167. Medial Epicondylalgia (Golfer's Elbow): Assessment and Treatment

In this episode of the PTs Snacks Podcast, host Kasey dives into medial epicondylalgia, commonly known as golfer's elbow. This condition involves chronic tendinosis of the wrist flexors and pronators that attach to the medial epicondyle of the humerus. Kasey explains how to assess and treat this condition, noting the importance of proper diagnosis and patient education. Key topics include risk factors, symptoms, clinical examination techniques, imaging options, and treatment strategies such as pain management, tendon loading, and patient education. This episode is a must-listen for physical therapists and students looking to enhance their understanding of medial elbow pain.

00:00 Introduction to PTs Snacks Podcast
00:13 Understanding Medial Epicondylalgia
02:39 Causes and Risk Factors
06:54 Symptoms and Diagnosis
08:22 Treatment Approaches
14:29 Conclusion and Additional Resources

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Transcript

Hey guys. Welcome to PTs Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals and buy segments of time. Today we're gonna be covering golfer's elbow as it's commonly called, or medial epicondylalgia. So if you've got a patient with elbow pain, especially medial elbow pain, this is the episode for you. But before we do that, if you've listened to at least three episodes and you feel like this has been really helpful to you, if you wouldn't mind just pausing really quick and leaving a review wherever that you listen to this podcast, that would be so helpful. Now with that being said, let's dive into today's topic. Again, medial epicondylalgia. We're gonna talk about what exactly this is, how do we assess for this, and then what do we do about it? General outline for today, so starting with what is medial epicondylalgia. So. Notice I didn't say medial epicondylitis. This is technically another term for it too. Um, the thing is itis suggests that there's inflammation, and this is actually chronic tendinosis of the wrist flexors and pronators that attach to the medial epicondyle of the humerus. So it's at the medial epicondyle epicondylitis. Now, you know where the name comes from again. With the chronic aspect of this 'cause we can say a tendinopathy as an overall umbrella term, and then under that can be itis, which is more acute. There's an inflammatory response that happens an os, which is more chronic,, an absence of a normal healing response. There's an absence of inflammation that's happening, so. Hence why I use Epicon osis or epicondylalgia. Think tendinosis is not tendonitis for most of what we're talking to today, and more specifically on what those tendons are. The tendons of the pronator tes, or flexor carpe radialis are the usual suspects. But again, test all of the muscles that attach into that area and see what's involved. Now the medial epicondyle is also home to the ulnar collateral ligament and the ulnar nerve. So when you are assessing this patient, they're coming in with medial elbow pain. Keep in mind that those could be tissues that are also involved in what the patient has. It could be something similar, an overlap or something different. So good for your differential diagnosis, and that's why it's so important to understand your anatomy, like the back of your hand. Now, how does this even happen in the first place? Like a lot of chronic tendon related injuries, um, or acute really to, essentially it happens when the demands of the task we're asking a tissue to do. So. In this case, tendon is more than what the tendon is actually able to do, especially over time. So, there could be something acute that happened, like a huge house project that happened over the weekend that involved these tendons in the elbow and they don't like it. They flare up, they inflame, et cetera. That's itis. Um, or it could be from different sports, repetitive use over time, where again, the stress that's applied. And the recovery that's allowed after don't line up to allow for positive adaptations. There's usually negative ones, so think repetitive stress, things that require a lot of repetitive gripping under load. Forearm pronation in wrist flexion. You could see this in golfers, tennis players, baseball pitchers, rock climbers, people who are in manual labor trades like carpenters, butchers, caterers, essentially, activities that allow for repetitive gripping, forearm pronation, and wrist flexion. Risk factors could be poor biomechanics. We'll see this a lot of times of someone learning form for golfing, for instance, or they are using improper technique that causes force, more force than necessary to go through another part of the body rather than a part of the body that has more capacity to handle that force, larger muscles, et cetera. So like golfing for instance, if someone is. Not putting their shoulder in the right spot. And now more of that force is being transferred down to the elbow. That could be an example. Improper equipment, smoking and diabetes, things that impact your ability to recover after stress. And then, activities that require two hours a day of or more of wrist flexion and pronation. So those are all risk factors. Now, medial epicondylalgia is a lot less common than lateral epicondylalgia. It's only really 10% of all epicondylosis injuries that are in the elbow, but it can be also very debilitating, affecting a lot of their ability to do their day-to-day tasks. Gripping, it usually affects people who are in their forties and fifties. Most often in the dominant arm makes sense because they're probably using that arm more, therefore repetitive overuse. And we also see it a little bit more often in women. Good news is that in 80% of these patients, they're gonna get better in one to three years without any sort of surgery, anything like that. The bad news is one to three years is a long time. So as physical therapists, the more we can identify if something actually is medial epicondylalgia or not, and then effectively treat it the better. Now, again, diving further, I talked about how the chronic version is basically a inability to facilitate a normal healing response. It's chronic overuse over time. So generally, if. There is an injury, there's gonna be a normal inflammatory response. You'll see inflammatory cells that are there to help to facilitate healing. In this instance, if you were to, from a histological perspective, zoom in on a chronic tendon issue, you might see disorganized collagen, immature fibroblast, neovascularization, and no real inflammatory cells. So that's why for chronic issues. Rest and NSAIDs alone don't really cut it because the, the problem isn't the inflammatory response. The problem is all the other stuff that's going on. So we have to load that a little bit differently rather than if it's an acute issue, that's when we're doing active rest and all that kind of stuff. If that patient is coming in to see you, they're probably gonna talk about. They have medial elbow pain, may not use medial, they're gonna have pain with gripping, throwing wrist flexion, pronation. They may have morning stiffness, probably decreased grip strength, so something good to test. And they could even have ulnar nerve symptoms like, , parasthesia in their pinky and their fourth fingers. So again, ulnar is in that same area. On their exam, they may be tender to palpation, five to 10 millimeters below the medial epicondyle. So probably a really good idea to get good at palpating the epicondyle, pain with resisted wrist flexion or pronation. Maybe even a positive tenal sign over the cubital tunnel if we're suspecting some sort of neuro. Neural ulnar pathology here. But you can also screen for ulnar collateral ligaments with valgus stress and milking maneuvers to see if that's at play. In terms of imaging, you can get all sorts if that is something you have access to, but the clinical exam is gonna be very important for diagnosis. X-rays though, can help to see if there's any sort of calcifications or bony abnormalities. An MRI is gonna be the gold standard for soft tissue visualization, and then an ultrasound can be really helpful for dynamic imaging and more cost effective. Someone might get an EMG or nerve conduction if there's concerns of a nerve conduction issue of the ulnar nerve. So now how do we treat this? First and foremost, if. The demands that are being asked of the tissue far outweigh what is capable of. We've gotta control the environment and make it a healing environment, so best that we can control. We're trying to stop excessive aggravating activities, and bring pain under control. Part of this is also from education. We need to help our patient understand that pain here is gonna be our best friend for helping them to get out of this. Eventually. Not something to be afraid of because again, we have an abnormal healing response and so we have to use pain as a measure of how much too much. So. It is okay to experience some pain with the loading exercises that we do. We have to help that tendon be able to accept more and more load to the point where now what it can do matches the demands of what it needs to do for that person, whether it's hobbies, work, et cetera. So. A lot of times people will use pain scales, like you can have pain less than a three to four, but if it's above that, that's a bit too much pain. We need to decrease the load and or how much of a stretch that tendon is being put under. If it is above that, not great. If it's below that, you're okay, and then monitor the next 24 hours, and if the day after it's also super elevated, like a seven outta 10, that was too much. But you know what? We are going to turn that into productive feedback by saying, oh, I observe that I have more pain. I'm going to use. My isometrics for pain relief, and then I'm gonna decrease the intensity of what I did by 10% and try again. And then that helps our patients be able to feel like they've got a say over their pain instead of feeling like there's that pain again, it's back. This is never gonna work. And then they do nothing or they do everything and it's just not playing in your favor. Give them a framework of how to put pain to work basically. So with that, once we are able to get the tendon in an environment where they can accept load, we load it. Isometrics tend to be a little bit less provocative, but the goal would be to work towards isokinetic where we're actually strengthening. And then we're, we're working, we're working at like a seven outta 10 difficulty level, not pain, difficulty level, and then eventually. Our later phases trying to mimic more of what they need to do, whether we're helping that tendon that has been able to do slower load to do now a faster load or awkward load, or have enough endurance for the load that they need to do, we have to match that to what the needs of the patient are in front of us. So again, summary phase one, create a healing environment. Calm things down, get things manageable as much as you can in your control. Educate your patient. Phase two, load up the tendon. You can also use phase two to load up around the tendon, shoulder, complex core, et cetera. Make them feel productive with that time. If it's from improper form, this is a good time for them to maybe study what good form is. And then phase three, now we're putting it all together. Essentially, that's it. Easier said than done, right? Now other options that may be used in conjunction with this type of pain could be corticosteroid injections may not be the best long term for tendon health, but is used. Uh, PRP prolotherapy, Botox. These all probably need a little bit more research on them, but. Could be something that you hear about with your patients. Modalities don't have as much good quality evidence. Evidence is kind of mixed, uh, with like Shockwave Massage tens and ultrasound. And then surgery is super rare. 'cause again, 80% of people are gonna get better just with time, but if it is not, sometimes they will de debris the de degenerated tendon, release, the common flexor origin. Do some cortical drilling to improve some blood flow or possibly transpose the ulnar nerve if neuropathy is involved. Now with that being said, here are some important things that you really should make sure that you're ruling out with your patients. So ulnar neuropathy, OUCL sprain, cervical radiculopathy, osteoarthritis elbow, elbow bursitis, synovial pica, rheumatoid arthritis, and even shingles. Make sure that you are effectively rolling in and rolling out different diagnoses that your patient may demonstrate signs and symptoms of to make sure that if your treatment is for a tendon, that the tendon is the problem. But most people do pretty well, especially with early intervention and proper rehab. The main thing that I see go wrong is. Not enough load or too much load and not being able to help educate patients on what's okay and what's not okay. Bring your patients along with you. Educate them, especially this 'cause it's not a quick fix, unfortunately, I wish it was. Sometimes we get lucky, but a lot of times it can be very frustrating so that the more that they are on board, the more they can help monitor their symptoms and load when they are not in front of you in the clinic. Education is definitely very key. Help them understand expectations. It takes a while for tendons to heal and improve in their load. Doesn't mean they're doing anything wrong. And then give them some tools in their back pocket in case pain is higher than usual on how to go about that temporarily decrease pain, uh, decrease load. If isometrics help them. That kind of stuff help to make everything as productive feeling as possible so they never feel like they're taking a step back, just more a step in a different direction. So all that being said, that what you should have gotten from this episode is what exactly is medial epicondylalgia? How do we assess for it and what do we do about it? So I would, if you get a chance, try and summarize what I just said in like three sentences to somebody that. Is a PT around you, just to really see if you got that, what your main takeaways were. Three sentences. If you have any questions, feel free to reach out Pt snacks podcast@gmail.com or I have a lot of other ways that you can reach me. I just started a Twitter. I have an Instagram. They're all PT snacks, podcasts, I on threads and I also have an email newsletter. Honestly, if you were to choose one, I would choose that because I try and give more. Study tips on there that you can take away. 'cause life is busy. The more that you can actively learn the information, when you're taking the time to sit down and learn it, the better versus. The time that we had in PT school and college usually doesn't exist for people once you leave those settings. So make that proactive. And then for those of you who wanna take a deeper dive or you need more CEUs, med Bridge is actually offering listeners over a hundred dollars off their year subscription. And if you don't know who Med Bridge is, uh, you might be living under a rock. But basically they have thousands of continuing education courses, webinars, and even. O-C-S-S-C-S specialty exam prep. I use them for my OCS. It was super helpful. But use the promo code, PT snacks podcast whenever you go to check out, or you can just go to the show notes and there's a link there for you. But other than that, I hope you guys have a great rest of your day, and until next time.