Epicondylitis, Medial and Lateral

© Reed Group

Risk: Risk increases with occupations and sports that require forceful movement of the forearm, often with repetition. "Golfer’s elbow" also may affect bowlers, weight lifters, and archers. Tennis elbow commonly affects tennis players, particularly those who play at least 2 hours per week, but it may also affect badminton and squash players. Lateral epicondylitis typically affects individuals ages 40 to 50 years (Bryant). Although men are twice as likely to develop medial epicondylitis as women, lateral epicondylitis affects men and women equally (Bryant).

Incidence and Prevalence: Lateral epicondylitis is more than 5 times more common than medial epicondylitis (Mercier). The exact incidence of lateral epicondylitis is difficult to determine, although among the US population it is estimated at 1% to 3% annually (Bryant).

History: Individuals commonly report elbow pain with forceful gripping, and decreased ability to use the wrist most often in the dominant arm. Swelling may occasionally occur. The symptoms may appear suddenly, but more often the onset is gradual and progressive. Over time, the pain may become severe and persist at rest. Pain is localized to the medial or lateral elbow region initially but may progress to involve the muscle mass of the forearm. Individuals may relate a change in activity or increase in size and weight of tools used for a period immediately preceding the onset of pain. Many cases, however, occur without an obvious cause. Medial epicondylitis can be observed with ulnar nerve dysfunction at the elbow (ulnar neuropathy or cubital tunnel syndrome) resulting in numbness and tingling in the small and ring fingers, or weakness in the hand. History should inquire about neck and shoulder and elbow injuries to rule out other causes of symptoms.

Physical exam: On physical examination, pain may be localized over either epicondyle and may increase with resisted wrist motion. Bending the wrist forward against resistance (flexion) causes pain for individuals with medial epicondylitis and bending the wrist backward against resistance (extension) causes pain for those with lateral epicondylitis. Passive stretch of the involved muscle/tendon units also causes pain. As the condition becomes chronic, pain and weakness may involve the forearm as well, especially with resisted wrist and finger motion. Tenderness 4 to 5 cm distal to the lateral epicondyle suggests entrapment of the radial nerve (radial tunnel syndrome). Numbness or weakness in the hand may indicate cubital tunnel syndrome as well as medial epicondylitis.

Tests: The diagnosis generally is made based upon the history and exam as noted above. In cases of medial epicondylitis, a Tinel test may be administered over the ulnar nerve to rule out ulnar neuropathy. An injection test, in which a local anesthetic is injected into the most tender point of the elbow, may suggest the diagnosis if the elbow pain is relieved by the injection. Injections can help differentiate lateral epicondylitis from radial tunnel syndrome. When the diagnosis is in doubt or if an individual fails to respond to treatment, x-ray done to rule out fractures or bony abnormalities including arthritis about the joint. MRI may reveal abnormalities in the medial or lateral epicondyle consistent with tendinopathy or tear, but MRI imaging usually is not necessary.

The primary focus of rehabilitation for medial and lateral epicondylitis is to control pain and restore function. Modalities such as cold packs may be helpful in controlling painful symptoms. Loss of motion is usually not a problem with epicondylitis. However, individuals may avoid full range of motion as a result of excessive pain. During the initial period of acute symptomatology, advise individuals to avoid any movements that exacerbate pain. Occasionally, a resting splint may be recommended. Stretching and strengthening exercises of the wrist and extrinsic hand muscles may be beneficial and, when performed in conjunction with modalities, may provide relief. Home exercises should be taught as well as pain control measure (heat and cold).

There is some evidence to support the use of topical non-steroidal anti-inflammatory agents for epicondylitis (Green), and further evidence to support treatment with iontophoresis (Nirschl) or ultrasound (Smidt, "Effectiveness of Physiotherapy") for relief of symptoms. Local corticosteroid injections can provide short term relief (Hart). However, physical therapy may be more successful in the long term outcome of epicondylitis (Hart; Smidt, "Corticosteroid Injections").

It is advisable to consider work and leisure activities that may have contributed to the condition and attempt to reduce the risk factors associated with epicondylitis (Haahr). An ergonomic evaluation may be beneficial if work tasks are suspected as a cause (Lewis).