Medial Epicondylitis

Posted: March 11, 2016

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Introduction

Medial epicondylitis is explained as the overuse injury that affects the flexor-pronator muscle origin of the elbow at the anterior medial epicondyle (Jayanthi, 2015). ME is often associated with lateral epicondylitis (LE) also knows as the tennis elbow, which tends to occur frequently. Medial Epicondylitis is known to be the most frequent cause of medial elbow pain in sports people (Prentice, Bobo, & Benson, 2014). However, clinicians are likely to get at least five cases of lateral epicondylitis for every single case of Medial Epicondylitis. Patients who suffer medial elbow pain and discomfort tend to appreciate their doctor’s knowledge of the subtle diversities in the diagnosis and the treatment required for the two conditions.

Epidemiology

Medial Epicondylitis is a usual case in golfers but most of the time it comes in disguise as Lateral Epicondylitis (McHardy, Pollard, & Luo, 2007). The occurrence of lateral epicondylitis is usually estimated at 1.3 percent while medial epicondylitis occurs at 0.4 percent of the active athletes (Prentice, Bobo, & Benson, 2014). The occurrence may approach 3 percent among the general public while for the popular sportsmen it may range between .4 to 0.7 percent depending on the intensity of the sport. The pain depends on how recurrent the activity is causing it is undertaken, as well as the precaution undertaken by the individual involved (Prentice, Bobo, & Benson, 2014). Medial Epicondylitis is more in the older generation of athletes as well as people who work in loading and unloading heavy luggage. For average men aged between 45 to 54 years, their complete load is not more than 20 kilograms in weight, since any extra is considered a strain on their elbow tendons (McHardy, Pollard, & Luo, 2007).

Anatomy and Kinesiology

In the human body, Tendons are the tough and strong connective tissues meant to attach muscles to the bones (Prentice, Bobo, & Benson, 2014). The tendons that are aligned to attach the forearm muscles to the bones are made to connect to other two small knobs located on the upper arm bone known as the epicondyles. The knob known as the medial epicondyle is the one felt on the inside of the elbow, lying closest to the body. Ulnar or the popularly known as medial collateral ligament together with the radial (lateral) collateral ligaments are the primary elbow stabilizers in human in the lower arm (Jayanthi, 2015). The ulnar collateral ligament is usually the principal valgus stabilizer; while on the other hand, the radial collateral ligament becomes the primary varus stabilizer (Prentice, Bobo, & Benson, 2014). This shows the distinction in the roles that these elements play in the elbow.

The ulnar collateral ligament carries out a very vital role during the surgical treatment procedure for medial epicondylitis. It is usually composed of three primary parts namely: Posterior-oblique ligament (POL), the Anterior oblique ligament (AOL) and the accessory AOL and finally the Transverse ligament (Prentice, Bobo, & Benson, 2014). The muscles that are directly involved in medial epicondylitis usually include the flexor carpi radialis and the pronator teres. However, there are others but are less likely to be directly involved, including the flexor digitorum superficialis, palmaris longus, and the flexor carpi ulnaris (Jayanthi, 2015).

Mechanisms of Injury

Although epicondylitis sends a signal that there is inflammation, there is usually a controversy with this pathology among doctors. The basic framework reveals that pathologic process of Medial Epicondylitis does not involve any bony inflammation at the elbow (McHardy, Pollard, & Luo, 2007). Histologically, it has been revealed that medial epicondylitis is brought about by micro-tearing of tendons that are not fully relapsed. Most physical therapists tend to prefer the term tendinosis rather than epicondylitis. There is another terminology used for this condition that is epicondylalgia. This is used to referring to pain in the elbow rather than inflammation of tendons (Prentice, Bobo, & Benson, 2014). Most of the time, ME is not as a result of inflammation; rather, it is caused by a complication within the cells of the tendon. In the process of tendinosis, wear and tear are believed to cause tissue degeneration. Medically, a degenerated tendon has an odd arrangement and structure of collagen fibers as well as the fiber separation which is caused by increased mucoid ground substance. Therapists believe that there can also be an increased prominence of cells, focal necrosis vascular spaces or calcification (Prentice, Bobo, & Benson, 2014). When any of these happen, the collagen tends to lose its strength, hence becoming fragile and could break or be injured easily (Jayanthi, 2015).

Clinical Presentation and Examination

Doctors trained to treat ME usually begin their examination with a thorough inspection of the medial injury aspect of the elbow. Then they proceed with palpation procedure of the medial as well as the lateral epicondyles, brachial pulse, olecranon, capitellum, olecranon fossa, and the radial head (McHardy, Pollard, & Luo, 2007). Finally, they proceed to palpate the biceps, triceps, flexor and the extensor muscles. The doctor goes to palpate the ulnar nerve that is found in the ulnar groove while, at the same time, the patient is required to persistently keep flexing the arm. This is usually a procedure to begin correcting the injury from the least affected nerves so that the severely affected can be isolated and well identified for the next stages of therapy. In some patients’ cases, the ulnar nerve subluxes out of their groove medially over medial epicondyle (Prentice, Bobo, & Benson, 2014).

Medical diagnosis of ME should be radically considered if the tenderness to palpation is confirmed present over the anterior element of the medial epicondyle (Jayanthi, 2015). However, clinically, it is recognized that some patients may have tenderness only distal to the medial epicondyle over their flexor-pronator tendinous bands. In such a case then, the affected elbow's range of motion (ROM) is supposed to be normal. The procedure of identifying the extent of the injury involves some complex examinations like neurologic examination that includes; motor, sensory, and reflex testing. This is imperative in excluding the cervical radiculopathy and the ulnar neuropathy (Prentice, Bobo, & Benson, 2014).

Initial Treatments

Once an athlete has suffered an injury suspected to be ME, the early stages of treatment involve a process well known as mnemonic PRICE, which includes; protection, rest, ice, compression, elevation. Treatment of ME starts with the application of cold packs or ice to the injured elbow together with oral NSAID therapy (Jayanthi, 2015). The other clinical approaches to the initial treatment include the use of a splint, application of ultrasound waves, one or more local corticosteroid injections as well as the guided rehabilitation program. The above measures are taken to combat the injury from getting complex. A surgery is then performed on the elbow if there is no clinical response to the procedures between 3 to 6 months after the conservative treatment (McHardy, Pollard, & Luo, 2007). Like any other medical breakdown, Medial Epicondylitis is treatable and has its procedures that the patient has to go through for the injury to be corrected (Jayanthi, 2015).

However, there have been some mechanisms of correcting the situation that raise concerns about their safety as well as the long-term effects. The principal goal of the treatment of acute medial epicondylitis using physical therapy is usually to maintain the patient’s range of motion (ROM). Mechanisms such as electrical stimulation, ultrasonography iontophoresis, and phonophoresis are used to treat ME. However, only a few incidences and studies have demonstrated long-term benefits of these procedures to the patient. This is since most of the times the effects fade shortly after the procedure is completed, taking back the athlete to the initial pain.

Other Treatment Options

In the treatment of ME, Prolo Therapy involves series of repeated injections of dextrose solution into the muscles, the joint and tendons in an attempt to rejuvenate the tissue activity and reasonable response. PRP, which means; Platelet-Rich Plasma is a therapy that takes about twenty minutes to be completed (Prentice, Bobo, & Benson, 2014). It begins with the collection of 30 milliliters of blood from the patient. The sample is then placed in a centrifuge to separate the platelet-rich plasma in the blood from the other components (Jayanthi, 2015). After a successful separation and isolation of blood components, Doctors then inject the platelets-rich plasma into the injury site using ultrasound guidance for the purpose of accuracy.

Return to Activity

Athletes who have been victims of medial epicondylitis may be allowed to return to activities by their physicians, although their symptoms will limit them. Since many athletes tend to assume pain during sports, the doctor should outline a strict activity procedure for the patient (McHardy, Pollard, & Luo, 2007). In general, the recovering patient should go back to active sports gradually and start with non-competitive activities to recover without vigor. This would help them in training the recovering tissues without straining them (Prentice, Bobo, & Benson, 2014).

Summary

Medial Epicondylitis is a medical condition that inflicts pain in the interior phases of the elbow, mostly associated with those sports where the player has to use hands to throw or strike with force. Most of the sports associated with this pain are golfing, tennis and the throwing of javelin (McHardy, Pollard, & Luo, 2007). It is the overstretching of the muscles when the player strikes or throws, hence distorting the structure of the inner parts of the elbow. It is a very painful condition if untreated and could lead to the termination of the sports career (McHardy, Pollard, & Luo, 2007). The process of correcting the injury may take up to 2 years depending on the severity at the point of first recovery attempt, as well as the obedience of the patient to follow instructions.

Work Cited

Jayanthi, N. (2015). UpToDate: Epicondylitis (tennis & golf elbow).

McHardy A., Pollard H., & Luo K. (2007). One-year follow-up study on the golf injuries in Australian amateur golfers, Am J Sports Med. 35(8):1354-60

Prentice, W.E., Bobo, L., & Benson, A.A. (2014). Principles of Athletic Training, New York: McGraw-Hill