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Golfer's Elbow Release

97 citationsUpdated Oct 2026

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Overview

Percutaneous common flexor origin release of the medial humeral epicondyle is a safe and effective treatment option for golfer's elbow [1]. This procedure provides significant and sustainable improvements in pain and function during a 1-year follow-up period [1]. Surgical intervention for refractory medial epicondylitis often has a high success rate [16]. Patients undergoing this intervention generally demonstrate an improvement in patient-reported outcomes [16]. An encouraging number of these patients return to work with limited complications [16]. The results of release of the flexor muscle for patients with medial epicondylitis alone were comparable with previously reported results [9]. However, the outcome of release of the flexor muscle was unsatisfactory for patients with coexistent ulnar neuritis [9].

In a review of 21 elbow operations in 17 patients who underwent a percutaneous release, 20 of 21 elbows resumed normal function [11]. In this same review, the Andrews-Carson rating was approximately 198/200 [11]. Overall, 41 (97.6%) out of 42 elbows with medial or lateral epicondylitis that were unresponsive to long-term conservative treatments were managed successfully with a mini-open muscle resection procedure under local anesthesia [25]. Arthroscopic release of contractures is a predictable technique to achieve a highly functional elbow in athletes [4]. With careful diagnosis and exclusion of other elbow problems, treatment with arthroscopic debridement and focused rehabilitation is highly successful for posterolateral elbow impingement from lateral synovial plicae in throwing athletes and golfers [10]. This approach allows athletes with posterolateral elbow impingement to return to their previous level of play [10].

Elbow arthroscopy has become a safer and more effective treatment modality for several elbow pathologies due to advances in equipment and surgical technique [18]. Recent advantages in arthroscopic surgical techniques and ligament reconstruction in the elbow have improved the prognosis for return to competition for the highly motivated athlete [71].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint comprising medial and lateral articulations that provide bony stability [75]. The trochlea articulates with the ulna within the greater sigmoid notch to form the ulnohumeral, hinged, or trochoid portion of the joint [75]. This ulnohumeral joint exhibits highly congruent anatomy through almost 180° of articular contact, excluding the bare area of the greater sigmoid notch which lacks cartilage [75]. The coronoid process features medial and lateral facets that buttress the trochlea anteriorly [75]. Just distal and medial to the coronoid lies the sublime tubercle, which serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [75]. The medial epicondyle, which is larger and more posteriorly oriented than the lateral epicondyle, forms the origin for the flexor pronator mass [75]. Laterally, the capitellum and radial head form the radiocapitellar joint [75]. The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [75]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [75].

The distal humeral articulation is angled 30° from the longitudinal axis [75]. The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side positioned more distally than the lateral side [75]. The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [75]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [75]. The distal humerus consists of an arch formed by two condyles, with the capitellum on the lateral side and the trochlea medial to it [84]. The trochlea possesses a 300-degree arc of cartilage [84]. The medial column diverges from the humeral shaft at a 45-degree angle, while the lateral column diverges at a 20-degree angle [84]. The distal humeral shaft is triangular in cross-section with its apex directed anteriorly [87]. The medial column diverges approximately 45 degrees from the humeral shaft in the coronal plane and terminates as the medial epicondyle [87]. The lateral column diverges at approximately 20 degrees from the shaft in the coronal plane and curves anteriorly, creating a 35 to 40 degrees angle with the shaft in the sagittal plane [87]. In the coronal plane, the trochlea is more distal than the capitellum, resulting in a valgus alignment of 4 to 8 degrees [87]. The elbow exhibits a valgus angle in extension of 10 to 17 degrees, termed the carrying angle [87]. The distal humerus articular surface is internally rotated 3 to 8 degrees axially [87]. The trochlea is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [87]. The olecranon fossa is located posteriorly and the coronoid fossa anteriorly, separated by a thin bony septum [87]. The articular surface of the distal humerus is in 5° to 6° of valgus with respect to the humeral shaft [85].

The normal range of elbow flexion/extension is 0 to 150 degrees, and normal forearm pronosupination is 80 to 85 degrees in each direction [82]. The functional range of motion for the elbow is 30 to 130 degrees for flexion/extension and 50 degrees for pronosupination [82]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [82]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [82].

Ligamentous Anatomy

Elbow stability is determined by primary and secondary stabilizers [43]. The three primary stabilizers are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [43]. Secondary stabilizers include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [43]. The medial ulnar collateral ligament is the primary valgus stabilizer of the elbow [77]. The anterior bundle of the medial ulnar collateral ligament is the most important for stability [77]. The posterior bundle of the medial ulnar collateral ligament has the greatest change in length and becomes taut at flexion beyond 120 degrees [77]. The lateral ulnar collateral ligament is the posterolateral stabilizer of the elbow [77]. Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [77]. The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [77].

The medial ulnar collateral ligament originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [82]. The anterior bundle of the medial ulnar collateral ligament is the primary restraint to valgus stress within functional elbow range of motion [82]. The posterior bundle of the medial ulnar collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [82]. Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [82]. The lateral collateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament [87]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [87]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [87]. The lateral ulnar collateral ligament arises from the isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [87]. The lateral collateral ligament complex functions as an important restraint to varus and posterolateral rotatory instability [87].

The medial ulnar collateral ligament is comprised of the anterior bundle, posterior bundle, and transverse ligament [74]. The anterior bundle of the medial ulnar collateral ligament is the strongest component and the primary restraint to valgus stress [74]. The anterior band of the medial ulnar collateral ligament is tight in extension, while the posterior band is tight in flexion [74]. The lateral ulnar collateral ligament origin center is 10.7 mm from the lateral epicondyle and its insertion is 3.3 mm from the apex of the supinator crest [74]. The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [77]. The capsule allows maximum distension at approximately 70 to 80 degrees of flexion [77].

Muscular Anatomy

The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [77]. The biceps brachii inserts at the ulnar margin of the radial tuberosity and is a powerful supinator of the forearm [77]. The triceps is the primary elbow extensor and inserts on the olecranon process [77]. The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [77]. The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [77]. The triceps has a broad tendinous insertion into the olecranon posteriorly [84]. The brachialis inserts on the coronoid process and the tuberosity of the ulna anteriorly [84]. The supinator-extensor muscle group attaches to the lateral epicondyle, which is slightly proximal and lateral to the capitellum [84]. The ulnar nerve passes through the cubital tunnel at the medial column of the elbow and enters the anterior forearm by traveling between the two heads of the flexor carpi ulnaris [84]. The ulnar nerve lies in a bony groove covered and restrained by the arcuate ligament posterior to the medial epicondyle [85]. The medial epicondyle is the origin of the flexor-pronator muscle group and the medial collateral ligament [85]. The lateral epicondyle is the origin of the extensor-supinator muscle group and the lateral collateral ligament complex [85]. Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [77].

Pathophysiology of Medial Epicondylitis

Medial epicondylitis involves pathologic alteration in the musculotendinous origins at the medial epicondyle [116]. The etiology of medial epicondylitis is caused by repetitive stress and eccentric loading of the common flexor tendons, resulting in microtrauma and degeneration [119]. Repeated microtrauma creates damage of the tendon followed by chronic ineffective healing that leads to degeneration and tendinosis [119]. Medial epicondylitis most commonly affects the origins of the pronator teres and flexor carpi radialis muscles [129]. The mechanism of injury for medial epicondylitis is thought to be repetitive stress or overuse that causes microtrauma to the origin of the flexor-pronator muscles [129]. Ulnar nerve irritation is often seen in medial epicondylitis because of local inflammation [129]. In athletes, medial epicondylitis occurs with repeated substantial valgus force on the elbow, which is absorbed by the flexor-pronator group, thereby reducing forces on the anterior band of the ulnar collateral ligament [129]. The histopathology of angiofibroblastic hyperplasia described for lateral epicondylitis is also seen in medial epicondylitis [129]. Inflammation is not typically seen in medial epicondylitis [129].

Medial epicondylitis is 5 to 20 times less common than lateral epicondylitis [119]. Medial epicondylitis has an incidence only 10% to 20% that of lateral epicondylitis [129]. Medial epicondylitis is most commonly seen in the fourth and fifth decades of life [129]. Medial epicondylitis affects men and women equally [129]. The dominant arm is affected in 75% of patients with medial epicondylitis [129]. The primary etiology of medial epicondylitis is repetitive stress, although it can also be caused by trauma [129]. In the occupational setting, medial epicondylitis affects 4% to 5% of individuals, and 80% of these patients report self-resolving symptoms by 3 years [119]. Epicondylitis is most prevalent in individuals aged 40-60 years [125]. Accurate diagnosis of medial epicondylitis requires distinguishing it from other elbow conditions, and treatment is guided by the specific pathologic stage of the tendon [21]. The surgical technique for medial epicondylitis involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin of the flexor pronator muscle group to the medial epicondyle [116]. Surgical treatment for medial epicondylitis results in a high degree of subjective relief, although objective strength deficits may persist [116]. Percutaneous common flexor origin release of the medial humeral epicondyle provides significant and sustainable improvements in pain and function during a 1-year follow-up period [1]. Players with a history of medial elbow injury exhibited harder forearm flexor-pronator muscle elasticity at baseline and during repetitive pitching compared to those without injury history [111]. Fragmentation of the medial epicondyle may contribute to compromised medial elbow dynamic stability in adult baseball players [113].

Biomechanics and Injury Mechanisms

Increasing elbow flexion places the medial elbow in a position to carry a greater amount of load, which may be exacerbated during the final moments of the pitching motion [20]. High elbow varus torque increases the risk of medial elbow disorder [109]. Pitch velocity is significantly associated with abnormality of the medial epicondyle and elbow pain in youth baseball players [121]. The late cocking phase is the critical point in the pitching motion where higher levels of torque at the shoulder and elbow can result in increased risk of injury [103]. Shoulder flexibility, arm speed, and elbow varus torque are interrelated and should be considered collectively when treating pitchers [102]. The greatest shoulder and elbow peak forces occurred in pitchers with 15° to 25° contralateral trunk tilt [110]. Spin rate alone may not be a reliable predictor of elbow torque or injury [123]. Throwing alone does not appear to change the morphology of the lateral elbow outside of an injured elbow [28]. Ulnar collateral ligament injuries in overhead athletes result from repetitive valgus forces during throwing [49].

Three types of mechanism have been proposed for acute injuries of the medial humeral epicondyle in children: direct trauma, an avulsion mechanism involving an indirect muscular pull, and a combined association with elbow dislocation [41]. With a direct blow to the medial epicondyle, the epicondyle is typically fragmented, and there may be a great deal of soft-tissue swelling and ecchymosis [41]. The avulsion mechanism of the medial epicondyle by the flexor-pronator mass is described as a valgus stress on the elbow joint while falling on an outstretched hand with the elbow in extension [41]. Further stress is imparted on the medial epicondyle with supination of the forearm and extension of the wrist and hand [41]. Isolated avulsions of the medial epicondyle have been documented in adolescents who arm wrestle due to sudden increased tension in the flexor-pronator mass [41]. The final proposed mechanism for medial epicondyle injury is associated with an elbow dislocation in which the ulnar collateral ligament provides the avulsion force [41]. In the dynamic mechanism of arm wrestling, the muscles activated in the winner’s arm are the flexors of the wrist, the triceps, and the internal rotators of the shoulder [65]. The torque produced between shoulder internal rotators and the long lever arm of the opposing competitor contributes to tension on the medial epicondyle during arm wrestling [65]. The static mechanism of arm wrestling involves shifting of the pivot point from the olecranon medially to the medial epicondyle, which may cause displacement of the medial epicondyle [65]. During the shifting of the pivot point in arm wrestling, the ulnar nerve may undergo compression in its groove [65].

In golf, most injuries to the elbow that are not linked to overuse occur as the golf club makes contact with the ground, creating a divot [76]. At impact in golf, sudden deceleration requires significant counteracting forearm muscle force to maintain control of the clubface, placing strain on either the lateral or medial epicondyle [76]. The overall contributing factors to elbow injuries in golf are overuse, poor swing mechanics, lack of conditioning, inadequate warm-up, age, improper equipment, and pre-existing pathologic mechanisms [76]. The throwing elbow is a common source of nerve injuries due to the unique combination of anatomy, high forces, and sheer repetition associated with throwing sports [122]. Early recognition after elbow injury and careful attention to soft tissue repair during lateral elbow surgery may diminish the incidence of posterolateral rotatory instability [13]. Residual instability following simple elbow dislocation is uncommon, with posterolateral instability being the best documented [58]. Posterolateral instability may develop in some patients despite the development of secondary contracture, suggesting that some ligamentous complexes heal in a contracted manner while others do not heal at all [58].

Classification

Pathologic Spectrum: Medial epicondylitis manifests as a spectrum of pathologic changes ranging from tendinosis to significant partial tears of the flexor-pronator origin [46]. Flexor-pronator tendon degeneration occurs with repetitive forced wrist extension and forearm supination during activities involving wrist flexion and forearm pronation [52]. This staged process of pathologic change can result in structural breakdown and irreparable fibrosis or calcification [52]. Patients typically report persistent medial-sided elbow pain exacerbated by daily activities, while athletes may be particularly symptomatic during the late cocking or early acceleration phases of the throwing motion [52].

Smith Classification: Smith described five types of injury to the medial epicondyle based on the degree of fracture displacement and entrapment of the fragment in the elbow joint [41]. Smith proposed that further stress is imparted on the medial epicondyle with supination of the forearm and extension of the wrist and hand [41]. With a direct blow to the medial epicondyle, the fragment is typically fragmented, and there may be a great deal of soft-tissue swelling and ecchymosis [41]. Isolated avulsions of the medial epicondyle have been documented in adolescents who arm wrestle, with the proposed mechanism being a sudden increased tension in the flexor-pronator mass [41].

Papavasiliou Classification: Papavasiliou described a four-type classification system based on the Watson-Jones classification for medial epicondylar humerus fractures [41]. Type 1 is defined as a small degree of avulsion of the epicondylar fragment [41]. Type 2 is defined as an avulsed epicondylar fragment on the same level of the joint but not trapped [41].

Other Considerations: The radiographic classification of persistent olecranon physis is useful for treatment decision making [134].

Clinical Presentation

Evaluation of elbow pain in the throwing athlete must begin with a thorough and detailed throwing history, including duration of symptoms, location, and timing during the throwing motion, and associated symptoms [104]. Physical examination of the elbow is a critical component in formulating an accurate diagnosis [29]. Accurate diagnosis of medial epicondylitis requires distinguishing it from other elbow conditions [21]. Adequate elbow assessment is essential for accurate diagnosis and initiating proper treatment, as isolated elbow injuries are rare and fractures should be interpreted as proxies for associated soft tissue injuries [35]. A large majority of patients with medial epicondyle apophyseal avulsion fractures reported medial elbow pain prior to fracture [19].

Inspection and Palpation: Throwers, particularly baseball pitchers, often have slight elbow flexion contractures on the throwing arm relative to the nondominant side, which is typically asymptomatic [108]. Palpation during elbow examination should include the medial epicondyle, flexor-pronator mass, sublime tubercle, medial head of the triceps, and ulnar nerve [108]. A careful neurologic examination can reveal evidence of associated ulnar neuropathy, particularly with more chronic injuries [108]. Ulnar nerve neuritis can be associated with valgus elbow instability in over 40% of cases [108]. In a series of UCL reconstructions, one-third of patients had a positive Tinel sign over the ulnar nerve at the elbow, while only 3% had persistent ulnar nerve paresthesias before surgery [108].

Imaging and Diagnostic Pitfalls: MRI was able to identify the cause of medial elbow pain in 20 (95%) of 21 throwing athletes [56]. Elbow dislocations associated with fractures of the medial epicondyle with intra-articular entrapment can be difficult to diagnose in the acute phase, and thus a high level of suspicion is required [61]. Incarceration of the medial epicondyle in the joint often occurs in association with an elbow dislocation and is important to consider to avoid diagnostic mistakes [37].

Investigations

Physical Examination

Elbow evaluation requires an intimate understanding of the joint's anatomy, biomechanics, and diagnostic tests [43]. The physical exam is directed by the history and the specific location of pain in the anterior, posterior, medial, or lateral aspect of the elbow [43]. Stability is conferred by bony articular anatomy and medial and lateral ligamentous structures, which must be the focus of the examination [43]. Normal range of motion (ROM) spans 0° to 140° from extension to flexion, with 75° of pronation and 85° of supination [43]. A functional arc in each plane is 100° for flexion/extension and forearm rotation [43]. Stability is determined by primary stabilizers (ulnohumeral articulation, MUCL, LUCL complex) and secondary stabilizers (radiocapitellar articulation, common flexor/extensor tendons, joint capsule) [43].

For elbow stiffness, active and passive flexion, extension, supination, and pronation are evaluated using a goniometer for accurate measurement [90]. If flexion is less than 90° to 100°, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [90]. Pain assessment during mid-arc or at terminal ends of motion is required, as mid-arc ROM pain is more common with intrinsic disease and may not improve with contracture release alone [90]. The ulnar nerve is of utmost importance due to its anatomic proximity to the elbow [90]. An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for arthroscopic procedures secondary to possible iatrogenic nerve injury [90]. Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [90].

Specific pathologies present distinct physical findings. Treatment of medial epicondylitis is guided by the specific pathologic stage of the tendon [21]. In valgus extension overload syndrome, crepitus and tenderness over the posteromedial olecranon may be noted, pain is reproduced when the elbow is forced into extension, and elbow flexion contracture may be seen [92]. For osteoarthritis of the elbow, inspection should check for prior surgical incisions and joint effusion at the lateral soft spot [93]. Pain in osteoarthritis is usually felt at the end ranges of flexion and extension rather than throughout the arc, while forearm rotation is relatively preserved until later in the disease process [93]. Ulnar neuropathy is present in up to 50% of patients with osteoarthritis of the elbow [93]. For elbow dislocations, the extremity is typically shortened and the elbow held slightly flexed; stability is tested to varus and valgus stress and to pronation and supination [94].

Imaging

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [43]. Radiographs should always be obtained for elbow stiffness, including AP, lateral, and oblique views [90]. Serial radiography is used as follow-up when heterotopic ossification is present in elbow stiffness [90]. Primary bony landmarks include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid/olecranon fossae, and trochlear ridge [90]. AP, lateral, oblique, and axillary views may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [92]. Standard AP and lateral radiographs should be obtained for osteoarthritis of the elbow [93]. Radiographs for osteoarthritis typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [93]. Joint spaces at the ulnohumeral joint are usually preserved, while radiocapitellar joint spaces are mildly narrowed [93]. Loose bodies may be evident on osteoarthritis radiographs, which typically underestimate the number present [93]. Diagnosis of elbow dislocation is made by clinical examination and verified by radiograph to rule out associated fractures [94]. Postreduction radiographs are necessary to rule out occult fracture after elbow dislocation reduction [94].

CT: CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies in elbow stiffness [90]. Three-dimensional CT is used to check for heterotopic ossification in elbow stiffness [90]. CT is not necessary when elbow stiffness is entirely soft-tissue related [90]. CT is beneficial if any joint incongruity or abnormal bony anatomy is present in elbow stiffness [90]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [92]. CT may be useful for surgical planning in osteoarthritis, allowing a detailed assessment of osteophytes and the presence of loose bodies [93].

MRI: MRI can be used to evaluate ligaments and tendons in elbow stiffness, but it is rarely indicated [90]. MRI may be most helpful in evaluating associated injuries including partial or complete tears of the MCL in valgus extension overload syndrome [92]. MRI from the institution was able to identify the cause of medial elbow pain in 20 (95%) of 21 throwing athletes [56]. MRI abnormalities involving the medial aspect of the elbow are common in year-round Little League baseball players, especially those with internal rotation deficits and private coaches [120]. Dominant elbow MRI abnormalities are common in asymptomatic youth baseball players [132].

Other Considerations: Controversy regarding imaging modality, displacement measurement accuracy, and surgical indications still exists for pediatric medial epicondyle fractures [42]. The coronoid opening angle can be of value alongside 3-dimensional imaging in evaluating elbow injuries and used as an adjunct in clinical decision making [57].

Treatment

Non-Operative

Conservative management remains the initial standard of care, as surgical intervention is typically reserved for patients with medial epicondylitis who have failed long-term conservative treatments [25]. In pediatric populations, nonoperative treatment may be appropriate for minimally displaced cases of medial epicondylar apophyseal avulsion fractures in youth throwers [64]. Most patients with proximal bony UCL avulsion fractures of the pediatric medial epicondyle return to activities at about 3 months without surgery, achieving excellent elbow range of motion and Timmerman-Andrews's scores regardless of union or nonunion [15]. At 1 year after initial presentation, bone union of medial epicondylar fragmentation was associated with a decreased prevalence of elbow pain in young baseball players treated nonoperatively [22].

Operative

Indications: Surgical intervention for refractory medial epicondylitis is indicated when conservative measures fail, often yielding a high success rate with improved patient-reported outcomes and a limited complication profile [16]. For athletes sustaining significant trauma, elbow laxity or instability, or significant fracture fragment displacement, surgical management can be successful [5]. Specific indications for surgical treatment of pediatric medial epicondyle fractures include fractures with greater than 5 mm of displacement combined with either instability demonstrated by a valgus stress test or a patient who participated in organized athletics and required a stable elbow for his or her sport [47]. Operative treatment is recommended only when an intra-articular fragment cannot be removed from the joint by manipulation for medial epicondyle fractures [72].

Surgical Approach / Technique: Percutaneous common flexor origin release of the medial humeral epicondyle under local anesthesia provides significant and sustainable improvements in pain and function during a 1-year follow-up period [1]. In a review of 21 elbow operations in 17 patients who underwent a percutaneous release, 20 of 21 elbows resumed normal function and had an Andrews-Carson rating of approximately 198/200 [11]. Overall, 41 (97.6%) out of 42 elbows with medial or lateral epicondylitis, which were unresponsive to long-term conservative treatments, were managed successfully using a mini-open muscle resection procedure under local anesthesia [25]. Arthroscopic evaluation and debridement of the origin of the flexor-pronator mass can be performed via a medial portal created approximately 1 cm proximal and 1 cm anterior to the medial epicondyle [131]. With careful diagnosis and exclusion of other elbow problems, treatment with arthroscopic debridement and focused rehabilitation is highly successful and allows athletes to return to their previous level of play [10]. A double-row repair technique for recalcitrant medial epicondylitis involves placing the patient under general anesthesia with an interscalene block, performing elbow arthroscopy to rule out MUCL and capsular pathology, and making a T-incision in the tendon after protecting the ulnar nerve and medial antebrachial cutaneous nerve [68]. Good pain control can be achieved during all steps of wide-awake surgery using local anaesthesia with adrenaline for ulnar nerve decompression and medial epicondylectomy [118]. Posterior oblique medial epicondylectomy may offer advantages over traditional medial epicondylectomy by preserving elbow stability and enabling early active range of motion during the postoperative period [7]. Good postoperative objective results were reached by partial medial epicondylectomy for cubital tunnel syndrome [8]. The results of release of the flexor muscle for patients with medial epicondylitis alone were comparable with previously reported results, but the outcome was unsatisfactory for patients with coexistent ulnar neuritis [9].

Implant Selection: Options for fixation of medial epicondyle fractures include sutures, Kirschner wires (K-wires), cannulated screws, and excision of the fragment with advancement of the medial soft tissues [133]. Many authors suggest the use of K-wires in younger children and cannulated screws in older children for medial epicondyle fracture fixation [133]. When using cannulated screws for medial epicondyle fractures, the use of a washer can help increase surface area for compression, avoid screwhead penetration of the fragment, and prevent screw migration [133]. Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of pediatric medial epicondyle fractures, even in thinner patients or competitive athletes [51].

Pain Management: Good pain control can be achieved during all steps of wide-awake surgery using local anaesthesia with adrenaline for ulnar nerve decompression and medial epicondylectomy [118].

Adjuncts: Examination (manipulation) under anesthesia can be a valuable adjunctive procedure to help regain the motion obtained at the time of surgical release [70]. The Roberts maneuver consists of applying a valgus stress on the elbow, with forearm supination and extension of the wrist and fingers, in order to extract the intra-articular fragment [133].

Setting of Care: Percutaneous common flexor origin release of the medial humeral epicondyle is performed under local anesthesia [1]. Mini-open muscle resection procedures are also performed under local anesthesia [25].

Revision: This case demonstrates the successful management of a failed medial epicondyle nonunion ORIF with revision ORIF using an interposition distal clavicle autograft with preservation of the medial epicondyle and MUCL [69]. The procedure for valgus instability of the elbow due to medial epicondyle nonunion by fragment excision and ligament repair is associated with rapid restoration of elbow stability, minimal surgical morbidity, a high rate of patient satisfaction, and an improvement in objective elbow scores [17].

Other Considerations: Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures [63]. Even with postoperative immobilization of the elbow (mean of 4 weeks), stiffness is rare following surgical treatment of displaced medial epicondyle fractures [23]. At the 1-year follow-up visit, patients with medial epicondyle fracture and concomitant flexor-pronator mass avulsion were pain free and had symmetric range of motion, elbow stability, and function when compared with their contralateral extremity [24]. Open reduction internal fixation of incarcerated medial epicondyle fractures after elbow dislocation leads to satisfactory motion and function; however, the injury carries a high risk for complications, particularly ulnar neuropathy [138]. Most authors agree that the ulnar nerve does not require routine exploration or transposition during medial epicondyle fracture fixation [133]. Any final disability was slight irrespective of the treatment used for medial epicondyle fractures in children, although surgery was more likely to restore the fragment to its normal position and achieve bony union [72]. Minor symptoms were less common in the non-operatively treated group for medial epicondyle fractures in children [72]. Instability of the elbow could not be demonstrated in any of the patients with medial epicondyle fractures in a review of 43 children [72]. Twelve studies have confirmed success rates between 72% and 94% for medial epicondylectomy [38].

Rehabilitation and Adjunctive Procedures

Rehabilitation following elbow injury or surgery follows a sequential and progressive multiphased approach with the ultimate goal of returning the athlete to the previous functional level as quickly and safely as possible [36]. Both open and arthroscopic surgery groups for chronic medial epicondylitis followed the same rehabilitation protocol, with active assisted range of motion exercises starting 2 days after surgery and return to sports activity attained by 3-6 months postoperatively [137]. A subset of pediatric patients with persistent stiffness following medial epicondyle fractures may benefit from additional interventions, including intensive therapy, transposition of the ulnar nerve, and open capsular release [30]. Surgical correction of elbow flexion contractures in pediatric patients through an anterior approach leads to a satisfactory result in the majority of cases, with a low incidence of complications [54].

Complications

Stiffness / Arthrofibrosis: Postoperative elbow immobilization for a mean of 4 weeks following medial epicondyle fracture fixation is associated with rare stiffness [23]. Elbow stiffness and loss of motion, particularly extension, represent the most common complications following elbow dislocation [127]. Surgical repair of complete triceps tendon injuries offers a predictable return of function with a small risk of loss of elbow motion [14]. In one case of an isolated depressed intraarticular olecranon fracture, right elbow range of motion measured 0° to 135° of flexion at 15 months, equaling that of the uninjured extremity [6].

Nerve palsy: Outcomes for patients with medial epicondylitis and coexistent ulnar neuritis were unsatisfactory [9]. Most recommendations for managing the ulnar nerve rely on retrospective reviews, anecdotal reports, and expert opinion rather than definitive data [27]. During the static mechanism of arm wrestling, the ulnar nerve may undergo compression in its groove, a probable mechanism for injury in reported cases [65]. Ulnar nerve transposition was performed for patients with preoperative ulnar nerve palsy or a fracture located less than 5 mm from the sulcus for the ulnar nerve [105]. In a series of 30 patients treated with medial epicondylectomy for cubital tunnel syndrome, no weakness in flexor-pronator function was noted, and no patient complained of complications [106]. Following partial medial epicondylectomy for cubital tunnel syndrome, there was no ulnar nerve palsy, subluxation, or medial elbow instability, although 45% of patients reported mild pain at 6-month follow-up [67].

Instability: Fragment excision and ligament repair for valgus instability due to medial epicondyle nonunion is associated with rapid restoration of elbow stability, minimal surgical morbidity, a high rate of patient satisfaction, and an improvement in objective elbow scores [17].

Thromboembolism: In the context of medial epicondyle fractures in children, emphasis was placed on the importance of early diagnosis of venous thrombosis and immediate institution of anticoagulant therapy [141].

Other Considerations: Other rare complications following elbow dislocation include redislocation, myositis ossificans after open fractures, and neurovascular injuries [127]. There was no statistically significant difference in the incidence of complications between operative and nonoperatively treated displaced medial epicondyle fractures in a matched cohort [146]. The preliminary results of distal medial epicondylectomy are comparable with other epicondylectomy techniques with lower complication rates [144]. At an average of 6.3 years after surgery, clinical outcomes for medial epicondyle fracture were excellent [98]. Percutaneous common flexor origin release of the medial humeral epicondyle in golfer's elbow appears to be a safe and effective treatment option, providing significant and sustainable improvements in pain and function during a 1-year follow-up period [1].

Recovery

Light activity (weeks): The evidence provided does not specify a distinct week-range for light activities such as desk work or driving. However, most patients with proximal bony ulnar collateral ligament avulsion fractures of the pediatric medial epicondyle return to activities at about 3 months without surgery [15].

Full activity (months): For pediatric medial epicondyle avulsion fractures, return to activities occurs at about 3 months [15]. In occupational settings, the prognosis for medial epicondylitis is good with a 3-year recovery rate at 81% [39].

Complete recovery / outcome plateau (months): At the 1-year follow-up visit, a patient with a medial epicondyle fracture with concomitant flexor-pronator mass avulsion was pain free and had symmetric range of motion, elbow stability, and function when compared with his contralateral extremity [24]. At 15 months, right elbow range of motion was measured at 0° to 135° of flexion equaling that of the uninjured extremity following open reduction and internal fixation of an isolated depressed intraarticular fracture of the olecranon [6].

Rehabilitation protocol: Achieving full elbow range of motion was described as a goal of the early stages of rehabilitation in all but 2 studies (87%) of those reviewed for return-to-competition criteria after ulnar collateral ligament reconstruction [34]. Regaining strength constituted a significant component of the rehabilitation protocol in 13 of 15 studies (87%), but no study provided a quantitative or qualitative level of strength that had to be achieved before return to competition [34]. Absence of pain was not listed as a return-to-competition criterion by any study, but 4 studies (27%) specified that the presence of pain precluded progression through the throwing program [34]. Any player who experienced pain during any stage of the throwing program was instructed to back up to the previous stage [34].

Functional milestones: In a review of 21 elbow operations in 17 patients who underwent percutaneous release, 20 of 21 elbows resumed normal function and had an Andrews-Carson rating of approximately 198/200 [11]. Overall, 41 (97.6%) out of 42 elbows with medial or lateral epicondylitis that were unresponsive to long-term conservative treatments were managed successfully using a mini-open muscle resection procedure under local anesthesia [25]. Most patients with proximal bony ulnar collateral ligament avulsion fractures of the pediatric medial epicondyle return to activities at about 3 months without surgery with excellent elbow range of motion and Timmerman-Andrews's score, regardless of union or nonunion [15].

Other Considerations: Surgical intervention for refractory medial epicondylitis is associated with a high success rate, with patients generally demonstrating an improvement in patient-reported outcomes and an encouraging number returning to work with limited complications [16]. Surgical management can be successful in athletes who sustain more significant trauma, who have elbow laxity or instability, or who have significant fracture fragment displacement regarding medial epicondyle fractures [5]. The procedure of fragment excision and ligament repair for valgus instability of the elbow due to medial epicondyle nonunion is associated with rapid restoration of elbow stability, minimal surgical morbidity, a high rate of patient satisfaction, and an improvement in objective elbow scores [17]. Partial resection of the triceps medial head resolved the snapping phenomenon and pain with full recovery in a case of dislocation of the medial head of the triceps with ulnar nerve location anterior to the medial epicondyle [140].

Key Evidence

• [L4] Percutaneous common flexor origin release of medial humeral epicondyle in golfer's elbow appears to be a safe and effective treatment option and provides significant and sustainable improvements in pain and function during a 1-year follow-up period. [1] (10.1016/j.rboe.2016.06.007)
• [L4] The arthroscopic release of contractures is a predictable technique to achieve a highly functional elbow in athletes. [4] (10.1177/0363546510376727)
• [L4] Surgical management can be successful in athletes who sustain more significant trauma, who have elbow laxity or instability, or who have significant fracture fragment displacement. [5] (10.1177/0363546513480797)
• [L5] At 15 months, right elbow range of motion was measured at 0° to 135° of flexion equaling that of the uninjured extremity. [6] (10.1016/s0363-5023(05)80060-7)
• [L4] This technique may offer advantages over traditional medial epicondylectomy by preserving elbow stability and enabling early active range of motion during the postoperative period. [7] (10.1016/j.jhsg.2025.100809)
• [L4] Good postoperative objective results were reached by partial medial epicondylectomy. [8] (10.1007/s00402-010-1160-x)
• [L4] The results of release of the flexor muscle for patients with medial epicondylitis alone were comparable with previously reported results, but the outcome was unsatisfactory for patients with coexistent ulnar neuritis. [9] (10.2106/00004623-199509000-00014)
• [L4] With careful diagnosis and exclusion of other elbow problems, treatment with arthroscopic debridement and focused rehabilitation is highly successful and allows these athletes to return to their previous level of play. [10] (10.1177/0363546505281917)
• [L4] In a review of 21 elbow operations in 17 patients who underwent a percutaneous release, 20 of 21 elbows resumed normal function and had an Andrews-Carson rating of approximately 198/200. [11] (10.1097/00132589-200112000-00003)
• [L5] Early recognition after elbow injury and careful attention to soft tissue repair during lateral elbow surgery may diminish the incidence of this condition. [13] (10.1016/j.csm.2004.06.010)
• [L5] Most complete triceps tendon injuries should be managed with surgical repair, which offers a predictable return of function with a small risk of loss of elbow motion. [14] (10.1016/j.hcl.2015.06.010)
• [L4] Most patients return to activities at about 3 months without surgery with excellent elbow range of motion and Timmerman-Andrews's score, regardless of union or nonunion. [15] (10.1177/2325967125s00095)
• [L4] Surgical intervention for refractory medial epicondylitis often has a high success rate with patients generally demonstrating an improvement in patient-reported outcomes and an encouraging number returning to work with limited complications. [16] (10.1177/03635465221095565)
• [L4] The procedure is associated with rapid restoration of elbow stability, minimal surgical morbidity, a high rate of patient satisfaction, and an improvement in objective elbow scores. [17] (10.1067/mse.2002.126206)
• [L5] Elbow arthroscopy has become a safer and more effective treatment modality for several elbow pathologies due to advances in equipment and surgical technique. [18] (10.5435/00124635-200810000-00003)
• [L3] A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable. [19] (10.1177/2325967121s00275)
• [L4] Increasing elbow flexion has been shown to place the medial elbow in a position to carry a greater amount of load, which may be exacerbated during the final moments of the pitching motion. [20] (10.1177/03635465211072223)
• [L5] Accurate diagnosis requires distinguishing it from other elbow conditions, and treatment is guided by the specific pathologic stage of the tendon. [21] (10.1016/j.csm.2004.04.011)
• [L3] At 1 year after initial presentation, bone union of the medial epicondylar fragmentation was associated with a decreased prevalence of elbow pain. [22] (10.1177/0363546512443807)
• [L4] Even with postoperative immobilization of the elbow (mean of 4 weeks), stiffness is rare. [23] (10.1007/s00402-009-1009-3)
• [L5] At the 1-year follow-up visit, the patient was pain free and had symmetric range of motion, elbow stability, and function when compared with his contralateral extremity. [24] (10.2106/jbjs.cc.19.00417)
• [L4] Overall, 41 (97.6%) out of 42 elbows with medial or lateral epicondylitis, which were unresponsive to long-term conservative treatments, were managed successfully. [25] (10.4055/cios.2009.1.3.123)
• [L4] Most recommendations for management of the ulnar nerve are based on retrospective reviews, anecdotal reports, and expert opinion rather than definitive data. [27] (10.2106/jbjs.f.00594)
• [L2] Throwing alone does not appear to change the morphology of the lateral elbow outside of an injured elbow. [28] (10.1097/corr.0000000000001468)
• [L5] Physical examination of the elbow is a critical component in formulating an accurate diagnosis. [29] (10.5435/jaaos-d-16-00622)
• [L4] A subset of pediatric patients with persistent stiffness following medial epicondyle fractures may benefit from additional interventions, including intensive therapy, transposition of the ulnar nerve, and open capsular release. [30] (10.1016/j.jhsg.2023.07.002)
• [L4] [34] (10.1177/03635465211016839)
• [L5] Adequate elbow assessment is essential for accurate diagnosis and initiating proper treatment, as isolated elbow injuries are rare and fractures should be interpreted as proxies for associated soft tissue injuries. [35] (10.1016/j.jhsa.2014.04.028)
• [L5] Rehabilitation following elbow injury or surgery follows a sequential and progressive multiphased approach with the ultimate goal of returning the athlete to the previous functional level as quickly and safely as possible. [36] (10.1016/j.csm.2004.06.006)
• [Case_report] Incarceration of the medial epicondyle in the joint often occurs in association with an elbow dislocation and is important to consider to avoid diagnostic mistakes. [37] (10.1016/j.jse.2011.09.030)
• [L5] The article outlines indications and a technique for medial epicondylectomy, noting that 12 studies have confirmed success rates between 72% and 94%. [38] (10.1016/j.hcl.2007.06.002)
• [L2] The prognosis for medial epicondylitis in this population was good with a 3-year recovery rate at 81%. [39] (10.1097/01.jom.0000085888.37273.d9)
• [L5] [41] (10.5435/jaaos-20-04-223)
• [L5] Controversy regarding imaging modality, displacement measurement accuracy, and surgical indications still exist. [42] (10.1097/bpo.0000000000000902)
• [L4] [46] (10.1016/j.jse.2015.03.017)
• [L4] [47] (10.1016/j.jse.2004.07.007)
• [L5] This article reviews the anatomy, biomechanics, pathophysiology, diagnosis, and treatment options for ulnar collateral ligament injuries in overhead athletes, emphasizing that the injury is not uncommon and results from repetitive valgus forces during throwing. [49] (10.1016/j.csm.2004.05.002)
• [L3] Use of a washer did not affect the need for subsequent implant removal or elbow ROM after fixation of pediatric medial epicondyle fractures, even in thinner patients or competitive athletes. [51] (10.1177/2325967119s00184)
• [L5] [52] (10.5435/JAAOS-D-14-00145)
• [L4] Surgical correction of elbow flexion contractures in pediatric patients through an anterior approach leads to a satisfactory result in the majority of cases, with a low incidence of complications. [54] (10.1016/j.jse.2020.01.081)
• [L3] MRI from our institution was able to identify the cause of medial elbow pain in 20 (95%) of 21 throwing athletes. [56] (10.1016/s1058-2746(95)80208-8)
• [L4] It can be of value alongside 3-dimensional imaging in evaluating elbow injuries and used as an adjunct in clinical decision making. [57] (10.1016/j.jse.2021.12.039)
• [Paper] [58] (10.1016/j.hcl.2007.11.013)
• [L4] Elbow dislocations associated with fractures of the medial epicondyle with intra-articular entrapment can be difficult to diagnose in the acute phase, and thus a high level of suspicion is required. [61] (10.1016/j.jse.2012.11.009)
• [L4] Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures. [63] (10.1007/s11832-009-0192-7)
• [L4] Nonoperative treatment may be appropriate for minimally displaced cases. [64] (10.1177/23259671251365974)
• [L4] [65] (10.1177/036354659202000319)
• [L4] There was no ulnar nerve palsy, no ulnar nerve subluxation, or medial elbow instability, although 45% of patients reported mild pain at the 6-month followup. [67] (10.1097/01.blo.0000201153.36948.29)
• [L4] [68] (10.1177/2325967119885608)
• [Case_report] This case demonstrates the successful management of a failed medial epicondyle nonunion ORIF with revision ORIF using an interposition distal clavicle autograft with preservation of the medial epicondyle and MUCL. [69] (10.1016/j.xrrt.2026.100671)
• [L4] Examination (manipulation) under anesthesia can be a valuable adjunctive procedure to help regain the motion obtained at the time of surgical release. [70] (10.1016/j.jse.2009.07.060)
• [L5] Recent advantages in arthroscopic surgical techniques and ligament reconstruction in the elbow have improved the prognosis for return to competition for the highly motivated athlete. [71] (10.1177/03635465030310042601)
• [L4] [72] (10.1016/0020-1383(88)90109-x)
• [L5] [76] (10.1016/j.csm.2004.06.003)
• [L4] At an average of 6.3 years after surgery, the clinical outcomes for medial epicondyle fracture were excellent. [98] (10.1016/j.jhsg.2021.02.006)
• [L4] Shoulder flexibility, arm speed, and elbow varus torque are interrelated and should be considered collectively when treating pitchers. [102] (10.1177/0363546517719047)
• [L3] The late cocking phase appears to be the critical point in the pitching motion, where higher levels of torque at the shoulder and elbow can result in increased risk of injury. [103] (10.1177/0363546510363402)
• [L5] [104] (10.1016/j.csm.2004.04.008)
• [L4] [105] (10.1016/j.jhsa.2022.02.008)
• [L4] [106] (10.2106/00004623-198062060-00016)
• [L5] [108] (10.1016/j.jhsa.2021.11.026)
• [L3] High elbow varus torque would increase the risk of medial elbow disorder. [109] (10.1177/2325967121s00748)
• [L3] The greatest shoulder and elbow peak forces occurred in pitchers with 15° to 25° contralateral trunk tilt (three-quarter arm slot). [110] (10.1177/03635465231151940)
• [L4] Players with a history of medial elbow injury exhibited harder forearm flexor-pronator muscle elasticity at baseline and during repetitive pitching compared to those without injury history. [111] (10.1016/j.jse.2022.07.032)
• [L2] Fragmentation of the medial epicondyle may contribute to compromised medial elbow dynamic stability in adult baseball players. [113] (10.1016/j.xrrt.2026.100680)
• [Paper] [116] (10.1097/00130911-200312000-00010)
• [L4] Good pain control can be achieved during all steps of the procedure. [118] (10.1177/17531934241252518)
• [Paper] [119] (10.1016/j.csm.2020.02.001)
• [L3] MRI abnormalities involving the medial aspect of the elbow are common in year-round Little League baseball players, especially those with internal rotation deficits and private coaches. [120] (10.2106/jbjs.15.01017)
• [L3] Pitch velocity was significantly associated with abnormality of the medial epicondyle and elbow pain. [121] (10.1177/0363546520914911)
• [L5] The throwing elbow is a common source of nerve injuries due to the unique combination of anatomy, high forces, and sheer repetition associated with throwing sports. [122] (10.1016/j.csm.2004.04.012)
• [L4] Although spin rate has become a popular topic in modern pitching strategies and analyses, this study found no significant relationship between spin rate and elbow varus torque across pitch types, suggesting that spin rate alone may not be a reliable predictor of elbow torque or injury. [123] (10.1177/03635465241309316)
• [L4] Epicondylitis is a common upper-extremity musculoskeletal disorder most prevalent in individuals aged 40-60 years, affecting women more frequently than men. [125] (10.1016/j.berh.2011.01.013)
• [L5] [131] (10.1016/j.arthro.2009.09.017)
• [L2] Dominant elbow MRI abnormalities are common in asymptomatic youth baseball players. [132] (10.1177/0363546519888647)
• [L4] [133] (10.1097/mop.0000000000000181)
• [L3] The radiographic classification of persistent olecranon physis is useful for treatment decision making. [134] (10.1177/0363546509342677)
• [L3] [137] (10.1016/j.jse.2022.09.018)
• [L4] Open reduction internal fixation of incarcerated medial epicondyle fractures after elbow dislocation leads to satisfactory motion and function; however, the injury carries a high risk for complications, particularly ulnar neuropathy. [138] (10.1016/j.jhsa.2014.06.012)
• [L4] Partial resection of the triceps medial head resolved the snapping phenomenon and pain with full recovery. [140] (10.1016/j.jhsa.2019.03.005)
• [L4] Emphasis was placed on the importance of early diagnosis of venous thrombosis and immediate institution of anticoagulant therapy. [141] (10.1016/0020-1383(75)90079-0)
• [L4] The preliminary results are comparable with other epicondylectomy techniques with lower complication rates. [144] (10.1007/s00402-012-1599-z)
• [L3] Finally, there was no statistically significant difference in incidence of complications between the two groups. [146] (10.1097/bpb.0000000000000584)

See Also

• Golfer's Elbow
• Elbow Arthroscopy
• Ligament Injuries
• Elbow Instability
• Cubital Tunnel Syndrome
• Olecranon Fracture

References

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