Clin Sports Med 23 (2004) 693 – 705

Diagnosis and treatment of medial epicondylitis

of the elbow
Michael C. Ciccotti, MA, RA, Michael A. Schwartz, MD,
Michael G. Ciccotti, MD*
Division of Sports Medicine, Department of Orthopaedic Surgery,
Thomas Jefferson University Hospital/Rothman Institute, Philadelphia, PA 19107, USA

Epicondylitis is one of the most common elbow problems in adults, occurring

both laterally and medially. Medial epicondylitis of the elbow, commonly referred
to as ‘‘golfer’s elbow,’’ is characterized by pathologic changes to the musculo-
tendonous origin at the medial epicondyle. Accurate diagnosis is dependent upon
a complete understanding of the anatomic, epidemiologic, and pathophysiologic
factors that distinguish epicondylitis from other elbow conditions.
Originally described by Henry Morris in 1882 as ‘‘lawn-tennis elbow,’’
epicondylitis has since been studied and written on extensively [1]. Lateral
epicondylitis, often labeled ‘‘tennis elbow,’’ has received the majority of this
attention. There exists, however, a paucity of literature regarding medial
epicondylitis, likely due to its infrequent incidence of only 9.8% to 20% of all
epicondylitis diagnoses [2– 4]. Originally thought to be an inflammatory process,
as the name suggests, epicondylitis has been shown histologically to result from
tendonous microtearing, followed by an incomplete reparative response. Conse-
quently, some physicians prefer the more accurate term, tendonosis, when
describing elbow epicondylitis.

Epidemiology and etiology

Medial epicondylitis occurs much less frequently than lateral epicondylitis,
which has been diagnosed seven to ten times more often [5]. Although the
syndrome has been identified in patients ranging from 12 to 80 years old, it
predominantly occurs in the fourth and fifth decades. Male and female prevalence

* Corresponding author.
E-mail address: nancyperron.rothmaninstitute@aol.com (M.G. Ciccotti).

0278-5919/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.csm.2004.04.011
694 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705

rates are reportedly equal. Seventy-five percent of patients are symptomatic in

their dominant arms.
The majority of the literature on epicondylitis suggests that the disorder’s
primary etiology is a repetitive stress or overuse of the flexor-pronator muscu-
lature [5– 8]. Degenerative changes in the musculotendonous region of the medial
epicondyle are the result of chronic repetitive concentric and eccentric contractile
loading of the flexor-pronator group. Most often such changes are seen in the
pronator teres and the flexor carpi radialis muscles, although larger diffuse tears
can occur in the palmaris longus [5], flexor digitorum superficialis [9], and flexor
carpi ulnaris. Although repetitive overuse has been identified as the primary
etiology, a single traumatic event, such as a direct blow or a sudden, extreme
eccentric contraction, may result in the development of epicondylitis. Medial
epicondylitis has been associated with activities involving repetitive forearm
pronation and wrist flexion. Although it occurs frequently in baseball pitchers,
resulting from intense valgus forces on the medial elbow during the late cocking
and acceleration phases of throwing [5,10], medial epicondylitis has also been
related to golf, tennis, bowling, racquetball, football [11], archery, weightlifting
[12], and javelin throwing [13]. This disorder, however, is not solely athletic
in origin, because it is also associated with occupations such as carpentry,
plumbing, and meat cutting, all of which require repetitive forearm, wrist, and
hand motions [12].

Biomechanics
The biomechanics of the medial elbow and the flexor-pronator musculature
are most often described in terms of the baseball pitching mechanism. The
acceleration phase of pitching—from the point at which the ball has virtually no
forward velocity to the point of release—may produce peak angular velocity and
extreme valgus forces greater than the tensile strength of the medial ligamentous
and musculotendonous structures. The forces are initially transmitted to the
flexor-pronator muscle group and then to the deeper medial collateral ligament.
Such repetitive activity may lead to the degenerative changes initiating epicon-
dylitis. Similarly, in tennis, the acceleration phase of the tennis serve has been
shown through electromyography by Morris et al to result in the highest muscular
activity in the flexor-pronator group, primarily the pronator teres [14]. Morris et al
suggested that during acceleration, the flexor pronator group provides the
optimal positioning of the forearm while transferring maximum momentum and
power to the ball. Hence forehands, serves, and overheads in tennis can result in
the medial tension overload, which initiates epicondylitis. In golf, medial
epicondylitis is attributed to incorrect technique, in which the club is ‘‘thrown’’
from the apex of the backswing down toward the ball. Appropriately termed
‘‘hitting from the top,’’ this incorrect technique creates similar valgus forces upon
the medial epicondyle of the dominant arm, leading to the same tension overload
pattern [15,16].
 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705 695

Anatomy
The flexor-pronator group comprises the musculotendonous structures of the
medial elbow. From the radial to the ulnar aspects of the forearm, the musculature
includes the pronator teres, the flexor carpi radialis, the palmaris longus, the
flexor digitorum superficialis, and the flexor carpi ulnaris. The pronator teres and
flexor carpi radialis both attach to the anterior aspect of the medial epicondyle.
These tendons are stretched during the acceleration phases of throwing and
swinging. Thus, the pronator teres and the flexor carpi radialis are most often the
muscles afflicted with these alterations. Professional throwing athletes are often
noted to sustain hypertrophy of the humerus and flexor-pronator forearm
muscles, 50% of which have a flexion contracture and 30% of which have an
increased valgus angle in comparison with the nondominant arm [11,17,18].
Though these changes have been identified in this particular athlete group, they
have never been directly correlated with the occurrence of medial epicondylitis.
The close proximity of the ulnar nerve to the medial epicondyle can result in
concomitant pathology. When stretched, the nerve can sustain direct injury with
an inflammatory response. This can lead to neuritis as well as entrapment or
compression. The ulnar nerve passes through the medial intermuscular septum
into a groove on the medial head of the triceps. Here the nerve passes through the
arcade of Struthers, a fascial layer extending from the medial head of the triceps
to the medial intermuscular septum, which is present in 70% of the population.
The nerve then descends posteriorly to the medial epicondyle to pass through the
fibro-osseous cubital tunnel. This cubital tunnel is bound by the medial
epicondyle anteriorly, the ulnar collateral ligament laterally, and the fibrous
arcade formed by the two heads of the flexor carpi ulnaris posteromedially. For
simplicity, Nirschl divided this medial epicondylar groove into three main zones,
the first of which is proximal to the medial epicondyle [19]. The second is at the
medial epicondyle, and the third zone is distal to the medial epicondyle. In
patients with symptomatic concomitant ulnar nerve compression undergoing
surgical treatment for medial epicondylitis, Nirschl has identified zone 3 to be
the most common site for nerve compression, as the ulnar nerve enters the flexor
carpi ulnaris arcade [19].
When evaluating medial elbow pain, one must also consider medial elbow
instability. The stability of the elbow is provided primarily by the congruous bony
articulation between the olecranon of the ulna and the trochlea of the humerus.
Soft-tissue structural stability is provided primarily by the medial collateral
ligament, but also to a lesser extent by the anterior capsule, lateral collateral
ligament, and the flexor and extensor muscles masses. Cadaveric studies by
Morrey and An have established that the medial collateral ligament is composed
of three bands: anterior, posterior and transverse [20]. It is the anterior band of
this ligament that stabilizes the elbow during valgus stress. Muscle strain can be
caused by poor mechanics, improper conditioning, lack of flexibility, or fatigue—
all of which may lead to increased transmission of forces to the medial collateral
ligament. Repetitive and excessive stress upon the medial collateral ligament can
696 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705

lead to microscopic damage, and ultimately to ligamentous insufficiency and

elbow instability.

Pathophysiology
Since Morris’ first description of epicondylitis in 1882, a vast amount of
literature has been dedicated to the pathophysiology of this disorder. Early
descriptions postulated an inflammatory process involving the radial humeral
bursa, periosteum, synovium, and annular ligament [21 – 24]. These theories,
however, have recently been discounted by the histologic analysis of Nirschl and
Pettrone [6], and Regan et al [25]. Their studies revealed that the normal collagen
architecture is disrupted by a fibroblastic and immature vascular response, an
incomplete reparative process, and a notable paucity of acute and chronic
inflammatory cells. In its earliest stages, epicondylitis may display inflammatory
or synovitic characteristics; its later stages demonstrate evidence of microtearing,
characterized by tendon degeneration, with or without calcification, and an
aborted, incomplete neurovascular response. Grossly, the pathologic tissue
appears gray and friable. These structural alterations have been termed ‘‘angio-
fibroblastic hyperplasia’’ by Nirschl and Pettrone and can occur medially or
laterally [6]. Nirschl went on to propose four descriptive stages of epicondylar
tendonosis [26]. Stage 1 exhibits generalized inflammation, which may recede.
Stage 2 injury is characterized by the pathologic tissue alterations of angio-
fibroblastic degeneration. Structural failure is the hallmark of stage 3. Stage 4
injury includes the components of stages 2 or 3, but is also accompanied by
fibrosis or calcification. The usage of exact terminology in the description of
epicondylitis is essential in understanding the nature of the disorder and
establishing goals of therapeutic intervention. Although the precise universal
pathophysiology of epicondylitis has yet to be established, it is generally
accepted that the injury results from microtearing of the tendon origin at the
epicondyle. This progresses to a failed reparative response and subsequent tendon
degeneration that ultimately alters the typical musculotendonous biomechanics
of the elbow.

Diagnosis
The diagnosis of medial epicondylitis requires a careful patient history and
physical examination, and radiographic and imaging studies, to distinguish it
from other possible etiologies of medial elbow discomfort, such as ulnar
collateral ligament instability or ulnar neuritis.
Medial epicondylitis is characterized by pain of insidious onset along the
medial elbow, which is worsened by resistance to forearm pronation and wrist
flexion. Tenderness to palpation usually occurs over the pronator teres and the
flexor carpi radialis, and maximally at 5 mm to 10 mm distal and anterior to the
 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705 697

midpoint of the medial epicondyle. The severity of pain may vary, but is most
often present and acute during the offending activity. Local swelling and warmth
may also exist [9]. Initially the range of motion of the afflicted extremity can be
full, but over time it may become limited and lead to a flexion contracture, which
is commonly noted in the throwing athlete [27,28]. King et al observed 50% of
professional baseball pitchers to have a flexion contracture in their elbow [18].
When examining for medial epicondylitis, it is also essential to consider ulnar
neuritis and ulnar collateral ligament instability, especially in the overhead
athlete. These may coexist, often consequent to the excessive valgus forces
imparted to the medial elbow with throwing. Ulnar neuritis is identified by a
positive Tinel’s sign, as indicated by local pain and numbness or tingling
radiating distally with the direct compression of the ulnar nerve at the elbow.
A Tinel’s sign in zone 1 may indicate congenital ulnar nerve subluxation; in
zone 2, a Tinel’s sign may be due to compression caused by osteophytes, loose
bodies, or rheumatoid synovitic changes. A zone 3 Tinel’s sign implies compres-
sion as the ulnar nerve passes through the two heads of the flexor carpi ulnaris
[29]. The elbow flexion test for ulnar neuritis is performed by placing the elbow
in maximum flexion, the forearm in pronation, and the wrist in extension for
approximately 30 to 60 seconds. If neuritis is present, the patient will experience
medial elbow pain, as well as numbness or tingling in the ring and little fingers.
Ulnar collateral ligamentous instability is best identified by applying a 30° valgus
stress test, or by the milking test, which is performed by pulling on the thumb
with the elbow flexed and the forearm supinated. Both of these elicit focal pain
along the ulnar collateral ligament.
The radiographs of affected elbows are generally normal, although 20% to
25% of patients can have soft-tissue calcification in proximity to the epicondyle
[27]. Throwing athletes may have medial ulnar traction spurs and medial
collateral ligament calcification [28]. Electromyography (EMG) is indicated in
patients with neurologic alterations. Laboratory studies can be helpful in patients
with suspected rheumatoid disorders. An MRI or dynamic ultrasonography may
be useful in the diagnosis of throwing athletes with confounding medial
symptoms by providing more precise evaluation of the ulnar collateral ligament
[30]. MRI and ultrasonography also aid in determining traumatic tears to the
flexor pronator origin at the epicondyle.

Nonsurgical treatment
Nonsurgical treatment is the cornerstone of care for both medial and lateral
epicondylitis. The objective of such conservative care is to relieve pain and
reduce inflammation, allowing sufficient rehabilitation and return to activities.
Although this treatment has been described as highly successful, there remains a
lack of information concerning the long-term outcome of nonsurgical treatment.
The available literature suggests that 5% to 15% of patients suffer recurring
symptoms, but the majority of these relapses are due to incomplete rehabilitation
698 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705

or premature discontinuation of the suggested preventative measures [28]. In a

prospective review of the nonoperative treatment, Binder and Hazleman saw
26% of patients experience a recurrence of symptoms, and over 40% had
prolonged minor discomfort [31]. Thus, the previously reported success rates
of 85% to 90% for nonsurgical treatment may be overly optimistic, with
symptoms recurring more often than thought. Nonetheless, nonsurgical treatment,
which can be divided into three phases, remains the mainstay of treatment for
medial epicondylitis.

Phase I
Phase I begins with the immediate, temporary cessation of offending activities.
Complete immobilization or inactivity is not recommended; this is to avoid
muscular atrophy, which can hinder rehabilitation efforts. The affected elbow is
iced for 15 to 20 minutes, three to four times per day. This is recommended for its
local vasoconstrictive and analgesic effects. Oral nonsteroidal anti-inflammatory
medication may be administered for a 10- to 14-day course, provided the patient
has no medical contraindications. Patients with improved but lingering symptoms
may benefit from a second course of medication after a brief period of abstinence.
Because epicondylitis is believed to be a degenerative process, the benefits of
anti-inflammatory medications are thought to stem from their ability to relieve
pain associated with the accompanying synovitis.
If the patient does not respond to these measures, a period of night splinting is
appropriate, with local corticosteroid injection around the affected tendon
insertion. As with the anti-inflammatory medication, the corticosteroid aids in
relieving the accompanying synovitis. The choice and dose of the corticosteroid
injection are at the discretion of the physician, because no carefully controlled
prospective study comparing the different agents exists in the current literature
[32]. The appropriate injection technique for administering the corticosteroid
requires instilling the agent into the fatty subaponeurotic recess deep to the flexor
pronator mass. Care must be taken to avoid injecting the mixture into superficial
tissues, which may cause subcutaneous atrophy, or into the tendon, which may
result in irreversible ultrastructural tendon alterations. Patients with more darkly
pigmented skin ought to be warned about the risk of depigmentation after local
corticosteroid injection. The short-term efficacy of such corticosteroid injections
has been documented in several prospective, randomized studies [33,34]. Stahl
and Kaufman noted a significant decrease in pain at 6 weeks after the injection;
however, there was no difference from preinjection pain and pain at 3 months and
1 year [33]. Price et al identified pain relief in 55% to 89% of patients; however
of those who initially experienced relief, 18% to 54% suffered a recurrence of
symptoms [32].
Ultrasound and high-voltage galvanic stimulation, among other physical
therapy modalities, have also been suggested as relieving the pain of epicondy-
litis. Though literature promoting the success of such modalities exists, no
prospective, randomized studies have been conducted to determine their efficacy.
 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705 699

Krishek et al demonstrated only a 28% success rate of shock-wave therapy at

1 year [35]. These modalities are often recommended at the initiation of a
nonsurgical program; however, if pain relief is not achieved soon after initiation,
they should be discontinued. Topical medications, such as dimethylsulfoxide,
provided no greater relief than placebos in a randomized, double-blind, prospec-
tive study [36].
Counterforce bracing can aid athletes with symptoms in daily life during the
first phase of nonsurgical treatment. Additionally, it can be helpful in returning
the athlete to sport. By limiting full contractile expansion of the musculoten-
donous unit, a counterforce brace decreases intrinsic muscle force; however, it
must be noted that compression of the anterior interosseous nerve and symptoms
of posterior interosseous nerve entrapment have been reported with counterforce
bracing [37,38]. Thus, it is essential to instruct the athlete on the proper
application of the brace. Should symptoms of epicondylitis fail to improve,
counterforce bracing should be discontinued.

Phase II
As soon as symptoms are improved by Phase I treatment, a guided rehabili-
tation program should be initiated. Establishing full, painless, wrist and elbow
range of motion is the first goal, soon followed by stretching and progressive
isometric exercises. Initially the elbow should be flexed during these exercises to
minimize pain, but as the patient progresses, greater elbow extension should be
continuously achieved. As preinjury flexibility and strength return, concentric
and eccentric resistive exercises are added to the Phase II program. The
achievement of greater-than-preinjury strength is the ultimate goal, because
preinjury muscle strength proved vulnerable to tension overload [19]. As soon
as a patient can perform sprint repetitions to fatigue without significant discom-
fort, a sports or occupational simulation is staged. If satisfactorily completed, the
patient is reinitiated into the sport or occupation with a gradual increase of
exposure and intensity. The importance of a maintenance exercise program for
the shoulder and elbow musculature to maintain optimal strength and flexibility is
especially stressed to the athlete.

Phase III
When the athlete returns to sport, it is critical that the athlete, coaches, and
trainers identify any inadequacies in equipment or technique that may contribute
to a recurrence of symptoms. Equipment properly sized to the athlete is essential,
especially in racquet sports, to prevent subsequent bouts of epicondylitis. Correct
grip size is calculated by measuring from the proximal palm crease to the tip of
the ring finger, along its radial border. Lighter graphite frames, racquets less
tightly strung, racquets with higher string count per unit area, and playing on
slower surfaces will all minimize vibration transmission to the medial elbow
[5,39]. A larger racquet head provides a larger area to hit the ball centrally on
700 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705

the strings, therefore preventing off-center contact, which is a source of

valgus stress to the elbow. In golf, clubs of proper weight, length, and grip are
similarly important and can significantly reduce the injurious forces generated
within the elbow. Examination of technique to identify faults allows a safe
return, reducing the risk of recurrence. Ilfield showed that patients with medial
epicondylitis who regularly played tennis often exhibited an improper serve and
forehand stroke [40]. These incorrect strokes included hitting the ball late,
hitting the ball with the head of the racquet behind the elbow as contact is
made, and hitting the ball off-center on the racquet, all of which contribute
to elbow problems. Continued conditioning of the entire body along with the
affected extremity is vital. Conditioning, including flexibility, strength, and
endurance, is best performed with a slow, structured interval program,
monitored by coach, trainer, and physician to ensure a successful return without
symptom recurrence.

Surgical treatment
If a patient fails to respond to a disciplined, 3- to 6-month nonoperative
program and all other possible pathologic causes for the pain of epicondylitis
have been excluded, surgical treatment is recommended. In elite throwing
athletes, operative treatment can be undertaken sooner if physical examination
and imaging studies indicate tendon disruption. At this stage, nonoperative
treatment will most likely prove insufficient to return the high-level athlete to
peak performance.

Historical treatment
The history of surgical management of epicondylitis spans nearly three
quarters of a century. Although much literature discusses operative treatment of
lateral epicondylitis, little exists concerning similar treatment of medial epicon-
dylitis. Various procedures ranging from percutaneous epicondylar release to
epicondylectomy have been used, without a single widely accepted technique
[28]. Currently, however, the standard surgical treatment consists of: (1) excision
of the pathologic portion of the tendon, (2) enhancement of local vascularity to
stimulate a healing response, (3) firm reattachment of any elevated tendon origin
back to the epicondyle, (4) repair of the resultant defect, and (5) management of
any concurrent ulnar nerve or ulnar collateral ligament pathology.

Surgical technique
With the patient lying supine, a tourniquet is applied and the arm is placed on
an arm board. A 5-cm to 7-cm oblique incision is made just anterior to the medial
epicondyle. The surgeon must take care to identify the medial antebrachial
cutaneous nerve during the approach through the subcutaneous tissue. Proximal
extension of the incision may be necessary when considering anterior transpo-
 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705 701

Fig. 1. Skin incision overlying the medial epicondyle with exposed cutaneous and ulnar nerves;
intended incision of common flexor-pronator mass. (From Ciccotti MG, Lombardo SJ. Lateral
and medial epicondylitis of the elbow. In: Jobe FW, Pin MM, Glousman RE, editors. Operative
techniques in upper extremity sports injuries. St. Louis (MO): Mosby-Year Book; 1996. p. 443;
with permission.)

sition of the ulnar nerve. The common flexor-pronator origin is identified, along
with the ulnar nerve, which is protected within the ulnar groove. Depending upon
the location and nature of the pathologic tissue, an incision of the pronator teres-
flexor carpi radialis interval is developed either longitudinally or transversely
(Fig. 1). If the pathology is focal, a longitudinal split and excision of the
abnormal tissue is performed. If the pathology is diffuse, which is less commonly
reported, a transverse incision is performed and the abnormal tissue is completely
excised (Fig. 2). Deep to the flexor-pronator mass, the ulnar collateral ligament
must also be evaluated for possible concurrent pathology. Surgical management
of the ulnar nerve or ulnar collateral ligament is performed when necessary.
Preparation of the medial epicondyle for reattachment of the common flexor-
pronator origin includes rongeuring any fibrous tissue and drilling multiple small
holes in the surface to create a sufficient vascular bed. The flexor-pronator origin
is then reattached to the bleeding surface with interrupted sutures, either through
drill holes or through the attached adjacent flexor-pronator origin (Fig. 3).
Finally, routine subcutaneous and skin closures are performed. A posterior plaster
splint is applied to the elbow and the wrist, with the elbow at 90° of flexion and
the forearm in neutral rotation.
Though arthroscopic debridement has been proposed for the surgical man-
agement of lateral epicondylitis, the close proximity of both the ulnar nerve and
the ulnar collateral ligament make such risks prohibitive for medial epicondylitis.
702 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705

Fig. 2. Distal reflection of the common flexor-pronator origin with excision of pathologic tissue.
(From Ciccotti MG, Lombardo SJ. Lateral and medial epicondylitis of the elbow. In: Jobe FW, Pin
MM, Glousman RE, editors. Operative techniques in upper extremity sports injuries. St. Louis (MO):
Mosby-Year Book; 1996. p. 444; with permission.)

Postoperative management
At 7 to 10 days postoperatively, the splint and skin sutures are removed. At
this point, gentle passive and active hand, wrist, and elbow exercises are begun.
Gentle isometrics are undertaken at 3 to 4 weeks postoperatively, with more
rigorous, resistive exercise, including wrist flexion and forearm pronation,
beginning at 6 weeks. A progressive strengthening program follows. Generally,
a patient will return to activities by 3 to 6 months postoperatively.

Surgical results
Vangsness and Jobe reviewed 35 patients with recalcitrant medial epicondy-
litis who underwent surgical treatment with a standard technique employing the
aforementioned surgical principles [11]. They reported 88% good to excellent
results after an average follow-up of 6 years. Fourteen percent required ulnar
nerve submuscular transposition; however, none of these patients suffered from
persistent symptoms. Nineteen of twenty athletes returned to their previous level
of sport. Fourteen percent of patients noted some loss of endurance or experi-
enced limitations with heavy lifting. Isokinetic and grip strength testing demon-
strated no significant side-to-side differences. Gabel and Morrey reviewed their
 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705 703

Fig. 3. Reattachment of the common flexor-pronator origin to the medial epicondyle. (From Ciccotti
MG, Lombardo SJ. Lateral and medial epicondylitis of the elbow. In: Jobe FW, Pin MM, Glousman
RE, editors. Operative techniques in upper extremity sports injuries. St. Louis (MO): Mosby-Year
Book; 1996. p. 444; with permission.)

results in 26 patients (30 elbows) using several different surgical techniques to

manage medial epicondylitis, including partial and complete elevation of the
flexor pronator mass, with or without complete reattachment [41]. They reported
87% good to excellent results after an average follow-up of 7 years, and 96%
good to excellent results in patients with absent to mild ulnar nerve symptoms.
Their surgical management of ulnar neuropathy also employed various tech-
niques, dependent on preoperative symptoms and intraoperative findings. More
than 50% of patients with preoperative ulnar nerve symptoms had a less favorable
outcome. Wittenberg et al noted good to excellent results in 14 of 17 patients with
medial epicondylitis [42]. Baumgard and Schwartz reported 83% excellent results
in a small series of 6 patients, having used a technique of percutaneous release of
the common flexor-pronator origin [2]. Despite the limited literature on medial
epicondylitis, surgical treatment appears to generally result in reliable pain
relief and high patient satisfaction. Some residual objective strength deficits in
the involved extremity may occur, but these do not seem to interfere with
functional activities.

Summary
Although limited literature exists on medial epicondylitis of the elbow, this
disorder is an injury affecting many professionals and athletes at every level,
especially throwing athletes. Care must be taken in diagnosing medial epicondy-
litis to distinguish it from other possible pathologies of the medial elbow, which
704 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705

may exist concurrently. The large majority of patients diagnosed with medial
epicondylitis will respond to a well-structured, nonsurgical program; however,
patients with persistent or recurring symptoms can be treated surgically, which
yields high patient satisfaction and ultimately a reliable return to preinjury levels
of activity.

References
[1] Morris H. The rider’s sprain. Lancet 1882;2:133 – 4.
[2] Baumgard SH, Schwartz DR. Percutaneous release of epicondylar muscles for humeral epicon-
dylitis. Am J Sports Med 1982;10:233 – 6.
[3] Meine J, Eicher E. Results of a denervating operation in radial and ulnar humeral epicondylitis.
Hand Surgery 1981;13:254 – 9.
[4] Spencer GE, Herndon CH. Surgical treatment of epicondylitis. J Bone Joint Surg Am 1953;35:
421 – 4.
[5] Leach RE, Miller JK. Lateral and medial epicondylitis of the elbow. Clin Sports Med 1987;6:
259 – 72.
[6] Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone
Joint Surg Am 1979;61:832 – 9.
[7] Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow: incidence, recurrence,
and effectiveness of prevention strategies. Am J Sports Med 1979;7:234 – 8.
[8] Ciccotti MG, Lombardo SJ. Lateral and medial epicondylitis of the elbow. In: Jobe FW, Pin MM,
Glousman RE, et al, editors. Operative techniques in upper extremity sports injuries. St. Louis
(MO): Mosby-Year Book; 1996. p. 431 – 46.
[9] Bennett JB. Lateral and medial epicondylitis. Hand Clin 1994;10:157 – 63.
[10] Glousman RE, Barron J, Jobe FW, et al. An electromyographic analysis of the elbow in the
normal injured pitchers with medial collateral ligament insufficiency. Am J Sports Med 1992;73:
311 – 7.
[11] Vangsness C, Jobe FW. Surgical technique of medial epicondylitis: results in 35 elbows. J Bone
Joint Surg Br 1991;73:409 – 11.
[12] Galloway M, DeMaio M, Mangine R. Rehabilitative techniques in the treatment of medial and
lateral epicondylitis. Orthopedics 1992;15:1089 – 96.
[13] Miller JE. Javelin thrower’s elbow. J Bone Joint Surg Br 1960;42:788 – 92.
[14] Morris M, Jobe FW, Perry J, et al. Electromyographic analysis of elbow function in tennis
players. Am J Sports Med 1989;17:241 – 7.
[15] McCarroll JR. Evaluation, treatment, and prevention of upper extremity injuries in golfers.
In: Nicholas JA, Hershman EB, editors. The upper extremity in sports medicine. St. Louis
(MO): Mosby; 1990. p. 883 – 9.
[16] McCarroll JR, Gloe TJ. Professional golfers and the price they pay. Phys Sportsmed 1982;12:
64 – 5.
[17] Barnes DA, Tullos HS. An analysis of 100 symptomatic baseball players. Am J Sports Med
1982;10:64 – 8.
[18] King JW, Brelsford JH, Tullos HS. Analysis of the pitching arm of the professional baseball
pitchers. Clin Orthop 1969;67:116 – 23.
[19] Nirschl RP. Muscle and tendon trauma: tennis elbow. In: Morrey BF, editor. The elbow and its
disorders. Philadelphia: WB Saunders; 1985. p. 489 – 96.
[20] Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orthop 1985;201:
84 – 90.
[21] Carp L. Tennis elbow epicondylitis caused radiohumeral bursitis. Arch Surg 1932;24:905.
[22] Trethowan WH. Tennis elbow. BMJ 1929;2:1218 – 24.
[23] Garden RS. Tennis elbow. J Bone Joint Surg Br 1961;43:100 – 6.
 M.C. Ciccotti et al / Clin Sports Med 23 (2004) 693–705 705

[24] Bosworth DM. The role of the oblicular ligament in tennis elbow. J Bone Joint Surg Am 1955;
37A(3):527 – 33.
[25] Regan W, Wold LE, Coonrad R, et al. Microscopic histopathology of chronic refractory lateral
epicondylitis. Am J Sports Med 1992;20:746 – 9.
[26] Nirschl RP. Prevention and treatment of elbow and shoulder injuries in the tennis player. Clin
Sports Med 1988;7:289 – 94.
[27] Ciccotti MG. Epicondylitis in the athlete. Instr Course Lect 1999;49:375 – 81.
[28] Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg
1994;2:1 – 8.
[29] Plancher KD, Halbrecht J, Lourie G. Medial and lateral epicondylitis in the athlete. Clin Sports
Med 1996;15:283 – 304.
[30] Nazarian LN, McShane JM, Ciccotti MG, et al. Dynamic ultrasound of the anterior band of
the ulnar collateral ligament in asymptomatic major league baseball pitchers. Radiology 2003;4:
149 – 54.
[31] Binder AI, Hazleman BL. Lateral humeral epicondylitis: a study of natural history and the effect
of conservative therapy. Br J Rheumatol 1983;22:73 – 6.
[32] Price R, Sinclair H, Heinrich I, et al. Local injection treatment of tennis elbow: hydrocortisone,
triamcinolone, and lidocaine compared. Br J Rhumatol 1991;30:39 – 51.
[33] Stahl S, Kaufman T. The efficacy of an injection of steroids for medial epicondylitis: a prospec-
tive study of sixty elbows. J Bone Joint Surg Am 1997;79:1648 – 52.
[34] Verhaar JAN, Walenkamp GHIM, van Mameren H, et al. Local corticosteroid injection versus
cyriax-type physiotherapy for tennis elbows. J Bone Joint Surg Br 1996;78:128 – 33.
[35] Krishek O, Hopf C, Nafe B, et al. Shock-wave therapy for tennis and golfer’s elbow—1 year
follow-up. Arch Orthop Trauma Surg 1999;119:62 – 6.
[36] Percy C, Carson JD. Use of DMSO in tennis elbow and rotator cuff tendonitis: double-blind
study. Med Sci Sports Exerc 1981;13:215 – 9.
[37] Enzenauer RJ, Nordstrum DM. Anterior interosseous nerve syndrome associated with forearm
band treatment of lateral epicondylitis. Orthopedics 1991;14:788 – 94.
[38] Field LD, Savoie FH. Common elbow injuries in sport. Sports Med 1988;26:1936.
[39] Harvey J, Glick J, Stanish W, et al. Tennis elbow: what’s the best treatment? Phys Sportsmed
1990;18:62 – 74.
[40] Ilfield FW. Can stroke modification relieve tennis elbow? Clin Orthop 1992;276:182 – 6.
[41] Gabel GT, Morrey BT. Operative treatment of medial epicondylitis: the influence of concomitant
ulnar neuropathy at the elbow. J Bone Joint Surg Am 1995;77:1065 – 9.
[42] Wittenberg RH, Schaal S, Muhr G. Surgical treatment of persistent elbow epicondylitis. Clin
Orthop 1992;278:73 – 80.