Medial epicondylitis is also known as Golfer’s Elbow as well as Medial Epicondylosis and refers to pain over the medial epicondyle of the elbow.

Like Tennis Elbow being known as Lateral epicondylitis, it is a misnomer as histology shows tendinosis with degeneration rather than inflammation.

Medial epicondylitis affects males and females equally with presentations peaking at 45 – 55 years of age.¹

It most commonly affects the dominant arm. The prevalence of medial epicondylitis is 0.4%, three times less than lateral epicondylitis.

In Finland it has been found to be more common in patients who are obese and perform either repetitive or forceful movements regularly.¹

Up to 25% of patients will have concurrent lateral epicondylitis, which can be termed ‘Country Club Elbow’ as it’s found in recreational players of both golf and tennis.

The Flexor Carpi Radialis (FCR), Palmaris Longus (PL) and Flexor Carpi Ulnaris (FCU) make up the Common Flexor Origin (CFO).

Along with Pronator Teres (PT) these muscles make up the flexor-pronator muscle group.

They originate from the anterior aspect of the medial epicondyle, with the origin of FCR, PT and PL most commonly involved with the origins of FCU and Flexor Digitorum Superficialis (FDS) involved to a lesser extent.^2,3

Up to 60% of patients may have musculotendinous dysfunction elsewhere.⁴

The pathologic features of medial epicondylitis are similar to those of lateral epicondylitis and include tendon degeneration and an inadequate reparative response, which leads to tendinosis and micro-tears.

The micro-trauma is often caused by repetitive valgus stresses to the elbow along with resisted flexion of the flexor-pronator group.⁵

The patient presents with an insidious onset of pain around the medial aspect of the elbow, which may radiate distally over the flexor surface of the forearm.

There is usually no history of injury but a recent increase in activity levels may have exacerbated the symptoms, which can worsen with lifting or repetitive activities.

Griping, especially with a flexed wrist may be painful.

The patients can also experience concomitant symptoms of ulnar neuritis (tingling of the medial two digits).

Clinical examination is the mainstay of diagnosis.

The main area of tenderness is the anterior aspect of the medial epicondyle and up to 1cm distal to this.

Simultaneous and resisted wrist flexion and forearm pronation exacerbates pain, which is heightened by extending the elbow.

Passive stretch should also recreate the patients’ symptoms (Elbow extended, forearm supinated and passive wrist extension).

Ulnar Nerve Compression

20-40% of patients with golfer’s elbow present with symptoms in keeping with ulnar nerve compression.⁴ The pain or paraesthesia will radiate distally towards the ulnar one and a half fingers. Altered sensation may be present along with signs of muscle weakness or wasting. The symptoms may be exacerbated by prolonged elbow flexion and Tinel’s sign may be positive. Nerve conduction studies may confirm the diagnosis if the clinical findings are not classical.

Medial Collateral Ligament (MCL) injury

The patient should present with a history of acute trauma or after repetitive activities that strain the MCL, such as valgus loading whilst throwing. MCL stability may be evaluated by applying a valgus stress or by performing the “milking test” (pulling on the thumb with the elbow in flexion and the forearm in supination).⁶

Cervical spine / Radicular pathology

Limitation of neck movement associated with pain, along with other radicular signs should be found on history and examination.

History and clinical examination are the most important steps in diagnosing golfer’s elbow.

If cases are refractory or the clinical picture is not quite clear then further imaging may be warranted.

Both Magnetic Resonance Imaging (MRI) and Ultrasound Scans (US) may be used in the evaluation of medial epicondylitis (they reveal tendinosis of the flexor/pronator origin).

If there are signs of ulnar neuritis and medial instability, MR imaging is preferred.

Radiographs often appear normal but may show calcification adjacent to the medial epicondyle.⁷ In chronic cases, traction spurs and medial collateral ligament calcification may be seen.

Watchful wait

Approximately 80% of patients will improve over 1-3 years, with the disease process being self-limiting in the majority of patients.⁸ In the acute phase exacerbating factors should be removed. Topical non-steroidal anti-inflammatories (NSAIDs) and ice may also be effective.

Physiotherapy and Orthoses 

As for tennis elbow, patients must remove the exacerbating factors that overload the tendon. A programme of eccentric exercises and graduated loading can be effective along with clasps that aim to offload the tendon. A home exercise program of eccentric exercise improved both pain and grip strength at 3 months.⁹

Corticosteroid Injections

Allows short-term relief but does not appear to affect the disease process in the long term.¹⁰ Complications include skin and sub-cutaneous fat atrophy at the injection site and patients need to be warned of this.

Platelet Rich Plasma / Autologous Blood Injections

Most of the research in this field has been carried out on tennis elbow. It has been shown in a study of 20 patients that neovascularisation and pain scores are improved at 10 months after dry needling and autologous blood injections.¹¹ Good quality research is needed to prove this treatment modality is effective.

Surgical intervention should be considered after at least 6 months of good quality conservative management.

The aim of surgical intervention is to excise unhealthy tissue, which in turn encourages an inflammatory response. This should increase the vascularity to the affected area and encourage healing.

During an open release care should be taken not to damage the medial antebrachial cutaneous nerve. Care should also be taken of the ulnar nerve as it runs posteriorly around the medial epicondyle and the anterior oblique ligament during debridement.

An extensive release with debridement of tendinopathic tissue followed by epicondylar drilling and reattachment of the flexor pronator muscle group gave an excellent/good outcome in 34 out of 35 patients using the Nirschl and Pettrone grading system.¹²

Co-existing ulnar neuritis gives a less favourable prognosis.¹³ In one study, CFO debridement along with ulnar nerve decompression was performed routinely, 50% of which had ulnar nerve symptoms. 87% of patients reported a good/excellent result.⁴ In general, early post-operative mobilisation is followed by progressive strengthening, with return to sporting activities after 6 to 12 weeks.

Medial Epicondylitis is a self-limiting disease process that causes tendinopathy at the insertion of the flexor-pronator group on the medial epicondyle.

It can resolve over time and settle with conservative management if the exacerbating factors causing repetitive overloading are removed.

If symptoms persist, surgical intervention is a reliable intervention although prognosis is less favourable with co-existing ulnar neuritis.