MEDIAL EPICONDYLITIS

1. 1.Medial Epicondylitis
Medial Epicondylitis:
Medial epicondylitis, often referred to as “golfer’s elbow,” is a common pathology. Flexor-pronator tendon degeneration occurs with repetitive
forced wrist extension and forearm supination during activities involving wrist flexion and forearm pronation. A staged process of pathologic
change in the tendon can result in structural breakdown and irreparable fibrosis or calcification. Patients typically report persistent medial-sided
elbow pain that is exacerbated by daily activities. Amin et at (2015) Athletes may be particularly symptomatic during the late cocking or early
acceleration phases of the throwing motion.

2. The part of the muscle that attaches to a bone is called a tendon. Some of the muscles in your forearm attach to the bone on the inside of your
elbow.
When you use these muscles over and over again, small tears may develop in the tendons. Over time, this leads to irritation and pain where the
tendon is attached to the bone.

3. The injury can occur from using poor form or overdoing certain sports, such as:
 Golf
 Baseball and other throwing sports, such as American football and javelin
 Baseball


4. American football
 Javelin
 Racquet sports: Improper technique with tennis strokes, especially the backhand, can cause injury to the tendon. Excessive use of topspin and
using a racket that's too small or heavy also can lead to injury.

5.  Tennis
 Weight training: Lifting weights using improper technique, such as curling the wrists during a biceps exercise, can overload the elbow muscles
and tendons.

6. Weight lifting
 Archery

7. Repeated twisting of the wrist (such as when using a screwdriver) can lead to golfer's elbow. People in certain jobs may be more likely to
develop it, such as:
 Painters
 Plumbers
 Construction workers
 Cooks
 Assembly-line workers
 Computer users
 Butchers
Anatomy:

8. The flexor-pronator tendon is the confluence of five muscles of the forearm: the pronator teres (PT), flexor carpi radialis, palmaris longus, flexor
carpi ulnaris (FCU), and flexor digitorum superficialis (Figure B). This CFT is approximately 3 cm long and, in most elbows, crosses the
ulnohumeral joint medially. The tendon attaches to the medial humeral epicondyle anteriorly and attaches proximally to the anterior bundle of
the ulnar collateral ligament (UCL), with the fibers parallel to the UCL. Otoshi, K.,(2014). The CFT, particularly the ulnar head of the PT, also
becomes confluent with a hyperplastic section of the anteromedial joint capsule.

9. Most authors believe the principle mechanism of injury is repetitive eccentric loading of the muscles conducting wrist flexion and forearm
pronation combined with valgus overload at the elbow. Barco, R et al (2017). Strain of the medial elbow with a valgus overload moment, which
occurs with overhead throwing, stimulates dynamic stabilization of the joint via eccentric contraction of the CFT. Lynch JR. et al (2008)
simultaneous wrist flexion or forearm pronation during ball release may produce even greater eccentric stress on the tendon. Sisto DJ et al
(1982) Historically, the Pronator Teres has been identified as the primary dynamic stabilizer and the most likely musculotendinous unit to be
injured in medial epicondylitis. Recent cadaver studies, however, have implicated every musculotendinous unit except the palmaris longus.
Repetitive supraphysiologic stress on the tendon eventually results in microtrauma and degeneration. Histopathologic examination has revealed a
staged process of pathologic tendon change. Riley, G. (2004) Initially, repetitive trauma results in peritendinous inflammation. Continued injury
results in angiofibroblastic hyperplasia, an invasion of vascular and fibroblastic elements into the tendon. Eventually, replacement of the normal
tendon with angiofibroblastic hyperplasia results in structural breakdown and irreparable fibrosis or calcification. Activity causing such
pathology to the CFT can eventually transfer forces deeper to the UCL, which mirrors CFT fiber orientation and histologic anatomy.
Risk Factors:
Medial epicondylitis, or “golfer’s elbow,” is a pathology commonly encountered by orthopaedic surgeons. Despite an overall prevalence of <1%,
medial epicondylitis may affect as many as 3.8% to 8.2% of patients in occupational settings. Raham et al (2006) Medial-sided pathology can be
found in as many as 10% to 20% of patients with epicondylitis. Baumgard et al (1982) A result of common flexor tendon (CFT) microtrauma
and degeneration, medial epicondylitis typically occurs in the fourth through sixth decades of life, Descatha et al (2003) the peak working years
noted nearly a 2:1 ratio of occurrence for women compared to men with a diagnosis of medial epicondylitis. Shiri et al (2006)
Overuse: Repetitive wrist and forearm movements, such as gripping, twisting, and lifting, can lead to the condition. Descatha, A et al (2013).

10. Age: It is more common in individuals between 40 and 60 years old. Seems to effect women is more then men. Shiri, R. et al, (2011)
Work and Hobbies: Occupations or activities that involve repetitive arm and wrist motions.
Biomechanical Factors: Poor technique or equipment in sports and activities. Ciccotti, M. G., & Ramani, M. N. (2003).
Muscle Imbalances: Weak forearm muscles can contribute to the development of medial epicondylitis.
Signs and Symptoms:
Symptoms of golfer's elbow include:

11. golfer's elbow are associated with decreased normalized eccentric peak torque ( NEPT) of shoulder external rotators and abductors compared
with those of healthy athletes. This tends to decrease the external stability of the shoulder joint and put high stress on the distal joints of the
upper kinetic chain. Nabil BA, et al ( 2019)
Elbow pain that runs along the inside of your forearm to your wrist, on the same side as your pinky finger
 Pain when flexing your wrist, palm down
 Pain when shaking hands
 Weak grasp
 Numbness and tingling from your elbow up and into your pinky and ring fingers (due to irritation of the ulnar nerve in this region)
Pain may occur gradually or suddenly. It gets worse when you grasp things or flex your wrist.
Aggravating Factors:
Overhead throwing athletes and those participating in sports that require repeated forearm pronation and wrist flexion are most commonly
affected by this disorder. Mishra,et al (2014).
It seems to be more common among athletes, including golfers (the source of “golfer’s elbow”), throwing athletes, baseball players and tennis
players Descatha A. et al (2003)
Forceful Gripping: Activities that require a strong grip, like using hand tools, racquet sports, or heavy lifting.

12. Incorrect Technique: Poor sports or work technique can contribute to the development or exacerbation of medial epicondylitis.
Prevention
You can take steps to prevent golfer's elbow:
 Strengthen your forearm muscles. Use light weights or squeeze a tennis ball. Even simple exercises can help your muscles absorb the
energy of sudden physical stress.
 Stretch before your activity. Walk or jog for a few minutes to warm up your muscles. Then do gentle stretches before you begin your
game.
 Fix your form. Whatever your sport, ask an instructor to check your form to avoid overload on muscles.
 Use the right equipment. If you're using older golfing irons, consider upgrading to lighter graphite clubs. If you play tennis, make sure
your racket fits you. A racket with a small grip or a heavy head may increase the risk of elbow problems.
 Lift properly. When lifting anything — including free weights — keep your wrist rigid and stable to reduce the force to your elbow.
 Know when to rest. Try not to overuse your elbow. At the first sign of elbow pain, take a break.
Rehabilitation Exercises (Different Stages):

13. Phase 1 (Pain Control): Rest, ice, and anti-inflammatory medications to reduce pain and inflammation. Gentle range of motion exercises,
isometrics, and wrist and forearm stretches.
Phase 2 (Strengthening): Gradual introduction of resistance exercises targeting the forearm and wrist. Eccentric exercises for the wrist flexors
and concentric exercises to build strength.
Phase 3 (Functional): Incorporate functional movements that mimic daily activities or sport-specific motions. For example, golf swings, bat
swings, or tool use, based on individual needs and goals.
Pathology:Medial Epicondylitis
PHASE: Early (rough time frame - ………………………0-4 weeks………)
Goals
1.Reduce pain and inflamation
2. improve flexibility and range of motion
Exercise Rationale (Aim/ component of fitness/tissue type)
Reps/
Time
Sets Rest
Other…
Tempo/Inten
1. Wrist stretches Stretching to alleviate tension in the affected muscles
30 sec hold
10 reps
3 30 sec
Perform after
activity or
when feeling
tiredness

14. 2. Towel Grip Strength
Place a Rolled up towel in your hand and squeeze
15 reps/
hold 2 sec
3 30 sec
Slow and
controlled
movement ,
focus on the
lowering
phase

15. 3.Resisted elbow flexion and extension
Strengthening the forearm muscles to support the
elbow joint
12 reps 3 30 sec
Use light
resistance
initially,
gradually
increase as
tolerated
PHASE: Intermediate (rough time frame - ………4-8 weeks………………………)
Goals
1.increase strength and endurance of the forearm muscles
2.improve stability of the elbow joint
Exercise
Rationale (Aim/ component of fitness/tissue
type)
Reps/
Time
Sets Rest
Other…
Tempo/Inten
1.Eccentric wrist flexion
Strengthening the wrist flexors eccentrically to
promote tendon healing and strength
10 reps 3 30 sec
Slow and
controlled
movement ,
focus on the

16. lowering
phase
2.Theraband flexion/ extension
Resistance training to further strengthen the wrist
flexors and extensors
15 reps 3 30 sec
Use a
theraband or
resistance
tubing,
increase
resistance
gradually
3.Eccentric pronation/supination
Strengthinig eccentrically to improve tendon
resilience and strength
10 reps 3 30 sec
Focus on
controlled
movement
during the
lowering
phase

17. PHASE: Late (rough time frame - ………8-12 weeks………………………)
Goals
1. Full restoration of strength and function
2. prevention of recurrence
Exercise
Rationale (Aim/ component of fitness/tissue
type)
Reps/
Time
Sets Rest
Other…
Tempo/Inten
1. Shoulder external rotation with cable
pulley 90-90
This exercise targets the rotator cuff muscles,
specifically the external rotators, to improve shoulder
stability and prevent compensatory movements.
8 3 60sec
Perform the
movement
with
controlled and
deliberate
motion,
focusing on
maintaining
proper form

18. throughout
the range of
motion.
2. Shoulder Lateral raises with dumbles
(scaption raise)
This exercise targets the deltoid muscles, particularly
the middle deltoid, to improve shoulder strength and
stability.
10 3 45 sec
Perform the
movement
with a
controlled and
smooth
motion,
avoiding
swinging or
momentum.
Focus on
lifting the
dumbbells to
shoulder
height in line
with the
shoulders and
maintaining a
slight bend in
the elbows.
3. Shoulder pull overs with cable
This exercise targets the muscles of the shoulder girdle
and upper back, including the lats and serratus
anterior, to improve shoulder stability and strength.
10 3 60sec
Perform the
movement
with
controlled

19. resistance,
focusing on
engaging the
muscles of the
shoulder and
upper back
throughout
the exercise.
Maintain a
stable core
and avoid
overarching
the lower
back.
References:
Amin, N. H., Kumar, N. S., & Schickendantz, M. S. (2015). Medial epicondylitis: evaluation and management. JAAOS-Journal of the American
Academy of Orthopaedic Surgeons, 23(6), 348-355.
Barco, R., & Antuña, S. A. (2017). Medial elbow pain. EFORT Open Reviews, 2(8), 362-371. Retrieved Feb 6, 2024,
from https://doi.org/10.1302/2058-5241.2.160006
Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. The American Journal of Sports
Medicine. 1982;10(4):233-236. doi:10.1177/036354658201000408

20. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. "Mobilization with movement and exercise, corticosteroid injection, or wait and
see for golfers elbow: randomised trial." British Medical Journal. 2006;333(7575):939.
Ciccotti, M. G., & Ramani, M. N. (2003). Medial epicondylitis. Techniques in hand & upper extremity surgery, 7(4), 190-196.
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14506342; PMCID: PMC4850209.
Descatha, A., Dale, A. M., Jaegers, L., Herquelot, E., & Evanoff, B. (2013). Self-reported physical exposure association with medial and lateral
epicondylitis incidence in a large longitudinal study. Occupational and environmental medicine.
Lynch JR, Waitayawinyu T, Hanel DP, Trumble TE. Medial collateral ligament injury in the overhand-throwing athlete. J Hand Surg Am. 2008
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Otoshi, K., Kikuchi, Si., Shishido, H. et al. The proximal origins of the flexor–pronator muscles and their role in the dynamic stabilization of the
elbow joint: an anatomical study. Surg Radiol Anat 36, 289–294 (2014). https://doi.org/10.1007/s00276-013-1168-3

21. Paoloni JA, Murrell GA, Burch R, et al. "Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceryl trinitrate patch for
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