Physical
Tenderness with palpation over the anterior aspect of the medial epicondyle is the most consistent finding. Other characteristics of ME include the following:
•Typically, pain is reproduced with resisted wrist flexion or resisted forearm pronation.
•Occasionally, the area of tenderness extends approximately 1 inch toward the proximal flexor-pronator muscle mass just distal to the epicondyle.
•The range of motion of the elbow and wrist is usually within normal limits.
•Patients may have symptoms of an ulnar neuropathy (eg, decreased sensation in the ulnar nerve distribution, a positive elbow-flexion test, a positive Tinel sign). In more severe cases, decreased sensation is associated with intrinsic weakness; intrinsic muscle atrophy may be noted.
Causes
The causes of ME include the following:
•The condition can result from the repetitive use of flexor-pronator muscles, especially with valgus stress at the medial epicondyle.
•The onset can be related to the patient's occupation (if, for example, his/her job requires repetitive actions, such as the consistent use of a screwdriver or hammer). •ME's onset can accompany acute injury.
•An excessive topspin in tennis, excessive grip tension, improper pitching techniques in baseball, and an improper golf swing are common sports-related causes of ME.
Rehabilitation Program
Physical Therapy
The physician may recommend that the patient with ME receive physical or occupational therapy. The discipline of therapy usually depends on the type of facility available, the accessibility of therapists, and physician preference. The proper means of treatment for ME are discussed below, in the Occupational Therapy section.
Occupational Therapy
Treatment begins with rest, ice, compression, and bracing, to decrease pain and inflammation. One to 6 weeks of relative rest of the affected muscles and tendons is typically advised, until discomfort subsides. Icing is employed for 5-10 minutes, 4-6 times per day and is particularly important if a patient presents after an acute event. Patients should be instructed to avoid icing over the ulnar nerve.
Compression with a medial counterforce brace (ie, a tennis elbow splint) with a pad placed anteromedially on the proximal forearm over the flexor-pronator mass is routine. Discontinue if symptoms of an ulnar neuropathy worsen. In addition, if the symptoms are severe, brace with a wrist splint worn in the neutral position in order to rest the wrist flexors. In milder cases, a counterbalance brace may be used alone instead of a rigid splint; this limits extremes of motion while allowing some movement for functional activities. In the case of ulnar nerve involvement, a nighttime elbow extension splint should be considered. The splint is made in 30-45 º of elbow flexion. A daytime elbow pad also may be useful, by limiting additional trauma to the nerve.
After the patient's initial discomfort has subsided, a rehabilitation program with an occupational therapist should be initiated for muscle/tendon reconditioning. Begin with gentle stretching and add gradual strengthening of the flexor-pronator muscles, as the patient tolerates. Follow this with functional activities and with patient education aimed at avoiding re-injury.
Surgical Intervention
Epicondylar debridement is rarely indicated but has proven to be effective in cases in which conservative treatment has failed. In addition, the ulnar nerve may be decompressed surgically.
Consultations
Referral to an orthopedic surgeon is appropriate after 6-10 months if conservative treatment fails.
Other Treatment
If conservative measures fail, injection with local anesthetic and steroid to the point of maximal tenderness is appropriate. Special care should be taken to avoid injection directly into the tendon or the ulnar nerve. If concern for dislocation of the ulnar nerve exists, the injection should be performed with the elbow extended or semiflexed. The number of injections should be limited to 3 to decrease the risk of tendon atrophy or rupture. Short-term relief of discomfort with cortisone injection may be expected, but a complete rehabilitation program, as previously described, is a more effective and long-lasting way to treat ME.
Medication
Nonsteroidal anti-inflammatory drugs (NSAIDs), taken orally, are the medicines of choice for ME to help control pain and any associated inflammation. NSAIDs are used on average only for the first 7-10 days of the treatment period. For the patient, taking these medications with food may help to decrease the possible gastrointestinal side effects. The following list is not meant to be comprehensive but simply to provide examples of options.
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Sore tendon (bicep?)
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Originally Posted by BennyLom
