Medial Spondylitis of the Elbow: Understanding Golfer's Elbow (Medial Epicondylitis)

What is medial spondylitis of the elbow?

While "medial spondylitis of the elbow" is not a recognized medical term, it is highly likely a misnomer for medial epicondylitis, commonly known as Golfer's Elbow. Spondylitis refers to inflammation of the spinal vertebrae, whereas medial epicondylitis is an overuse injury affecting the common flexor tendon origin at the medial (inner) aspect of the elbow.

Clarifying the Terminology: Spondylitis vs. Epicondylitis

It's crucial to distinguish between these terms. Spondylitis is a medical condition characterized by inflammation of the vertebrae, the bones that make up the spine. Conditions like ankylosing spondylitis primarily affect the axial skeleton (spine and pelvis) and are systemic inflammatory diseases.

Conversely, epicondylitis refers to inflammation or degeneration of the tendons that attach to the epicondyles, the bony prominences on either side of the elbow. When this occurs on the medial epicondyle (the inner aspect of the elbow), it is termed medial epicondylitis. This condition is a localized musculoskeletal injury, not a systemic disease of the spine. Therefore, the phrase "medial spondylitis of the elbow" is anatomically and medically inaccurate.

What is Medial Epicondylitis (Golfer's Elbow)?

Medial epicondylitis, or Golfer's Elbow, is an overuse injury affecting the tendons that attach the forearm flexor muscles to the medial epicondyle of the humerus (upper arm bone). It's characterized by pain and tenderness on the inner side of the elbow, which can radiate down the forearm. Despite its name, it affects many individuals beyond golfers, particularly those involved in activities requiring repetitive wrist flexion and forearm pronation.

Anatomy Involved

Understanding the anatomy of the elbow is key to grasping medial epicondylitis:

• Bones: The elbow joint is formed by the humerus (upper arm bone) and the radius and ulna (forearm bones). The medial epicondyle is a prominent bony knob on the inner side of the distal humerus, serving as the common attachment point for several muscles.
• Muscles: The primary muscles involved originate from the medial epicondyle and are responsible for wrist flexion and forearm pronation. These include:
  • Flexor Carpi Radialis (FCR): Flexes and abducts the wrist.
  • Palmaris Longus (PL): Flexes the wrist (often absent in individuals).
  • Flexor Carpi Ulnaris (FCU): Flexes and adducts the wrist.
  • Flexor Digitorum Superficialis (FDS): Flexes the middle phalanges of the fingers.
  • Pronator Teres (PT): Pronates the forearm.
• Tendons: These muscles converge into a common flexor tendon that attaches to the medial epicondyle. It is this tendon, particularly the FCR and Pronator Teres components, that is most commonly affected in medial epicondylitis.
• Nerve Proximity: The ulnar nerve (responsible for sensation to the little finger and half of the ring finger, and some hand muscles) passes directly behind the medial epicondyle in the cubital tunnel. Inflammation in this area can sometimes irritate the ulnar nerve, leading to tingling or numbness in the fingers.

Causes and Risk Factors

Medial epicondylitis is typically an overuse injury, resulting from repetitive strain that overwhelms the capacity of the common flexor tendon.

• Repetitive Motions: Activities involving repeated forceful wrist flexion and forearm pronation are common culprits. Examples include:
  • Sports: Golf (especially with poor swing mechanics), throwing sports (baseball, javelin), racquet sports (tennis, badminton), bowling.
  • Occupations: Plumbers, carpenters, painters, butchers, assembly line workers, and those who use screwdrivers or hammers frequently.
  • Weightlifting: Certain exercises like bicep curls, tricep extensions, and pull-ups/chin-ups, especially with improper grip or technique, can place excessive stress on the medial elbow.
• Improper Technique: Poor form in sports or occupational tasks can exacerbate stress on the tendons.
• Insufficient Warm-up: Skipping warm-up routines before intense activity can leave tendons unprepared for stress.
• Weakness or Imbalance: Weak forearm muscles or imbalances between forearm flexors and extensors can increase susceptibility.
• Sudden Increase in Activity: Rapidly increasing the duration, intensity, or frequency of activities without adequate conditioning.
• Age: While it can affect anyone, it is most common in individuals between 30 and 50 years old.

Signs and Symptoms

The hallmark symptom of medial epicondylitis is pain on the inner side of the elbow.

• Localized Pain: Tenderness and pain directly over the medial epicondyle.
• Pain with Movement: Worsening pain with activities involving wrist flexion (e.g., shaking hands, turning a doorknob, lifting objects palm-up), forearm pronation (e.g., using a screwdriver), or gripping.
• Radiating Pain: Pain may extend down the forearm towards the wrist and fingers.
• Weakness: Difficulty with grip strength, especially when trying to make a fist or carry objects.
• Stiffness: A feeling of stiffness in the elbow, particularly in the morning.
• Tingling/Numbness: In some cases, if the ulnar nerve is irritated, there may be tingling or numbness in the ring and little fingers.

Diagnosis

Diagnosis of medial epicondylitis is primarily clinical, based on a thorough physical examination and patient history.

• Medical History: The physician will inquire about the onset of pain, aggravating activities, and occupational or sporting habits.
• Physical Examination:
  • Palpation: Tenderness will be elicited by pressing directly on the medial epicondyle.
  • Resisted Movements: Pain is typically reproduced when the patient attempts to flex the wrist or pronate the forearm against resistance.
  • Range of Motion: The physician will assess the elbow's range of motion to rule out other conditions.
• Imaging Studies:
  • X-rays: Usually not necessary to diagnose medial epicondylitis but may be performed to rule out other bone-related issues, such as fractures, arthritis, or calcification in the tendon.
  • Ultrasound: Can visualize tendon thickening, tears, or inflammation.
  • MRI (Magnetic Resonance Imaging): Provides detailed images of soft tissues and can confirm tendon pathology, though it is usually reserved for cases that are resistant to treatment or when the diagnosis is unclear.

Treatment and Management

The vast majority of medial epicondylitis cases respond well to conservative (non-surgical) treatment, focusing on reducing pain and inflammation, promoting healing, and preventing recurrence.

• Rest and Activity Modification: This is paramount. Avoiding or modifying activities that aggravate the pain is essential for healing. Complete rest is rarely necessary, but relative rest is crucial.
• Ice Application: Applying ice packs to the affected area for 15-20 minutes several times a day can help reduce pain and inflammation.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter NSAIDs like ibuprofen or naproxen can help manage pain and inflammation.
• Physical Therapy (Rehabilitation): A cornerstone of treatment, physical therapy aims to:
  • Pain Management: Modalities like ultrasound, phonophoresis, or iontophoresis.
  • Stretching: Gentle stretches for the wrist flexor muscles and forearm.
  • Strengthening Exercises: Progressive strengthening of the forearm muscles, initially with isometric contractions, then eccentric exercises (where the muscle lengthens under tension) which are particularly effective for tendinopathies. Strengthening of the wrist extensors and shoulder muscles is also important for overall arm stability.
  • Manual Therapy: Soft tissue massage and joint mobilizations.
  • Ergonomic and Technique Correction: Guidance on proper form for sports or work activities to minimize strain.
• Bracing: A counterforce brace (worn just below the elbow) can help redistribute forces away from the injured tendon, reducing strain.
• Injections:
  • Corticosteroid Injections: Can provide temporary pain relief, but repeated injections are generally discouraged due to potential tendon weakening.
  • Platelet-Rich Plasma (PRP) Injections: Involve injecting a concentrated solution of the patient's own platelets to promote healing, though evidence for long-term efficacy is still evolving.
  • Dry Needling: Involves inserting a fine needle into the tendon to stimulate a healing response.
• Extracorporeal Shockwave Therapy (ESWT): A non-invasive procedure that uses sound waves to stimulate healing in chronic cases.
• Surgery: Rarely needed, typically reserved for chronic cases (pain lasting 6-12 months) that have not responded to extensive conservative management. Surgical procedures usually involve debridement (removal of damaged tissue) or release of the common flexor tendon.

Prevention Strategies

Preventing medial epicondylitis involves addressing the underlying causes of overuse and strain.

• Proper Warm-up: Before engaging in sports or activities, perform a thorough warm-up, including light cardio and dynamic stretches for the arms, wrists, and shoulders.
• Gradual Progression: Slowly increase the intensity, duration, or frequency of activities to allow tendons to adapt. Avoid sudden spikes in training volume.
• Correct Technique: Ensure proper form in sports (golf swing, throwing mechanics) and occupational tasks. Consider professional coaching or ergonomic assessments.
• Strengthening and Conditioning:
  • Forearm Strengthening: Regularly strengthen both the wrist flexors and extensors to create muscular balance.
  • Grip Strength: Improve grip strength through various exercises.
  • Overall Arm and Shoulder Strength: Stronger shoulder and core muscles can help stabilize the entire kinetic chain, reducing stress on the elbow.
• Flexibility: Maintain good flexibility in the forearm and wrist muscles through regular stretching.
• Equipment Check: Ensure sports equipment (e.g., golf clubs, tennis racquets) are appropriate for your size and skill level. Heavier or stiffer equipment can increase strain.
• Listen to Your Body: Do not push through pain. If you experience discomfort, rest and adjust your activity.

Prognosis and Recovery

The prognosis for medial epicondylitis is generally good with consistent adherence to conservative treatment. Most individuals experience significant improvement within a few weeks to months. However, complete recovery can take several months, especially for chronic cases. Patience and compliance with rehabilitation exercises and activity modification are key to a successful outcome and preventing recurrence. Ignoring symptoms or returning to strenuous activities too soon can lead to chronic pain and prolonged recovery.