Medial Epicondylitis (Golfer's Elbow)
Medial epicondylitis affecting the flexor-pronator muscle insertion on the medial epicondyle. Less common than lateral epicondylitis (ratio 1:4 to 1:7). Frequent association with ulnar neuropathy at the elbow in 50% of cases.
Characteristics
Medial epicondylitis, or golfer's elbow, is a tendinopathy of the flexor-pronator muscle insertion on the medial epicondyle of the humerus. It is 4 to 7 times less common than lateral epicondylitis, with an estimated prevalence of 0.4-0.6% in the general population [1]. The mainly affected muscles are the pronator teres and flexor carpi radialis (FCR), which form the superficial layer of the medial epicondylar group. Peak incidence is between 40 and 60 years with a slight male predominance in manual worker populations.
Pathophysiology is identical to lateral epicondylitis: angiofibroblastic degeneration of tendon fibers rather than true inflammation [2]. Association with ulnar nerve neuropathy at the elbow is particularly frequent (40-60% of cases) because the ulnar nerve runs in the cubital tunnel immediately behind the medial epicondyle. This neuropathy must be systematically sought and treated concurrently.
Risk factors include occupations with repetitive movements (masonry, butchery, carpentry), throwing sports (golf, javelin, baseball) and racket sports (tennis serve). Conservative treatment follows the same principles as lateral epicondylitis: eccentric strengthening, shockwave therapy, ergonomics [3].
- Pain on the medial aspect of the elbow, at the medial epicondyle, radiating toward the anteromedial forearm. Aggravated by resisted wrist flexion, resisted pronation and power gripping. Tender palpation of the medial epicondylar insertion.
- Clinical tests: resisted wrist flexion with elbow in extension, resisted forearm pronation, passive flexor stretching (wrist extension + supination + elbow extension). Tinel's test and flexed elbow test to assess for associated ulnar neuropathy.
- Risk factors: repetitive manual work (masonry, butchery, carpentry, assembly line), throwing sports (golf, javelin, baseball), racket sports (tennis serve), smoking, obesity, diabetes. Peak between 40 and 60 years.
- Frequent association with ulnar neuropathy at the elbow (40-60% of cases): paresthesias in the 4th and 5th fingers, positive Tinel's sign over the cubital tunnel, positive flexed elbow test at 60 seconds. Valgus instability may coexist in overhead athletes (MCL injury).
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- Stage 1 – Acute inflammation
Reversible acute peritendinous inflammatory phase. Pain only during activity, subsiding at rest. No structural tendon changes on imaging. Treatment with relative rest, cryotherapy, anti-inflammatories and ergonomic correction. Resolution in 2-4 weeks.
- Stage 2 – Tendon degeneration
Angiofibroblastic degeneration of the common flexor-pronator tendon with pathological neovascularization visible on Doppler ultrasound. Pain during activity and sometimes at rest. Tendon thickening on ultrasound. Prolonged conservative treatment necessary: eccentric, shockwave, PRP.
- Stage 3 – Partial or complete tear
Partial or complete tear of the common flexor-pronator tendon with fissuring visible on MRI or ultrasound. Pain at rest, significant functional weakness. Insufficient response to conservative treatment. Indication for PRP, debridement surgery or tendon reinsertion depending on tear extent.
Medical and Surgical Management
- Medial epicondylar corticosteroid injection: short-term efficacy, same reservations as for lateral epicondylitis. Peritendinous injection under ultrasound guidance recommended to avoid the ulnar nerve. PRP as alternative with promising medium-term results.
- Management of associated ulnar neuropathy: initial conservative treatment (night splint with elbow in extension, avoid prolonged flexion positions). Surgical ulnar nerve decompression (in situ neurolysis or anterior transposition) if failure after 3-6 months.
- Surgery if conservative treatment fails after 6-12 months: debridement of angiofibroblastic tissue at the medial epicondylar insertion, with or without concomitant ulnar nerve release. Medial approach. Success rate of 75-85%.
Physiotherapy treatment
- Eccentric wrist flexor strengthening: same principle as Tyler protocol for lateral epicondylitis but in flexion. 3 sets of 15 repetitions, twice daily, for 6-8 weeks. Slow eccentric wrist flexion with progressive loading.
- Radial shockwave therapy on the medial epicondylar insertion: 3-5 sessions one week apart. 2000 impulses, 8-12 Hz. Caution with adjacent ulnar nerve: orient probe anterior and lateral to the cubital tunnel.
- Flexor-pronator stretches: passive wrist extension with elbow in extension and forearm in supination. 3 sets of 30 seconds, 3 times daily. Cyriax deep transverse massage on the medial epicondylar insertion.
- Ulnar nerve neurodynamics if associated neuropathy: neural gliding techniques (ULNT3), postural education (avoid prolonged elbow flexion, leaning on the cubital tunnel). Night splint with elbow in extension if nocturnal paresthesias.
After the session
You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.
Questions About Elbow Rehabilitation
When should I start physiotherapy after elbow surgery?
Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.
What are the goals of elbow rehabilitation?
Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.
Is elbow rehabilitation painful?
The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.
Scientific sources
Average duration
8 to 16 weeks of rehabilitation, often slower recovery than lateral epicondylitis