Medial Epicondylitis (Golfer's Elbow)

Look: Swelling rare, assess carrying angle, look for muscle atrophy (chronic cases or if ulnar neuropathy)

Point tenderness: Maximum tenderness 5-10mm distal and anterior to medial epicondyle (flexor-pronator origin). Compare to UCL (more posterior and distal).

Active and passive: Usually full ROM. Pain at terminal extension (stretches flexors). Pronation/supination should be compared to contralateral side.

Grip strength: Reduced compared to contralateral (Jamar dynamometer objective measurement). Resisted wrist flexion: Reproduces pain (golfer's elbow test). Resisted pronation: Reproduces pain (pronator teres).

Golfer's elbow test: Elbow extended, forearm supinated, resist wrist flexion (reproduces medial elbow pain - POSITIVE). UCL stress: Valgus stress at 30 degrees flexion (should be negative unless concurrent UCL injury). Milking maneuver: Pull thumb with elbow flexed (valgus stress - assess UCL in overhead athletes).

Ulnar nerve: Tinel's at cubital tunnel, elbow flexion test (60 seconds), intrinsic muscle strength (first dorsal interosseous, abductor digiti minimi). Median nerve: Assess for pronator syndrome (rare association). Vascular: Radial pulse, capillary refill.

Symptom control:

• Activity modification (avoid aggravating activities)
• Relative rest (not immobilization)
• Ice 15-20 minutes TDS
• NSAIDs (oral or topical) for 2 weeks
• Counterforce brace (below elbow, 2-3cm distal to epicondyle)
• Gentle ROM exercises (wrist flexion/extension, pronation/supination)

Physiotherapy program:

• Eccentric strengthening (key intervention - wrist flexion eccentrics)
• Isometric strengthening
• Stretching (wrist extensors and flexors)
• Progressive loading
• Activity modification continues
• Return to light activities as tolerated

Gradual return to activity:

• Continue eccentric program
• Sport-specific training (golf swing mechanics, throwing program)
• Progressive resistance exercises
• Gradual return to work activities
• Monitor symptoms

Consider injection:

• If persistent symptoms after 3 months of PT
• Corticosteroid injection (methylprednisolone 40mg + local anesthetic)
• Maximum 2-3 injections (tendon weakening risk)
• Platelet-rich plasma (PRP) alternative (less evidence but safer)
• Continue PT after injection

Landmarks: Medial epicondyle (palpate). Incision: 5-7cm longitudinal incision centered over medial epicondyle, extending distally along flexor-pronator mass. Avoid excessive anterior curve (median nerve). Avoid excessive posterior curve (ulnar nerve). Technique: Sharp dissection through skin and subcutaneous tissue. Ligate or cauterize superficial veins. Identify medial antebrachial cutaneous nerve branches (retract or sacrifice if unavoidable).

Critical step: Identify the ulnar nerve in cubital tunnel before any tendon work. Technique: Palpate posterior to medial epicondyle. Gentle dissection through subcutaneous tissue. Identify nerve in cubital tunnel. Assess nerve for subluxation (over epicondyle with flexion). Assess cubital tunnel for Osborne's ligament thickening. Place vessel loop around nerve for gentle retraction (DO NOT OVER-RETRACT).

Technique: With ulnar nerve protected, expose flexor-pronator origin on anterior aspect of medial epicondyle.

• Longitudinal incision through tendon origin
• Split pronator teres and FCR at their origin
• May elevate tendon from bone subperiosteally
• Expose underlying bone (medial epicondyle)
• Assess for degenerative tissue (gray, friable, mucoid appearance)

Key step: Remove all degenerative tendon tissue. Technique:

• Identify abnormal tissue (gray, friable, no normal tendon architecture)
• Excise with scalpel or rongeur
• Debride back to healthy, bleeding tendon
• Avoid excessive resection (preserve UCL deep to flexor mass)
• Assess UCL integrity if athlete (should be intact - if torn, different pathology)

Goal: Create bleeding bone bed for tendon healing. Technique:

• Use curette or rongeur to remove cortical bone
• Create multiple small holes (drill or curette)
• Expose cancellous bone (punctate bleeding)
• Avoid excessive bone removal (weakens epicondyle)

Technique: Reattach flexor-pronator mass to medial epicondyle. Options:

• Bone tunnels (traditional): Drill 2-3 holes through epicondyle, pass non-absorbable sutures (FiberWire No. 2), tie over bone bridge
• Suture anchors (modern): Place 2-3 anchors in epicondyle, suture tendon to bone (allows earlier ROM)
• Side-to-side repair: If minimal debridement, repair split tendon edges Goal: Restore anatomic tension, avoid over-tightening (limits ROM)

Decision: Based on preoperative symptoms and intraoperative findings. If no preoperative symptoms and nerve healthy: No decompression needed, gentle inspection only. If preoperative symptoms or tight nerve: In situ decompression (release Osborne's ligament, arcade of Struthers). If nerve subluxes or severe symptoms: Anterior subcutaneous transposition (create subcutaneous pocket anterior to medial epicondyle, transpose nerve, secure with fascia sling).

Release tourniquet. Achieve meticulous hemostasis (bipolar cautery). Avoid cautery near ulnar nerve (thermal injury).

Close fascia/subcutaneous tissue with absorbable sutures (2-0 or 3-0 Vicryl). No drain typically needed unless extensive dissection.

Options: Running subcuticular 3-0 or 4-0 monocryl (cosmetic), interrupted nylon, or skin staples. Steri-strips and sterile dressing.

Apply posterior elbow splint at 90 degrees flexion, neutral forearm rotation. Splint for 7-14 days (balance protection vs stiffness).

• Posterior splint at 90 degrees flexion, neutral rotation
• Elevation, ice packs
• Finger ROM encouraged (prevent stiffness, promote circulation)
• Wound care, dressing change at 48 hours
• Pain management (NSAIDs, opioids short-term if needed)

• Remove splint at 7-14 days (based on repair strength)
• Begin gentle active ROM (elbow flexion/extension, forearm rotation)
• Avoid resisted wrist flexion (protect repair)
• No lifting (protect tendon repair)
• Removable splint for comfort/protection between exercises

• Active ROM - full elbow and forearm motion expected by 6 weeks
• Light ADLs - typing, light household tasks
• Gentle stretching - wrist flexors and extensors
• No resisted strengthening yet
• No lifting more than 1kg

• Begin isometric strengthening (wrist flexion, pronation)
• Progress to eccentric exercises (key for tendon remodeling)
• Grip strengthening (putty, stress ball, then Jamar dynamometer)
• Light resistance exercises (1-2kg)
• Sport-specific training begins (golf swing mechanics, throwing program)

• Progressive resistance strengthening
• Return to work: Desk work 6-8 weeks, manual labor 3-6 months
• Return to sport: Golf/tennis 4-6 months, overhead throwing 6-9 months
• Monitor for recurrent symptoms

• Full strength expected by 12 months
• Unrestricted activities
• Ongoing maintenance exercises (eccentric program)
• Return to baseline function in 80-90% of patients

• Splint at 90 degrees flexion (reduces tension on transposed nerve)
• Limit elbow extension to 45 degrees for first 3 weeks
• Gentle active ROM within protected range
• Avoid full extension (stretches nerve)

• Gradually increase extension ROM (10 degrees per week)
• Goal: full extension by 6 weeks
• Monitor for ulnar nerve symptoms (if increase, slow down)
• Continue gentle active ROM

• Resume standard strengthening protocol
• Ulnar nerve should be healed in new position
• Continue to 12 months as per standard timeline