Shoulder and Elbow cases medial epicondylitis

A 55-year-old, right-hand-dominant male presents to the office complaining of medial-sided, right elbow pain for the past year. He denies any numbness or paresthesias. He complains of pain primarily at the medial epicondyle. He has seen a couple of other doctors for this problem and has had physical therapy, bracing, and corticosteroid injections which gave him short-lived relief. He is an avid golfer. On physical examination, he is neurovascularly intact distally with full elbow range of motion. He has tenderness at the medial epicondyle and pain with resisted wrist flexion. He has no instability with valgus stress.

What is the most likely diagnosis?

1. Ulnar nerve entrapment

2. Ulnar collateral ligament tear

3. Valgus extension overload

4. Medial epicondylitis

5. Elbow osteoarthritis

 

Discussion

The correct answer is (D). This patient has medial epicondylitis or golfer’s elbow. This entity is 7 to 20 times less common than its lateral counterpart. It occurs during the fourth and fifth decades of life, with equal male to female prevalence rates. The condition is characterized by medial elbow pain of insidious onset. Tenderness is distal to the medial epicondyle in the pronator teres and flexor carpi radialis. Patients have pain that is worsened with resisted forearm pronation or wrist flexion. Plain radiographs of the elbow are most often normal. However, throwing athletes may have traction spurs and ulnar collateral ligament calcification.

What common occupational factors are associated with the development of this condition?

1. Office work, sedentary duties

2. Repetitive varus stress at the elbow

3. Repetitive wrist bending, forearm rotation

4. Repetitive shoulder abduction

5. Proper conditioning and stretching prior to heavy lifting

 

Discussion

The correct answer is (C). Medial epicondylitis occurs in 0.4% to 0.6% of the working age population. Although termed golfer’s elbow, it is commonly found in baseball pitchers as well as a variety of sports and occupations which create valgus stresses at the elbow. Golf, rowing, baseball (pitching), javelin and tennis (serving) are commonly cited recreational activities associated with this condition. It also tends to be found in manual laborers. In a large, longitudinal study, self-reported physical exposures involving repetitive and prolonged wrist bending and forearm rotation were associated with medial epicondylitis. Repetitive bending/straightening of the elbow may also be associated with disease occurrence. Proper conditioning and stretching are protective, not a risk factor for medial epicondylitis. Varus stress and shoulder abduction are not risk factors for this condition.

Which of the following tendons does not share a proximal origin with the flexor-pronator mass?

1. Flexor pollicis longus

2. Pronator teres

3. Flexor carpi radialis

4. Palmaris longus

5. Flexor carpi ulnaris

 

Discussion

The correct answer is (A). The flexor pollicis longus originates from the volar surface of the radius and adjacent interosseous membrane, not the common flexor-pronator mass. In addition to answer Choices B, C, D, and E, the flexor digitorum superficialis is the other muscle that shares the common flexor tendon origin. All of the common flexor muscles are innervated by the median nerve, except for flexor carpi ulnaris which is innervated by the ulnar nerve.

The patient presented above undergoes further conservative treatment but develops

web space atrophy and diminished sensation of his ring and small finger. He elects to proceed with surgery.

In addition to common flexor tendon debridement, what other procedure must be considered for this patient?

1. Tendon transfer

2. Neuroma excision

3. Carpal tunnel release

4. Ulnar nerve transposition

5. Ulnar collateral ligament repair

 

Discussion

The correct answer is (D). This patient has medial epicondylitis with concomitant ulnar neuropathy. Ulnar nerve symptoms are associated with medial epicondylitis in 23% to 60% of cases according to reports. In these cases, ulnar nerve release or transposition must be considered in the same sitting. Results of medial epicondylitis surgery are generally more guarded when ulnar nerve symptoms are present.

What nerve is prone to injury with surgical treatment for medial epicondylitis?

1. Median

2. Anterior interosseous

3. Medial antebrachial cutaneous

4. Radial

5. Posterior antebrachial cutaneous

 

Discussion

The correct answer is (C). The medial antebrachial cutaneous nerve arises from the medial cord of the brachial plexus in most cases (nearly 80%). It travels parallel to the course of the median and ulnar nerves in the upper arm and divides into anterior and posterior branches above the elbow. Due to its variable location, the posterior branch is more commonly reported to be injured in the literature. Injury of the medial antebrachial cutaneous nerve is thought to be underreported as it does not affect the hand and patients may be minimally symptomatic.

 

Objectives: Did you learn...?

 

Diagnose medial epicondylitis?

 

Recognize occupational and activity related risk factors for medial epicondylitis?

 

Understand nerve conditions related to medial epicondylitis?