis/Tendinosis

Introduction

As with the lateral elbow we prefer the term tendinosis to epicondylitis as the problem is in the common flexor tendons not the epicondyle. The histopathology (see Chapter 59 ) has no inflammatory cells. Medial elbow tendinosis is less common than lateral elbow tendinosis by a factor of 1 : 5.

Indications

As with lateral epicondylitis, the indications for surgery are pain that limits daily activity and/or interrupts sleep ( Table 61.1 ). The duration of nonoperative management is usually 6–9 months. All conservative measures should have been tried. At least one injection to control pain, possibly using local anesthetic without a steroid, is helpful to isolate the lesion location while offering temporary pain relief. Limited, temporary pain control with this therapy strengthens the indications for surgery. Total failure (e.g., no pain control) raises concern about the etiology of symptoms (e.g., emotional factors or secondary gain motivation) or possibly inadequate injection technique.

Contraindications

The most significant contraindication is a history and examination that does not accurately coincide with expectations of medial epicondylitis. Poor motivation, worker's compensation, and unrealistic expectations are also issues of concern and to be considered before surgical intervention is carried out. Individuals who are improving or who have had symptoms less than 6 months are generally not considered candidates for surgery. They may, however, be ideal candidates for percutaneous ultrasonic tenotomy (see Chapter 60 ).

Presentation and Classification

Medial epicondylitis is a consequence of acute or chronic loads applied to the flexor–pronator mass of the forearm as a result of activity related to the medial elbow and proximal forearm. The concomitant presence of ulnar neuropathy at the elbow is seen in 30% to 50% of patients and may be the primary management concern. Physical examination reveals common flexor origin and direct epicondylar tenderness and indirect pain with resisted pronation and wrist flexion. Ulnar nerve examination may demonstrate a positive Tinel sign, elbow flexion test, or nerve compression test. Valgus stress examination is essential to assess ulnar collateral ligament sprain or medial instability either as an associated concern or as the primary process. Subluxation of the medial head of the triceps and medial antebrachial cutaneous neuropathy should also be ruled out.

Plain radiographs are helpful to evaluate additional diagnoses, most commonly degenerative arthritis (which may require diagnostic lidocaine injection of the elbow to differentiate an intraarticular from an extraarticular source of symptoms). Valgus stress radiographs should be obtained if indicated. Magnetic resonance imaging (MRI) can be helpful if symptoms suggest additional abnormalities but is not required in the usual case, which is primarily a clinical diagnosis. Today, ultrasound imaging is a rapid and inexpensive means of making a definitive diagnosis (see Chapters 9 and 60 ).

Medial epicondylitis is classified with a combined epicondylitis and ulnar neuropathy classification system. To simplify the original classification, type I is an isolated medial epicondylitis, and type II is medial epicondylitis with an associated ulnar neuropathy. This may be further classified as minimal (type IIa) or moderate (type IIb) ulnar nerve severity.

The initial management of type I medial epicondylitis is similar to lateral epicondylitis, including rest, counterforce bracing, wrist splinting, and a conditioning program. Instances of type I and type II medial epicondylitis that fail to respond to nonoperative management are indications for surgical intervention or percutaneous ultrasonic tenotomy (see Chapter 60 ).