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Medial Epicondylitis (Golfer's Elbow)

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Rehabilitasyon na batay sa pagkarga para sa golfer's elbow (flexor-pronator tendinosis), kasama ang pagsusuri ng ulnar nerve, eccentric reverse-Tyler-twist loading, at hiwalay na post-operative na landas para sa iilan na nangangailangan ng operasyon.

Illustrasyon ng panloob na bahagi ng siko na nagpapakita ng mga tendon ng flexor-pronator na nakadikit sa medial epicondyle, kasama ang ulnar nerve na dumadaan kaagad sa likod nito.
Golfer's elbow: pagkasira ng mga tendon ng flexor-pronator kung saan ito nakakabit sa butong tumatayo sa loob ng siko (medial epicondyle). Dumaan ang ulnar nerve sa likod nito. Kieran Hirpara 4.0

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ang pahinang ito ay nagbibigay-daan sa iyong paggaling mula sa medial epicondylitis (karaniwang tinatawag na golfer's elbow) sa ilalim ng pag-aalaga ni Dr Kieran Hirpara sa Mater Private Hospital Rockhampton. Karamihan sa mga tao ay gumagaling nang buo nang walang operasyon, at ang pangunahing batayan ng paggamot ay isang matatag na programa ng ehersisyo na nakabase sa pagbebenta ng bigat (loading-based exercise) imbes na pahinga. Nagsisimula ito sa iyong home exercise program, sinundan ng istrukturadong klinikal na protokol na isinulat para sa iyong physiotherapist o hand therapist; dalhin ang pahinang ito o ang PDF nito sa iyong unang bisita sa terapiya upang manatiling koordinado ang iyong rehabilitasyon. Maaaring baguhin ng iyong therapist ang plano depende sa kung paano ang iyong paggaling.

Kung ikaw ay magkaroon ng pins-and-needles, numbness o weakness sa iyong little at ring fingers, ipaalam ito sa mga kwarto o sa iyong therapist; ang ulnar nerve ay tumatakbo sa likod ng loob ng siko at minsan ay nangangailangan ng hiwalay na atensyon.

Ano ang inaasahan

Ang golfer’s elbow ay isang problema sa pagkasira (degenerative) ng mga tendon sa loob na bahagi ng siko: ang mga flexor-pronator tendon, na yumuyuko sa pulso at nagpapababa ng palad, kung saan sila dumudugtong sa butong tawag na medial epicondyle. Kahit ang lumang pangalan ay "epicondylitis," hindi ito talaga pamamaga; ang tendon ay naging mahina at hindi maayos ang istruktura dahil sa sobrang gamit. Ito ang dahilan kung bakit ang modernong paggamot ay hindi pahinga at anti-inflammatories, kundi isang unti-unting programa na dahan-dahang binibigyan ng karga ang tendon hanggang sa mabawi ang buong lakas.

Ang paggaling ay nangangailangan ng pasensya. Ang golfer’s elbow ay karaniwang self-limiting, ngunit maaaring tumagal ng 6 hanggang 18 buwan bago ito lubos na makalma. Ang magandang balita ay ang karamihan sa mga tao ay gumagaling sa pamamagitan ng isang mahusay na conservative program at hindi kailangan ng operasyon. Ang operasyon ay isasagawa lamang kung hindi na epektibo ang hindi bababa sa anim na buwan ng de-kalidad na terapiya.

Isang katangian na nagpapakita ng pagkakaiba ng loob na siko mula sa labas (tennis) elbow ay ang ulnar nerve (ang "funny bone" nerve), na dumadaan sa isang guhit agad sa likod ng medial epicondyle. Sa humigit-kumulang kalahati ng mga taong may golfer’s elbow, mayroon ding kaunting iritasyon sa nerbiyong ito, kaya ang iyong therapist ay susuriin ito sa bawat bisita at maaaring magdagdag ng mga tiyak na ehersisyo para sa paggalaw ng nerbiyo.

Mga Precautions at Limitasyon

Gawin:

  • Patuloy na gamitin ang braso para sa karaniwang gawain sa araw-araw na pamumuhay hangga't nasa komportableng limitasyon.
  • Baguhin, imbes na lubos na itigil, ang mga gawaing nagpapalala ng sintomas.
  • Magsuot ng counterforce brace sa ibabaw ng kalamnan ng forearms habang nagpapatibay ng gawain kung ito ay nakakatulong.
  • Gawin ang iyong mga pagsusuklay at loading exercises nang regular; ang konsistensya ay mas mahalaga kaysa sa intensity.

Huwag Gawin:

  • Huwag pahinga ang siko nang lubusan o ilagay ito sa cast; ang tendon ay nangangailangan ng banayad na load upang gumaling.
  • Iwasan ang mga mabibigat na valgus-loading activities sa maagang yugto: golf, pagtapon (lalo na ang cocking at acceleration phases), paglangoy, at racquet sports, hanggang sa mabawi ang iyong lakas.
  • Huwag ipilit ang anumang exercise hanggang sa matutulis na sakit, at huwag ipilit ang nerve glides hanggang sa may pakiramdam ng pins-and-needles o numbness.
  • Kung lumala ang iyong mga sintomas ng ulnar nerve (pakiramdam ng tingling o numbness sa maliit at ring fingers), bumagal at humingi ng pagsusuri bago paandarin ang pagtaas ng loading.

Ang iyong mga ehersisyo

Ito ang mga ehersisyo mula sa iyong handout. Simulan ang mga ito ayon sa gabay ni Dr. Hirpara at ng iyong terapeuta. Sa mga unang linggo, ang pokus ay nasa pagpapababa ng sakit, banayad na paggalaw, at mga isometric na hawak; ang eccentric reverse Tyler twist at pagpapalakas ng hawak ay idadagdag habang umuunlad ka. Kasama ang ulnar-nerve glide dahil madalas na kabilang ang nerbiyong ito sa loob ng siko; panatilihin itong banayad.

Ang iyong klinikal na protokol

Ang natitirang bahagi ng pahinang ito ay ang klinikal na protokol sa rehabilitasyon. Dapat ibigay ang seksyong ito sa iyong pisyoterapeuta o terapeuta sa kamay. Ito ay batay sa mga pamantayan (criteria-gated) imbes na puro batay sa oras: ang pag-unlad sa pagitan ng mga yugto ay nakadepende sa pagtupad sa mga layunin na nakalista, hindi lamang sa kalendaryo. Sinusuri ang nerbiyong ulnar sa bawat bisita (Tinel's sign, subluxation), dahil humigit-kumulang 50–60% ng mga kaso sa medial na bahagi ay may kasamang sintomas ng nerbiyong ulnar, na ang pangunahing dahilan kung bakit nababigo ang konserbatibong paggamot.

Mayroong dalawang landas sa ibaba: ang non-operative na programa (una sa pagkakasunod-sunod, para sa karamihan) at ang post-operative na programa (para sa iilan na pumasa sa operasyon matapos mabigo ang konserbatibong paggamot).

Non-operative pathway

Phase I: Acute / pain control (0–2 weeks)

Goals: settle pain; restore full unloaded range of motion.

  • Relative rest and activity modification: use pain as the limiter; avoid immobilisation. Modify golf, throwing, swimming, racquet sports, weightlifting and repetitive gripping.
  • Optional counterforce brace over the common flexor mass; a wrist splint may be used if acutely painful.
  • Pain-control adjuncts: ice, soft-tissue work / IASTM, gentle pain-free active range of motion (AROM), nerve glides.
  • Screen the ulnar nerve (Tinel, subluxation).
  • Criteria to progress: full unloaded AROM without pain; independent home program.

Phase II: Sub-acute / early loading (2–4 weeks)

Goals: begin flexor-pronator loading; address the proximal chain.

  • Isometric wrist-flexor and pronator loading (light).
  • Progressive stretching of the wrist flexors at 90° elbow flexion.
  • Proximal kinetic chain: scapular stabilisers (serratus anterior, mid/lower trapezius) and rotator cuff, critical in throwers where medial elbow overload is valgus-driven.
  • Criteria to progress: full ROM maintained; tolerates the 90° stretch; ~70% of contralateral strength.

Phase III: Strengthening / return (4–6+ weeks)

Goals: restore load tolerance and return to function and sport.

  • Eccentric-concentric loading of wrist flexion and forearm pronation: the medial analogue of the Tyler twist is the "reverse Tyler twist" (eccentric wrist flexion on a FlexBar). Combined eccentric-concentric loading is favoured; isometrics remain useful for early analgesia.
  • Mobilisation-with-movement; progress stretching towards the elbow-extended position.
  • Grip strengthening, then sport-specific loading; for throwers, an interval throwing program; plyometrics last.
  • Wean the counterforce brace as the elbow becomes asymptomatic; address equipment and technique.
  • Return-to-sport criteria: ~90% of contralateral strength, pain-free function, self-management.

Post-operative na daan (flexor-pronator na debridement ± pagkumpuni ± prosedura sa ulnar nerve)

Ang operasyon ay inialok lamang sa iilan na hindi nakakuha ng benepisyo mula sa higit sa 6 buwan ng konservatibong paggamot. Ang bukas na operasyong uri Nirschl ay nagde-debride ng pathological na pinagmulan ng flexor-pronator at karaniwang nagkukumpuni o nag-aattach pabalik nito; ang ulnar nerve ay sinusuri at pinoprotektahan, at ang decompression o anterior transposition ay isinasagay sa kasama ng iba pang mga kaso.

Yugto 1: Proteksyon (0–2 linggo)

  • Posterior long-arm splint (siko + pulso) sa loob ng 10–14 araw; sling para sa paggamit sa komunidad.
  • Pagtaas at kontrol sa edema; AROM ng daliri/tendon-glide; aktibong ROM ng balikat; banayad na AROM ng leeg.
  • Mga paalala: WALANG pagbuhat, itulak, hilahin o matinding pagkapit: protektahan ang pagkumpuni.

Yugto 2: Pagpapanumbalik ng ROM (2–6 linggo)

  • Sa bisita sa ~2 linggo: pag-alis ng sutura; paglipat sa neutral wrist orthosis nang buong oras (tanggalin lamang para sa kalinisan); Tubigrip sa siko para sa pamamaga.
  • Simulan ang AROM ng siko na pagliko/pagwasto (2–4 linggo), pagkatapos ay 4-way wrist AROM + pag-ikot ng forearms at AROM ng daliri/palad (4–6 linggo).
  • Mga galaw ng ulnar nerve ay ipinakilala sa linggo 4–6 (ang idinagdag na espesipiko sa medial).
  • Pagpapatatag ng scapula (laban sa gravity). Walang resistive strengthening hanggang pagkatapos ng 6 linggo.

Yugto 3: Pagpapalakas (6–12 linggo)

  • Unahan ang orthosis ayon sa kakayahan (maaaring magpatuloy ang paggamit sa gabi sa unang yugto).
  • Progressive resistive strengthening ng pulso at forearm. Walang resistive supination/pronation sa maagang yugto; simulan ang pagbuhat sa supination/neutral, at mababang pronated na pagbuhat mula sa ~linggo 9.

Yugto 4: Pagbabalik sa aktibidad / sports (12–16+ linggo)

  • Pagtaas ng pagbuhat sa lahat ng posisyon ng forearm ayon sa kakayahan; buong pagbabalik sa aktibidad sa ~12–16 linggo; espesipiko sa sports / interval throwing program para sa mga atleta. Ang buong paggaling ay karaniwang 3–6 buwan.

Mga paalala para sa ulnar nerve: kung isinagawa ang anterior transposition, limitahan ang pagliko ng siko sa end-range sa maagang yugto at unti-unting pagtaasan ang galaw ng nerve. Ang patuloy o lumalalang mga sintomas ng ulnar nerve ay nangangailangan ng pagsusuri ng doktor bago pagtaasan ang pagbuhat.

Pagbabalik sa trabaho at gawain

Ang bilis ng iyong pagbabalik ay nakadepende sa kung anong landas ang iyong pinapuntahan at sa mga pangangailangan ng iyong trabaho at isport.

Hindi operatibo. Karaniwang maaari kang magpatuloy sa trabaho at manatiling aktibo sa buong panahon, na binabago ang mga gawain na nagpapalala ng sakit sa siko imbes na huminto nang buo. Ang golf, mga isport na may paghagis, paglangoy, at mga isport na may raket ay dahan-dahang ibabalik sa panahon ng pagpapalakas, kapag ang iyong lakas ay humigit-kumulang 90% ng kabilang bahagi at ang pag-andar ay walang sakit. Dahil self-limiting ang golfer's elbow, maaaring tumagal ng 6 hanggang 18 buwan ang buong paggaling kahit na mas maaga nang umuunlad ang pang-araw-araw na pag-andar.

Pagkatapos ng operasyon. Ang magaan at limitado na paggamit ay nagsisimula nang maaga, ngunit ang mas mabigat na pagbuhat at pagkapit ay pinipigilan upang protektahan ang pagkukumpuni. Karamihan sa mga tao ay bumabalik sa buong gawain sa loob ng mga 12 hanggang 16 linggo, na may karaniwang paggaling na tumatagal ng 3 hanggang 6 buwan. Ang mga atleta na nagpapahagis ay sumusunod sa isang gradwal na programa ng pagpapahagis sa mga itinakdang interval bago bumalik sa kompetisyon.

Pagmamaneho: iwasan ang pagmamaneho habang nasa splint o sling ka, o habang ang siko ay masyadong masakit upang kontrolin ang sasakyan nang ligtas. Ibalik ang pagmamaneho kapag wala ka nang sa splint at maaari mong galawin ang braso nang komportable, ayon sa kumpirmasyon sa iyong pagpupulong sa pagsusuri.

Pagkatapos ng iyong protocol

Ang protocol na ito ay nagtatrabaho kasama ng pangkalahatang payo para sa paggaling ng klinika; tingnan ang pamamahala ng post-operative na sakit, pag-aalaga sa sugat at mga batayan ng hand therapy. Ang golfer's elbow ay may ikinabahaging pag-asa batay sa pag-load na katulad ng kanyang kaibigan sa labas ng siko, tennis elbow; tanungin ang iyong therapist kung gusto mo ng katumbas na lateral epicondylitis na gabay. Ang iyong patuloy na paggaling ay pinamumunuan ng iyong physiotherapist o hand therapist ayon sa kung paano ang iyong siko ay nag-uunlad.

Reviewed by Dr Kieran Hirpara · 18 June 2026.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

Medial Epicondylitis (Golfer's Elbow) — Flexor-Pronator Tendinosis: Conservative Loading & Post-operative Rehabilitation

Topic scope: (A) the loading-based non-operative rehabilitation of medial epicondylitis — a degenerative tendinopathy of the flexor-pronator origin (chiefly flexor carpi radialis and pronator teres) at the medial epicondyle — with mandatory ulnar-nerve screening; and (B) post-operative rehabilitation after open flexor-pronator debridement (± repair, ± concurrent ulnar nerve decompression/transposition), reserved for the minority failing ≥6 months of quality conservative care.

Defining principle: medial epicondylitis is not an inflammatory condition but a degenerative tendinosis, so the treatment is graded tendon loading, not rest. The protocol mirrors lateral elbow tendinopathy but with two practice-defining differences Dr Hirpara emphasises: (1) the loaded group is the wrist flexors/pronators (hence the eccentric "reverse Tyler twist" rather than the lateral Tyler twist), and (2) the ulnar nerve lies immediately behind the medial epicondyle, so concomitant ulnar neuritis (~50–60% of cases) is screened at every visit and is the leading reason conservative care fails. Surgery is a last resort after ≥6 months.

Medial epicondylitis is far less studied than its lateral counterpart — it is ~5–10× less common (prevalence ~0.4% vs 1.3%; ~10–20% of all epicondylitis). Most evidence is extrapolated from lateral elbow tendinopathy and from older operative case series; dedicated medial RCTs are sparse. Phase timelines below come from institutional Standard-of-Care protocols (Mass General Brigham combined medial/lateral; UVA medial debridement; Campbell's / Nirschl) plus operative series.

A. NON-OPERATIVE REHABILITATION (phased)

First-line; the majority resolve without surgery. Largely the SAME phased structure as the lateral elbow (Mass General Brigham publishes ONE combined medial/lateral protocol), with the loading target shifted to the flexor-pronator mass. Expected resolution 6–18 months (self-limited).

Phase I — Acute / pain control (~0–2 weeks). Relative rest + activity modification using pain as the limiter (avoid immobilisation). Aggravators to modify: golf, throwing (esp. late-cocking / acceleration valgus load), swimming, bowling, racquet sports, weightlifting, repetitive gripping. Optional counterforce brace over the common flexor mass; wrist splint if acutely painful. Pain-control adjuncts: ice, soft-tissue / IASTM, gentle pain-free AROM, dry needling, nerve glides. Screen the ulnar nerve (Tinel, subluxation). Criterion to progress: full unloaded AROM without pain; independent home program.

Phase II — Sub-acute / early loading (~2–4 weeks). Isometric wrist-flexor and pronator loading (minimal load). Progressive stretching of the wrist flexors at 90° elbow flexion. Proximal kinetic chain: scapular stabilisers and rotator cuff — critical in throwers, where medial elbow overload is valgus-driven. Criteria to progress: full ROM maintained; tolerates the 90° stretch; ~70% contralateral strength.

Phase III — Late / strengthening & return (~4–6+ weeks). Eccentric and concentric loading of wrist flexion and forearm pronation — the medial analogue of the Tyler twist is a "reverse Tyler twist" (eccentric wrist flexion on the FlexBar). Combined eccentric-concentric loading is favoured; isometrics for early analgesia. Mobilisation-with-movement; progress stretching to the elbow-extended position. Grip strengthening, then sport-specific loading; for throwers, an interval throwing program; plyometrics last. Wean counterforce brace as asymptomatic; equipment/technique modification. Return-to-sport criteria: ~90% contralateral strength, pain-free function, self-management.

B. POST-OPERATIVE REHABILITATION (flexor-pronator debridement ± repair, ± ulnar nerve procedure)

Surgery is for the minority failing ≥6 months of conservative care. The open Nirschl-type operation debrides the pathologic flexor-pronator origin (incision posterior to the medial epicondyle to spare the medial antebrachial cutaneous nerve), with repair/reattachment commonly by suture anchor. The ulnar nerve must be assessed and protected: ulnar neuritis is addressed concurrently (decompression or anterior transposition) in roughly 20–50% of operative series. The phase timeline blends the UVA "Golfer's Elbow Debridement (with tendon repair)" protocol and the Verma / Midwest-Orthopaedics-at-Rush medial/lateral debridement protocol.

Phase 1 — Protect / immobilise (Weeks 0–2). Posterior long-arm splint (elbow + wrist) for 10–14 days; sling for community use. Elevation; oedema control; finger/tendon-glide AROM; unaffected-joint motion; active shoulder ROM; gentle cervical AROM. Precautions: NO lifting / pushing / pulling / forceful gripping; protect the repair.

Phase 2 — ROM restoration (Weeks 2–6). At the 2-wk visit: suture removal; transition to a wrist orthosis in neutral full-time (off for hygiene); Tubigrip at the elbow for swelling. Begin AROM elbow flexion/extension (2–4 wk), then 4-way wrist AROM + forearm rotation, finger/thumb AROM (4–6 wk). Ulnar nerve glides introduced ~weeks 4–6 (the explicit medial-specific addition). Scapular stabilisation (gravity-resisted). No resistance strengthening until after 6 weeks.

Phase 3 — Strengthening (Weeks 6–12). Wean the orthosis as tolerated (consider night use early). Progressive resistive strengthening of wrist and forearm; per Verma, no resisted supination/pronation early, lifting begun in supination/neutral, with light pronated lifting from ~week 9.

Phase 4 — Return to activity / sport (Weeks 12–16+). Progress lifting in all forearm positions as tolerated; full return to activity by ~12–16 weeks; sport-specific / interval throwing program for athletes. Full recovery commonly 3–6 months.

Ulnar nerve precautions: if an anterior transposition was performed, limit end-range elbow flexion early and progress nerve excursion gradually; persistent or worsening ulnar symptoms warrant surgeon review before advancing loading.

C. PHASED TIMELINE SUMMARY

Pathway Phase Window Immobilisation Loading / key actions Criteria / milestone
Non-op I — Pain control 0–2 wk None (avoid casting); optional counterforce brace Activity modification; pain-free AROM; nerve glides; ulnar screen Full unloaded AROM, pain-free
Non-op II — Early loading 2–4 wk None Isometric flexor/pronator load; 90° wrist-flexor stretch; scapular/cuff ~70% contralateral strength
Non-op III — Strengthen / return 4–6+ wk Wean brace Reverse Tyler twist (eccentric); grip; sport-specific; throwers' interval program ~90% strength, pain-free → RTS
Post-op 1 — Protect 0–2 wk Posterior long-arm splint 10–14 d + sling Finger glides, shoulder ROM; oedema control No resistance; repair protected
Post-op 2 — ROM restore 2–6 wk Neutral wrist orthosis Elbow AROM → 4-way wrist + forearm rotation; ulnar glides wk 4–6 No resistance until >6 wk
Post-op 3 — Strengthen 6–12 wk Wean orthosis Progressive resistance; supinated/neutral lifting → light pronated ~wk 9 Restored strength in safe positions
Post-op 4 — Return 12–16+ wk None Lifting all forearm positions; interval throwing Full return ~12–16 wk; recovery 3–6 mo

D. KEY CONTROVERSIES / EVIDENCE QUALITY

  1. Sparse high-level evidence. Almost no medial-specific RCTs; recommendations are extrapolated from lateral elbow and from retrospective operative series (Kurvers & Verhaar 1995 remains a cornerstone). Strength of evidence is materially weaker than for lateral epicondylitis.
  2. Ulnar nerve is the dominant modifier. Concomitant ulnar neuropathy (reported 23–60%) worsens prognosis and is the leading reason conservative care fails; whether and how to address it surgically (decompression vs transposition vs medial epicondylectomy) is debated. Outcomes are reliably worse when ulnar symptoms coexist and are untreated.
  3. PRP may rival surgery for type-1 disease. Bohlen et al (OJSM 2020) found 2 leukocyte-rich PRP injections matched surgery for recalcitrant type-1 medial epicondylitis (29/33 success each) with faster recovery (pain-free ~56 vs ~108 days; full ROM ~42 vs ~96 days) — the surgical delay partly attributed to post-op bracing. Small evidence base.
  4. Corticosteroid: short-term only. As with the lateral elbow, steroid gives transient relief without durable benefit and risks recurrence; repeated injections show diminishing returns.
  5. Eccentric vs concentric. Same unsettled debate as the lateral elbow; combined eccentric-concentric flexor-pronator loading is the pragmatic standard, but direct medial trial data are minimal.
  6. Surgical technique. Open Nirschl debridement with repair is reliable in case series; arthroscopic medial debridement is emerging (claimed ulnar-nerve protection) but is technically demanding and under-evidenced. Debridement alone vs with repair remains unsettled.

E. EVIDENCE STRENGTH FLAGS (summary)

  • MODERATE (non-operative rehab): the phased loading program — extrapolated largely from lateral elbow tendinopathy and combined medial/lateral institutional protocols; combined eccentric-concentric flexor-pronator loading is the pragmatic standard.
  • LOW–MODERATE (post-operative rehab): phase timelines from institutional debridement protocols (UVA; Verma/Rush) and operative case series; no defining post-op rehab RCT.
  • MODERATE (PRP for type-1 disease): single comparative study (Bohlen OJSM 2020) matching surgery with faster recovery; small sample.
  • CONSENSUS / EXPERT: ulnar-nerve screening at every visit, ulnar-glide timing (wk 4–6 post-op), and the forearm-position lifting progression — drawn from surgeon-guidance protocols and operative practice rather than trial data.

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Kurvers H, Verhaar J. The results of operative treatment of medial epicondylitis. J Bone Joint Surg Am. 1995. (ulnar neuritis coexistence 23–50%)
  • Bohlen HL, et al. Platelet-rich plasma is an equal alternative to surgery in the treatment of type 1 medial epicondylitis. Orthop J Sports Med. 2020. DOI: 10.1177/2325967120908952
  • Platelet-rich plasma versus Tenex in the treatment of medial and lateral epicondylitis. J Shoulder Elbow Surg. 2019.
  • Ellenbecker TS, Nirschl R, Renstrom P. Current concepts in examination and treatment of elbow tendon injury. Sports Health. 2012.
  • Rehabilitation of the thrower's elbow. Clin Sports Med. 2004.
  • Nirschl surgical technique for concomitant lateral and medial elbow tendinosis. Am J Sports Med. 2011.
  • Imaging of the elbow in the overhead throwing athlete. Am J Sports Med. 2003. (ulnar neuritis in ~60% of throwers with medial epicondylitis)
  • Outcome of partial medial epicondylectomy for cubital tunnel syndrome. Clin Orthop Relat Res. 2006.
  • Coonrad RW, Hooper WR. Tennis elbow: its course, natural history, conservative and surgical management (includes medial). J Bone Joint Surg Am. 1973.
  • Green's Operative Hand Surgery. 2021. (medial vs lateral prevalence; combined treatment chapter; Nirschl technique)
  • Campbell's Operative Orthopaedics. 2020. (Box 46.3 Rehabilitation Protocol for Epicondylitis [Wilk/Arrigo/Andrews]; Nirschl medial technique, posterior incision sparing the MABC nerve)

Published protocols (URLs)

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f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.