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This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Percutaneous common flexor origin release of the medial humeral epicondyle is a safe and effective treatment option for golfer's elbow [3].
• Percutaneous common flexor origin release provides significant and sustainable improvements in pain and function during a 1-year follow-up period [3].
• Arthroscopic debridement and focused rehabilitation for posterolateral elbow impingement from lateral synovial plicae is highly successful in throwing athletes and golfers [4].
• Arthroscopic treatment of posterolateral elbow impingement allows athletes to return to their previous level of play [4].
• Medial epicondylectomy has confirmed success rates between 72% and 94% across 12 studies [41].

Anatomy & Pathophysiology¶

Bony Anatomy¶

• The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [51].
• The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [51].
• The ulnohumeral joint provides highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area on the greater sigmoid notch devoid of cartilage [51].
• The coronoid process has medial and lateral facets that buttress the trochlea anteriorly [51].
• The sublime tubercle is located just distal and medial to the coronoid process and serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [51].
• The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle and forms the attachment site for the origins of the flexor pronator mass [51].
• The radiocapitellar joint is formed by the articulation of the capitellum and radial head [51].
• The proximal radioulnar joint holds the radius in close approximation to the ulna via the annular ligament [51].
• The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [51].
• The distal humeral articulation is angled 30° from the longitudinal axis of the humerus [51].
• The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [51].
• The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [51].
• The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [51].
• The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [24].
• The normal range of elbow flexion/extension is 0 to 150 degrees [24].
• The normal range of forearm pronosupination is 80 to 85 degrees in each direction [24].
• The functional range of motion for the elbow is 30 to 130 degrees for flexion/extension and 50 degrees for pronosupination [24].
• The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [24].
• In full extension, 60% of axial load is transmitted through the radiocapitellar joint [24].
• The trochlea has a 300-degree arc of cartilage [54].
• The medial column of the distal humerus diverges from the humeral shaft at a 45-degree angle [54].
• The lateral column of the distal humerus diverges from the humeral shaft at a 20-degree angle [54].

Ligamentous Anatomy¶

• Elbow stability is determined by primary stabilizers (ulnohumeral articulation, medial ulnar collateral ligament, lateral ulnar collateral ligament) and secondary stabilizers (radiocapitellar articulation, common flexor tendon, common extensor tendon, joint capsule) [17].
• The medial collateral ligament complex comprises the anterior oblique, posterior oblique, and transverse ligaments [71].
• The anterior oblique ligament is the strongest component of the medial collateral ligament complex and is the primary stabilizer to valgus stress [71].
• The anterior oblique ligament originates on the anterior-inferior edge of the medial epicondyle and inserts on the sublime tubercle of the ulna [71].
• The anterior oblique ligament is composed of anterior and posterior bands that provide reciprocal function in resisting valgus stress [71].
• The anterior band of the medial collateral ligament is taut in extension, while the posterior band is tight in flexion [71].
• The anterior bundle of the medial collateral ligament is the primary restraint to valgus stress within functional elbow range of motion [24].
• The posterior bundle of the medial collateral ligament is the primary restraint to valgus stress with the elbow in maximal flexion [24].
• Stability in full extension is provided by the medial collateral ligament, joint capsule, and ulnohumeral articulation [24].
• The medial collateral ligament originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [24].
• The lateral ulnar collateral ligament complex originates at the geometric center of the radiocapitellar articulation, just distal to the lateral epicondyle [51].
• The ulnohumeral articulation contributes to elbow stability, and olecranon resection increases valgus angulation and medial collateral ligament strain during valgus stress [10].

Pathophysiology¶

• Medial epicondylar tendinopathy is a pathology of the flexor-pronator muscle group at its origin overlying the medial epicondyle [31].
• The etiology of medial epicondylar tendinopathy is associated with overuse of the flexor-pronator muscle group [31].
• Histological analysis of medial epicondylar tendinopathy reveals a brief inflammatory period followed by microtearing, collagen architectural disruption, an incomplete vascular response, and angiofibroblastic degeneration [31].
• Elbow tendinopathy is a tendon degeneration resulting from continued microtrauma and failed attempts at healing rather than an inflammatory condition [28].
• Valgus torque generated at the elbow during throwing maneuvers is highest in the late cocking and early acceleration phases of throwing [71].
• During throwing, the olecranon is repeatedly and forcefully driven into the olecranon fossa, exerting shear forces on the medial aspect of the olecranon tip and the olecranon fossa [10].
• This process may cause cartilage injury and the development of osteophytes [10].
• Medial ligamentous laxity commonly exacerbates valgus extension overload syndrome [10].
• The pathoanatomy of valgus extension overload syndrome includes chondrosis, osteophyte development on the posteromedial olecranon and humerus, and loose bodies [10].
• The flexor-pronator mass dynamically stabilizes the elbow against valgus torque [62].
• The medial elbow joint space is significantly reduced under 60-N valgus stress plus 50% maximum voluntary contraction compared to 60-N valgus stress alone [63].
• Incorporating the pronator teres into contraction tasks significantly reduces the medial joint space, emphasizing the role of the pronator teres in elbow joint stability [64].
• Repetitive baseball pitching reduces elbow valgus stability, attributed to decreased flexor-pronator mass contractile function [97].
• Fragmentation of the medial epicondyle may contribute to compromised medial elbow dynamic stability in adult baseball players [93].
• High elbow varus torque increases the risk of medial elbow disorder [82].
• A reduction in proximal Hounsfield Unit values of the ulnar collateral ligament may reflect localized structural attenuation that is functionally relevant to medial elbow stability [44].
• The valgus-hyperextension overloading of the elbow during throwing causes repetitive microtrauma and shear stresses to the medial elbow at the medial epicondyle physis, ulnar collateral ligament, and flexor pronator origin [67].
• The surrounding elbow musculature, specifically the flexor digitorum superficialis and flexor carpi ulnaris, provide a dynamic stabilizing force across the elbow joint and may be protective of the static restraint of the medial collateral ligament [71].

Classification¶

• The Copenhagen Classification of Distal Humeral Fractures (CCDHF) is a classification system designed to distinguish fractures that may not be suitable for open reduction and internal fixation (ORIF) and require treatment with elbow hemiarthroplasty (EHA) or total elbow arthroplasty (TEA) [114].
• The primary objective of the Copenhagen Classification of Distal Humeral Fractures is to identify patients who may require treatment at a specialized tertiary center where EHA and TEA are available [114].
• The Wrightington classification system is a tool for characterizing the majority of elbow-fracture dislocations and guiding surgical interventions [56].
• Accurate diagnosis of medial epicondylitis requires distinguishing it from other elbow conditions, and treatment is guided by the specific pathologic stage of the tendon [9].
• In a systematic review of medial epicondylitis, elbows were classified as either type Ia/Ib (n = 287; 64.5%) or type IIa/IIb (n = 158; 35.5%) using Gabel-Morrey scoring [21].
• Concomitant ulnar neuritis was described in 169 elbows (38.0%) in a systematic review of medial epicondylitis where data were available on 445 elbows (92.9%) [21].
• The most common topic in the contemporary group of the top 100 classical and contemporary papers on elbow surgery was lateral epicondylitis and medial epicondylitis and associated therapies [13].
• Identification of injury patterns in pediatric humeral medial epicondyle fractures is a key first step in understanding the variability in clinical outcomes with different management strategies for medial elbow injuries [27].

Clinical Presentation¶

History and Symptoms¶

• Patients with medial elbow tendinopathy report a gradual onset of elbow pain localized to the medial epicondyle and over the flexor pronator muscle mass [20].
• Pain is increased with the offending activity such as throwing or playing golf [20].
• In the overhead throwing athlete, pain occurring during the acceleration phase over the medial elbow may indicate medial epicondylosis [31].
• Patients typically present with persistent medial-sided elbow pain that is often localized to the medial epicondyle, with radiation into the proximal forearm [40].
• Elbow pain is exacerbated by activity and is particularly bothersome during the late cocking phase in overhead throwing or during early acceleration for the thrower, tennis player, or golfer [40].
• Patient history may include an acute traumatic blow to the elbow resulting in an avulsion of the common flexor tendon [40].
• More commonly, the pain is characterized by an insidious onset, with persistence despite rest [40].
• The pain associated with medial epicondylosis is typically insidious in nature and is made worse with specific activities or upper extremity motions for throwing and swinging [31].
• A history of fluoroquinolone use is associated with increased rates of tendinopathy and rupture [31].
• Medial epicondylitis is commonly found in occupational settings involving repetitive forceful grip, manual handling of loads 44 lbs (20 kg), or exposure to constant vibratory forces at the elbow [40].
• In the athlete, medial epicondylitis is typically associated with overhead throwing, golf, or tennis [40].
• In the literature, medial epicondylitis has been associated with other sports, including football, weightlifting, and bowling [40].
• The hallmark activity for most medial elbow apophysitis in adolescents is youth baseball [74].
• A history of repetitive throwing, often year-round or on more than one team, as well as overrepresentation of symptoms in the pitching and catching positions is common in medial elbow apophysitis [74].
• Poor form and lower-body mechanics during transitional growth years may contribute to an increased valgus position during throwing that increases symptoms in medial elbow apophysitis [74].
• Pain during and after throwing at the medial elbow is seen in medial elbow apophysitis [74].
• A large majority of patients with medial epicondyle apophyseal avulsion fractures reported medial elbow pain prior to fracture [15].
• Medial-sided elbow pain encompasses a significant differential diagnosis, including ulnar neuritis, tendinopathy, ligamentous instability, intra-articular pathology, and trauma [40].
• Accurate diagnosis of medial epicondylitis requires distinguishing it from other elbow conditions [9].
• Medial elbow pain is uncommon and requires a broad differential diagnosis including ulnar nerve disorders, cervical radiculopathy, and ligament injuries [19].
• The patient’s history is critical to differentiating medial epicondylosis from other pathologies on the medial side of the elbow such as valgus extension overload, ulnar neuritis, UCL injury, or even cervical radiculopathy [31].

Physical Examination¶

• Physical examination typically reveals tenderness over the flexor pronator origin anterior and distal to the medial epicondyle [20].
• Pain and weakness on resisted pronation of the forearm have been found to be the most sensitive physical examination findings for medial elbow tendinopathy [20].
• Pain can also be reproduced with resisted wrist flexion in medial elbow tendinopathy [20].
• Grip strength can be decreased in medial elbow tendinopathy [20].
• Focused examination of the medial elbow generally yields pain to palpation over the medial epicondyle [31].
• Pain with resisted forearm pronation has been described as the most sensitive examination finding for medial epicondylosis [31].
• Physical examination may detect tenderness 5 to 10 mm distal and anterior to the medial epicondyle that is accompanied by soft-tissue swelling [40].
• Resisted wrist flexion, forearm pronation, or forceful grip may be weakened compared with that of the contralateral side and may exacerbate elbow pain [40].
• Patients may present with elbow flexion contracture secondary to pain and guarding [40].
• Most patients present with normal passive and active range of motion at the elbow and wrist [40].
• The examination of the athlete with medial elbow pain should include a complete evaluation of the integrity of the ulnar collateral ligament and assessment for ulnar neuritis [20].
• Ulnar neuritis has been reported in up to 60% of patients ultimately requiring surgery for medial epicondylitis [20].
• Patients should be evaluated for ulnar neuritis in the setting of medial epicondylosis as 60% of patients requiring surgery have concomitant ulnar neuritis [31].
• Direct tenderness over the epicondyle is seen in medial elbow apophysitis [74].
• Tenderness to medial flexor muscle palpation is seen in medial elbow apophysitis [74].
• Pain with valgus testing is usually less than with direct palpation in medial elbow apophysitis [74].
• The patient may occasionally present with loss of full elbow extension in medial elbow apophysitis [74].
• The location, quality or type, context, duration, and severity of elbow pain are important to understanding patients’ pathology and focus the physical examination [68].
• It is extremely helpful to determine the symptom trajectory, that is, if the pain is getting better, worse, or remaining constant over a period of time [68].

Imaging¶

• Plain radiographs are typically normal in medial epicondylitis, although calcifications can sometimes be seen adjacent to the medial epicondyle [20].
• Plain radiographs of the elbow should always be performed as part of the workup for the etiology of medial-sided elbow pain [31].
• Given the older age of presentation of most cases of medial epicondylosis, plain radiographs are helpful to rule out arthritis as a possible source of pain [31].
• A proper diagnosis of medial epicondylosis does not necessarily require advanced imaging [31].
• Ultrasonography and MRI have the added ability to evaluate the surrounding soft tissues as well as demonstrate objective findings consistent with medial epicondylosis [31].
• Ultrasonography has a sensitivity of 95% and specificity of 92% in the diagnosis of clinical medial epicondylitis [20].
• The most common positive ultrasonographic findings in patients with medial epicondylitis were focal hypoechoic regions demonstrating tendinopathy, focal anechoic areas indicating partial common flexor tendon tears, cortical irregularities, and tendon thickening [20].
• Ultrasonography has a sensitivity of 95% and specificity of 92% with focal hypoechoic areas and intratendinous calcifications representing the typical findings during evaluation of medial epicondylosis [31].
• MRI has been described as the standard of care for radiographic diagnostic purposes and is extremely helpful if trying to rule out or identify concomitant pathology in medial epicondylosis [31].
• When reviewing MRI scans for medial epicondylosis a positive finding on the T2-weighted sequence will likely demonstrate intermediate to high signal intensity within the proximal flexor-pronator mass [31].
• Compared with age-matched control patients, the most specific MRI findings for medial epicondylitis are the presence of intermediate to high T2-weighted signal intensity or high T2-weighted signal intensity within the common flexor tendon and the presence of paratendinous soft-tissue edema [20].
• The epicondyle may enlarge, exhibit distal traction related avulsive changes, or may have increased apophyseal cartilage width in medial elbow apophysitis [74].
• While an MRI is often not indicated in the absence of an acute event, edema at the medial epicondyle or sublime tubercle, and occasionally periosteal thickening or layering, may be seen in medial elbow apophysitis [74].

Investigations¶

Clinical Evaluation¶

• Patients with medial elbow tendinopathy report a gradual onset of pain localized to the medial epicondyle and over the flexor pronator muscle mass [20].
• Pain in medial elbow tendinopathy is increased with offending activities such as throwing or playing golf [20].
• Physical examination for medial elbow tendinopathy typically reveals tenderness over the flexor pronator origin anterior and distal to the medial epicondyle [20].
• Pain and weakness on resisted pronation of the forearm are the most sensitive physical examination findings for medial elbow tendinopathy [20].
• Pain in medial elbow tendinopathy can be reproduced with resisted wrist flexion [20].
• Grip strength can be decreased in patients with medial elbow tendinopathy [20].
• The examination of an athlete with medial elbow pain should include a complete evaluation of the integrity of the ulnar collateral ligament [20].
• The examination of an athlete with medial elbow pain should include an assessment for ulnar neuritis [20].
• Treatment of medial epicondylitis is guided by the specific pathologic stage of the tendon [9].
• The physical exam for the elbow is directed by history and the location of the patient's pain in the anterior, posterior, medial, or lateral aspect of the elbow [17].
• Pathologic entities associated with discrete elbow compartments aid the examiner in detecting pathologic conditions [17].
• Patients with valgus extension overload syndrome report posteromedial elbow pain that occurs during the deceleration phase of throwing as the elbow reaches terminal extension [10].
• Pain in valgus extension overload syndrome may also occur during the acceleration phase of throwing [10].
• Loss of terminal elbow extension may occur in valgus extension overload syndrome [10].
• Crepitus and tenderness over the posteromedial olecranon may be noted in valgus extension overload syndrome [10].
• Pain in valgus extension overload syndrome is reproduced when the elbow is forced into extension [10].
• Elbow flexion contracture may be seen in valgus extension overload syndrome [10].
• The evaluation of elbow joint instability using fluoroscopy during surgery proved to be valuable for understanding pathology and assessing treatment effectiveness in a case of pediatric medial epicondyle fracture [7].
• 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 [33].

Imaging¶

• Ultrasonography has a sensitivity of 95% and specificity of 92% for the diagnosis of clinical medial epicondylitis [20].
• The most common positive ultrasonographic findings in patients with medial epicondylitis are focal hypoechoic regions demonstrating tendinopathy, focal anechoic areas indicating partial common flexor tendon tears, cortical irregularities, and tendon thickening [20].
• Ultrasonography is recommended as an initial imaging method for the diagnosis of clinical medial epicondylitis [120].
• The most specific MRI findings for medial epicondylitis are the presence of intermediate to high T2-weighted signal intensity or high T2-weighted signal intensity within the common flexor tendon and the presence of paratendinous soft-tissue edema [20].
• AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [10].
• CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [10].
• MRI may be most helpful in evaluating associated injuries including partial or complete tears of the MCL in valgus extension overload syndrome [10].
• Radiographs of the elbow should be obtained if the patient has acute traumatic injury or chronic pain [57].
• CT can be helpful in identifying mineralized intra-articular loose bodies or delineating the anatomy of a complex intra-articular fracture [57].
• Ultrasonographic soft-tissue evaluation in the elbow is most useful in evaluating the distal biceps and the common flexor and extensor tendons [57].
• Ultrasonography allows dynamic imaging, which may be useful in evaluating for ulnar nerve subluxation or a snapping triceps [57].
• MRI is the imaging modality best suited for evaluating soft-tissue structures in the elbow including ligaments, tendons, cartilage, and nerves [57].
• Conventional MRI sequences should be obtained in all three planes using T1-weighted and fluid-sensitive sequences (short tau inversion recovery or T2-weighted sequences with fat suppression) [57].
• Magnetic resonance arthrography (MRA) is particularly beneficial in the evaluation of osteochondral lesions, loose bodies, and ulnar collateral ligament (UCL) injury in a throwing athlete [57].
• Coronal MRI studies should be obtained along a line connecting the medial and lateral epicondyles [57].
• Sagittal MRI studies should be perpendicular to the coronal studies [57].
• MRI units with a 3-Tesla magnetic field strength can generate high signal-to-noise ratios and are more able to show normal anatomy than a 1.5-Tesla unit [57].
• Caution is necessary with 3-Tesla imaging because it can show mild signal alterations of tendons, ligaments, and nerves of the elbow that may not be symptomatic [57].
• Ligaments and tendons appear anechoic (black) on all MRI imaging sequences [57].
• With tissue remodeling or degeneration, the signal increases on all MRI sequences [57].
• Tears are diagnosed on MRI by identifying signal in the tissue that brightens to the level of simple fluid, representing focal discontinuity of tendon or ligament fibers [57].
• Partial tears on MRI are described by identifying whether the involved pathology occurs at the articular side, intrasubstance, or involves superficial fibers [57].
• Both partial-thickness and full-thickness tears on MRI should identify whether failure occurs proximally, mid-substance, or distally [57].
• A combined approach with both MR arthrography and US shows higher accuracy than each modality alone for the assessment of medial elbow pain [79].
• There is substantial variation in imaging practices across the United States when diagnosing a medial epicondyle fracture [111].
• CT scans are more likely to be used in smaller cities and older children when diagnosing a medial epicondyle fracture [111].
• MRI is more likely to be used in smaller hospitals and younger children when diagnosing a medial epicondyle fracture [111].
• A reduction in proximal Hounsfield Unit values on CT may reflect localized structural attenuation that is functionally relevant to medial elbow stability [44].
• Providers should take information regarding radiographs missing the real injury into consideration when evaluating medial epicondyle elbow pain in skeletally immature patients [36].
• Radiographs should always be obtained for the evaluation of elbow stiffness [26].
• AP, lateral, and oblique radiographs are standard for the evaluation of elbow stiffness [26].
• Serial radiography is used as follow-up when heterotopic ossification is present in elbow stiffness [26].
• CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies in elbow stiffness [26].
• Three-dimensional CT is used to check for heterotopic ossification in elbow stiffness [26].
• CT is not necessary when elbow stiffness is entirely soft-tissue related [26].
• CT is beneficial when any joint incongruity or abnormal bony anatomy is present in elbow stiffness [26].
• MRI can be used to evaluate ligaments and tendons in elbow stiffness, but it is rarely indicated [26].
• Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists in the evaluation of elbow stiffness [26].
• An assessment for ulnar nerve subluxation should be performed in the evaluation of elbow stiffness [26].

Treatment¶

Non-Operative Management¶

• Nonsurgical treatment for elbow tendinopathy is successful in most cases, with surgical intervention reserved for patients with continued symptoms after 6 months or more of treatment [28].
• Rest and activity modification are paramount in the nonsurgical management of elbow overuse disorders [28].
• The current literature provides no definitive recommendations regarding the efficacy of nonsurgical interventions for elbow tendinopathy [28].
• Regardless of the specific nonsurgical treatment type used, most symptoms improve [28].
• For valgus extension overload syndrome, nonsurgical treatment includes activity modification with a period of rest from throwing, intra-articular corticosteroid injections, NSAIDs, and a course of dedicated flexor-pronator muscle strengthening [10].
• Pitching instruction should be started to correct flaws in pitching technique that may contribute to valgus extension overload syndrome [10].
• For nondisplaced or minimally displaced medial epicondyle fractures (<2 mm) in upper extremity athletes, immobilization in a posterior splint, long-arm cast, or sling for 1 to 2 weeks followed by early active range-of-motion exercises is recommended [85].
• Following initial immobilization for nondisplaced medial epicondyle fractures, a physical therapy program focusing on strengthening of shoulder, elbow, and wrist muscles associated with throwing should begin at 3 to 4 weeks [85].
• Wrist flexor strengthening should be avoided for 6 to 8 weeks and any motion causing a valgus moment should be avoided during the rehabilitation of nondisplaced medial epicondyle fractures [85].
• A throwing program can be initiated at 8 to 12 weeks for nondisplaced medial epicondyle fractures based on radiographic and clinical healing, with no throwing permitted until the fracture site is pain-free [85].
• Nonoperative treatment may be appropriate for minimally displaced medial epicondylar apophyseal avulsion fractures in youth throwers [116].
• The outcome of non-operative treatment for medial epicondyle fractures is usually satisfactory, as even a fibrous union is compatible with excellent function [112].

Operative Management: Indications and General Principles¶

• Surgical intervention for valgus extension overload syndrome is indicated for patients who continue to have symptoms despite nonsurgical treatment [10].
• MCL insufficiency is a relative contraindication for isolated olecranon débridement in the treatment of valgus extension overload syndrome [10].
• Careful evaluation of possible concomitant MCL injury is required before treating valgus extension overload, as treating secondary effects of MCL insufficiency without addressing the underlying MCL pathology leads to unsatisfactory results and increased revision surgery rates [10].
• Surgical management can be successful in athletes who sustain more significant trauma, have elbow laxity or instability, or have significant fracture fragment displacement in the setting of medial epicondyle fractures [23].
• Operative treatment of recalcitrant medial epicondylitis is effective in restoring patient function and strength [43].
• Open and arthroscopic techniques are very effective and comparable for treating chronic medial epicondylitis [46].
• Arthroscopic surgical treatment for medial epicondylitis of the elbow provides good outcomes and is safe and effective [61].
• 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 [3].
• A mini-open muscle resection procedure under local anesthesia for lateral and medial epicondylitis unresponsive to long-term conservative treatments was managed successfully in 41 (97.6%) out of 42 elbows [86].
• Surgical outcomes for arthroscopic posteromedial decompression of valgus extension overload are generally good, with a cited return to sport rate between 68% and 85% [10].
• Overaggressive olecranon resection during treatment of valgus extension overload may result in valgus instability of the elbow [10].
• To prevent increased strain on the MCL during valgus extension overload surgery, it is important to remove only the osteophyte and not the normal olecranon [10].
• With careful diagnosis and exclusion of other elbow problems, treatment with arthroscopic debridement and focused rehabilitation for posterolateral elbow impingement is highly successful and allows athletes to return to their previous level of play [4].
• The evaluation of elbow joint instability using fluoroscopy during surgery proved to be valuable for understanding pathology and assessing the effectiveness of treatments in pediatric medial epicondyle fractures with ligament injury [7].
• Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures [94].
• The procedure of 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 [11].

Operative Management: Specific Procedures¶

• Surgical procedures for valgus extension overload include diagnostic elbow arthroscopy, removal of osteophytes on the posteromedial aspect of the olecranon, removal of loose bodies, and débridement of chondromalacia [10].
• The authors present a surgical technique for arthroscopic extra-articular ulnar nerve release in the setting of stiff elbow applicable to posteromedial elbow pathology by 2 medial portals [6].
• Surgical techniques currently used for MCL reconstruction include the modified Jobe technique, the docking technique, and the hybrid interference screw technique [10].
• A muscle-splitting approach is preferred for MCL reconstruction to limit morbidity to the flexor-pronator mass [10].
• Ulnar nerve transposition is reserved for patients with subluxating nerves or motor weakness in the context of MCL injuries [10].
• Smith et al proposed treatment of chronic medial epicondyle nonunion by open reduction of the fragment with excision of the fibrinous nonunion tissue and screw fixation with a 3.5 mm or 4.5-mm screw [84].
• The technique of open reduction and screw fixation for chronic medial epicondyle nonunion is technically challenging because the bony fragment is often too small for this fixation method [84].
• Five patients required a second procedure for implant removal following the technique of open reduction and screw fixation for chronic medial epicondyle nonunion [84].
• A suture-augmented lateral ulnar collateral ligament and radial collateral ligament reconstruction provides a reproducible, anatomically based construct that restores posterolateral elbow stability and addresses the complex spectrum of lateral-sided injuries observed in PLRI [29].
• Strut allograft augmentation restores bone stock in revision elbow arthroplasty, but survivorship free of revision with death as competing risk approaches 75% at 10 years [14].
• Humeral implants of 10 cm-length could be privileged as first intention implant regardless of the indication for total elbow arthroplasty if there is no imperative to use a longer stem [101].
• Total elbow arthroplasty is best reserved for low demand, elderly patients who will be able to comply with the 5-lb weightlifting restriction imposed postoperatively to protect the implants from bearing wear, hardware loosening, or failure [75].
• Open or arthroscopic débridement may be effective in the treatment of early arthritis of the elbow [75].
• Interposition arthroplasty or total elbow arthroplasty is best reserved for more advanced cases of elbow arthritis [75].
• Elbow arthrodesis is reserved for patients with painful arthritis who are not candidates for total elbow arthroplasty, especially individuals who place high demands on the upper extremities, such as manual laborers [70].
• For unilateral arthrodesis of the elbow, a position of 90 to 100 degrees of flexion is desirable to provide the most powerful grip strength [70].
• If bilateral elbow arthrodesis is indicated, one elbow should be placed in 110 to 120 degrees of flexion to permit the patient to reach the mouth, and the other should be placed in 45 to 65 degrees to aid in personal hygiene [70].
• For successful elbow arthrodesis, adequate bone stock must be present, although resection of the radial head may be necessary to preserve pronation and supination, and internal or external fixation with bone grafting is typically required [70].
• The result of interposition arthroplasty in untreated chronic dislocation of the elbow is completely satisfactory, achieving the objective of a minimum range of motion of 100 degrees in addition to elbow stability [8].
• Both elbow hemi arthroplasty and total elbow arthroplasty provided acceptable elbow function for irreparable distal humeral fractures [1].

Postoperative Rehabilitation¶

• Postoperatively for chronic medial epicondyle avulsion treated with fragment excision and ligament reconstruction, the patient is immobilized in a posterior 90 splint for 7 to 10 days until their first postoperative visit [84].
• The wrist is not necessary to be immobilized to encourage early range of motion following chronic medial epicondyle avulsion surgery [84].
• Active and active-assisted range of motions are initiated with physical therapy at the first postoperative visit after splint removal for chronic medial epicondyle avulsion [84].
• No further brace or dynamic immobilization device is used after splint removal for chronic medial epicondyle avulsion [84].
• The patient is expected to regain full range of motion in the first 3 to 4 weeks after surgery for chronic medial epicondyle avulsion [84].
• Strengthening is initiated at 6 weeks postoperatively for chronic medial epicondyle avulsion [84].
• In overhead throwers, an interval throwing program is started at 6 months postoperatively and progresses over 6 weeks for chronic medial epicondyle avulsion [84].
• Most throwers are able to return to full activities in 6 to 8 months following chronic medial epicondyle avulsion surgery [84].
• The athlete’s arm is placed in a posterior splint with the elbow immobilized at 90° of flexion for the first 7 days postoperatively following UCL reconstruction to allow early healing of the UCL graft and fascial slings involved in the nerve transposition [110].
• Following UCL reconstruction, the athlete is progressed from the posterior splint to a hinged elbow ROM brace to protect the healing tissues from valgus stresses that can be detrimental [110].
• The hinged elbow ROM brace is discontinued at the beginning of week 5 following UCL reconstruction [110].
• The arm is kept in a splint for 1 week in the immediate postoperative period following combined flexor-pronator and UCL injuries [92].
• After 1 week, the elbow is managed in a hinged brace for approximately 3 additional weeks following combined flexor-pronator and UCL injuries, allowing motion from 45° of extension to 90° of flexion [92].
• Motion is slowly advanced to full over the next 5 weeks following combined flexor-pronator and UCL injuries [92].
• Formal physical therapy begins around 6 weeks and the brace is no longer used following combined flexor-pronator and UCL injuries [92].
• Patients typically started an interval throwing program at postoperative month 4 following combined flexor-pronator and UCL injuries [92].
• Players were not allowed to start pitching again competitively until at least 9 months after surgery for combined flexor-pronator and UCL injuries [92].
• The elbow is maintained in a postsurgical dressing with splint for 5 to 7 days following unilateral interposition arthroplasty of the elbow [87].
• After initial immobilization, the patient is given a hinged brace and permitted load-free, active motion following unilateral interposition arthroplasty of the elbow [87].
• Resisted activities, including lifting and pushing, are permitted at 10 to 12 weeks following unilateral interposition arthroplasty of the elbow [87].
• The patient is placed into a well-padded light splint with the elbow at 90 degrees of flexion and the forearm in pronation following operative treatment of elbow dislocations [108].
• Ideally, the dressing is removed and motion begun 48 hours after surgery for elbow dislocations unless static joint fixation has been required [108].
• The elbow should not be immobilized for longer than 2 weeks to avoid excessive stiffness following elbow dislocation surgery [108].
• Active motion is preferred over passive motion following elbow dislocation surgery as this tends to stabilize the elbow [108].
• If the MCL is intact and the LCL requires protection, the forearm should be rehabilitated with the forearm in pronation with prosupination only performed at 90 degrees or greater of flexion [108].
• Varus positioning of the arm should be avoided in patients with LCL injuries and repairs following elbow dislocation surgery [108].
• If the MCL has been injured but not repaired and the LCL is competent, flexion–extension of the elbow should be performed with the forearm maintained in supination [108].
• If both the MCL and LCL have been injured, active range of motion should be initiated with the forearm in neutral position [108].
• Extension is allowed only to the extent that allows congruent tracking intraoperatively following elbow dislocation surgery [108].
• Passive stretching of the elbow is not performed until ligament healing is progressing, typically beginning 6 weeks postoperatively following elbow dislocation surgery [108].
• Light strengthening may be started 6 weeks postoperatively with a formal strengthening program initiated at 3 months following elbow dislocation surgery [108].
• Elbow flexion showed satisfactory recovery on the operated side (135 ± 5°) compared to the contralateral side (138 ± 4°) following biceps brachii tendon reattachment using an adjustable cortical button mechanism, with no statistically significant difference (p 0.212) [91].

Complications¶

Heterotopic Ossification and Stiffness¶

• The reported incidence of heterotopic ossification (HO) after surgical treatment of distal humerus fractures varies from 0% to 49% [98].
• In a retrospective review of 89 consecutive patients with distal humerus fractures, HO was identified in 37 elbows (42%) [98].
• HO was associated with less extension and less overall flexion-to-extension movement after distal humerus ORIF [98].
• Risk factors for elbow stiffness and HO include head injury, polytrauma, severe soft tissue injury, delay to surgical intervention, prolonged postoperative immobilization, and open fractures [98].
• The development of HO was associated with the method of fracture fixation (perpendicular plating > parallel plating) and the use of bone graft or substitute [98].
• Most patients with HO do not experience significant functional deficits, so resection is not always necessary [98].
• Surgical excision of symptomatic HO is associated with significantly better gains in range of motion than release of soft tissue only contractures [98].

Ulnar Collateral Ligament Reconstruction¶

• Complications were found in 20% of a cohort undergoing medial ulnar collateral ligament reconstruction, with 4% being major complications including ulnar nerve injuries, medial epicondyle fractures, and revision surgery for osteophyte formation [109].
• Medial elbow pain during the return-to-throwing period after ulnar collateral ligament reconstruction is not uncommon, with up to half of pitchers potentially experiencing pain [42].

Medial Epicondyle Fractures¶

• A large majority of patients with medial epicondyle apophyseal avulsion fractures reported medial elbow pain prior to the fracture [15].
• At 1 year after initial presentation, bone union of medial epicondylar fragmentation was associated with a decreased prevalence of elbow pain [5].
• In a study of youth overhead athletes treated with open reduction and internal fixation for medial epicondyle fractures, no major surgical complications were reported, although one patient underwent elective hardware removal [118].

Surgical Procedures for Epicondylitis¶

• There were no self-reported differences in complication rates between open (4.4%) and arthroscopic (5.5%) procedures for tennis elbow [39].
• Percutaneous common flexor origin release of the medial humeral epicondyle in golfer's elbow appears to be a safe treatment option [3].

Recovery¶

Non-Operative¶

• Conservative treatment without prohibiting tennis play resulted in an 83% rate of spontaneous bone union for medial epicondylar fragmentation in male junior tennis players [125].
• Elbow pain persisted in 50% of subjects at re-examination following conservative treatment for medial epicondylar fragmentation in male junior tennis players [125].
• The prognosis for medial epicondylitis in occupational settings was good with a 3-year recovery rate at 81% [126].
• Bone union of the medial epicondylar fragmentation was associated with a decreased prevalence of elbow pain at 1 year after initial presentation in young baseball players [5].

Operative¶

• 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 [3].
• Open, anatomical reduction is recommended to ensure restoration of elbow stability for biepicondylar fracture dislocation of a child's elbow [2].
• Fragment excision and ligament repair for valgus instability due to medial epicondyle nonunion is associated with rapid restoration of elbow stability [11].
• Fragment excision and ligament repair for valgus instability due to medial epicondyle nonunion is associated with minimal surgical morbidity [11].
• Fragment excision and ligament repair for valgus instability due to medial epicondyle nonunion is associated with a high rate of patient satisfaction [11].
• Fragment excision and ligament repair for valgus instability due to medial epicondyle nonunion is associated with an improvement in objective elbow scores [11].
• After open reduction internal fixation of the medial epicondyle in professional pitchers with a history of ulnar collateral ligament reconstruction, 73.3% were able to return to sport [49].
• After open reduction internal fixation of the medial epicondyle in professional pitchers with a history of ulnar collateral ligament reconstruction, 55% returned to the same level or higher [49].
• After open reduction internal fixation of the medial epicondyle in professional pitchers with a history of ulnar collateral ligament reconstruction, there was no significant decline in most performance variables when compared with preoperative performance or matched controls [49].
• A patient with a medial epicondyle fracture and concomitant flexor-pronator mass avulsion was pain free at the 1-year follow-up visit [32].
• A patient with a medial epicondyle fracture and concomitant flexor-pronator mass avulsion had symmetric range of motion at the 1-year follow-up visit [32].
• A patient with a medial epicondyle fracture and concomitant flexor-pronator mass avulsion had elbow stability at the 1-year follow-up visit [32].
• A patient with a medial epicondyle fracture and concomitant flexor-pronator mass avulsion had function symmetric to the contralateral extremity at the 1-year follow-up visit [32].
• A patient with a greatly delayed complication of medial epicondyle injury had full range of movement at the elbow at 6 weeks [12].
• A patient with a greatly delayed complication of medial epicondyle injury had no obvious deformity at 6 weeks [12].
• A patient with a greatly delayed complication of medial epicondyle injury had no weakness in the limb at 6 weeks [12].
• Delayed neuropathy of the ulnar nerve associated with elbow dislocation and medial epicondyle fracture appears to be associated with complete recovery in children when promptly treated [127].

Key Evidence¶

• [L1] Both treatments provided acceptable elbow function. [1] (10.1016/j.jse.2022.01.016)
• [L5] They recommend open, anatomical reduction to ensure restoration of elbow stability. [2] (10.1016/s0020-1383(96)00138-6)
• [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. [3] (10.1016/j.rboe.2016.06.007)
• [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. [4] (10.1177/0363546505281917)
• [L3] At 1 year after initial presentation, bone union of the medial epicondylar fragmentation was associated with a decreased prevalence of elbow pain. [5] (10.1177/0363546512443807)
• [L4] The authors present a surgical technique applicable to posteromedial elbow pathology by 2 medial portals. [6] (10.1016/j.eats.2024.103062)
• [Case_report] The evaluation of elbow joint instability using fluoroscopy during surgery proved to be valuable for both understanding the pathology and assessing the effectiveness of treatments. [7] (10.1016/j.jseint.2024.05.014)
• [L4] The result is completely satisfactory, achieving the objective of a minimum range of motion of 100 in addition to elbow stability. [8] (10.5435/jaaosglobal-d-21-00034)
• [L5] Accurate diagnosis requires distinguishing it from other elbow conditions, and treatment is guided by the specific pathologic stage of the tendon. [9] (10.1016/j.csm.2004.04.011)
• [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. [11] (10.1067/mse.2002.126206)
• [L5] The patient had full range of movement at the elbow with no obvious deformity at 6 weeks and no weakness in the limb. [12] (10.1016/s0020-1383(98)00141-7)
• [L5] The most common topic in the classical group was elbow anatomy and function, and the most common topic in the contemporary group was lateral epicondylitis and medial epicondylitis and associated therapies. [13] (10.5435/jaaosglobal-d-23-00287)
• [L4] Despite early success of this technique for most elbows within the first two tears, survivorship free of revision with death as competing risk approaches 75% at 10 years. [14] (10.1016/j.jseint.2025.101581)
• [L3] A large majority of patients reported medial elbow pain prior to fracture, suggesting this severe presentation of Little League elbow may be preventable. [15] (10.1177/2325967121s00275)
• [L5] Medial elbow pain is uncommon and requires a broad differential diagnosis including ulnar nerve disorders, cervical radiculopathy, and ligament injuries. [19] (10.1302/2058-5241.2.160006)
• [L4] [21] (10.1177/03635465221095565)
• [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. [23] (10.1177/0363546513480797)
• [L4] As the treatment rationale for ME injuries is often predicated on restoring elbow biomechanics through anatomical restoration of the UCL, identification of these injury patterns is potentially a key first step in understanding the variability in clinical outcomes with different management strategies for medial elbow injuries. [27] (10.1177/2325967125s00159)
• [L5] The described method provides a reproducible, anatomically based construct that restores posterolateral elbow stability and addresses the complex spectrum of lateral-sided injuries observed in PLRI. [29] (10.1016/j.eats.2025.103797)
• [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. [32] (10.2106/jbjs.cc.19.00417)
• [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. [33] (10.1016/j.jse.2011.09.030)
• [L4] Providers should take this information into consideration when evaluating medial epicondyle elbow pain in skeletally immature patients. [36] (10.1177/2325967126s00147)
• [L5] [40] (10.5435/JAAOS-D-14-00145)
• [L5] The article outlines indications and a technique for medial epicondylectomy, noting that 12 studies have confirmed success rates between 72% and 94%. [41] (10.1016/j.hcl.2007.06.002)
• [L3] Medial elbow pain during the return-to-throwing period after UCLR is not uncommon, with up to half of pitchers potentially experiencing pain. [42] (10.1177/2325967118808782)
• [L4] Operative treatment of recalcitrant medial epicondylitis is effective in restoring patient function and strength. [43] (10.1308/003588413x13629960048479)
• [L3] A reduction in proximal HU values may reflect localized structural attenuation that is functionally relevant to medial elbow stability. [44] (10.1177/23259671261472961)
• [L3] Open and arthroscopic techniques were very effective and comparable for treating chronic medial epicondylitis. [46] (10.1016/j.jse.2022.09.018)
• [L4] After ORIF of the medial epicondyle in professional pitchers with a history of UCLR, 73.3% were able to return to sport (only 55% at the same level or higher) without a significant decline in most performance variables when compared with their preoperative performance or matched controls. [49] (10.1177/2325967119852896)
• [L4] The Wrightington classification system is a valuable tool for characterizing the majority of elbow-fracture dislocations and guiding surgical interventions. [56] (10.1016/j.jseint.2024.08.035)
• [L4] Arthroscopic surgical treatment for medial epicondylitis of the elbow provides good outcomes and is safe and effective. [61] (10.1016/j.jse.2017.08.019)
• [L5] The flexor-pronator mass dynamically stabilizes the elbow against valgus torque. [62] (10.2106/00004623-200410000-00020)
• [L5] The medial elbow joint space was significantly reduced under 60-N valgus stress plus 50% MVC compared to 60-N valgus stress alone. [63] (10.1016/j.jse.2022.03.027)
• [L4] Incorporating the pronator teres into contraction tasks significantly reduced the medial joint space, emphasizing the important role of the PT in elbow joint stability. [64] (10.1016/j.jse.2024.12.025)
• [L2] The combined approach with both MR arthrography and US shows higher accuracy than each modality alone for the assessment of medial elbow pain. [79] (10.1148/radiol.2015151256)
• [L3] High elbow varus torque would increase the risk of medial elbow disorder. [82] (10.1177/2325967121s00748)
• [L4] [84] (10.5435/jaaos-d-17-00446)
• [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. [86] (10.4055/cios.2009.1.3.123)
• [L5] [87] (10.1016/j.eats.2023.09.010)
• [L4] Elbow flexion showed satisfactory recovery on the operated side (135 ± 5°) compared to the contralateral side (138 ± 4°), with no statistically significant difference (p 0.212). [91] (10.1016/j.jseint.2025.101582)
• [L4] [92] (10.1177/0363546509351558)
• [L2] Fragmentation of the medial epicondyle may contribute to compromised medial elbow dynamic stability in adult baseball players. [93] (10.1016/j.xrrt.2026.100680)
• [L4] Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures. [94] (10.1007/s11832-009-0192-7)
• [L5] Repetitive baseball pitching reduced elbow valgus stability, attributed to decreased flexor-pronator mass contractile function. [97] (10.1016/j.jse.2023.03.026)
• [L4] Humeral implants of10 cm-length could therefore be privileged as first intention implant regardless of the indication, if there is no imperative to use a longer stem. [101] (10.1016/j.jseint.2025.101575)
• [L3] There is substantial variation in imaging practices across the United States when diagnosing a medial epicondyle fracture, with CT scans more likely in smaller cities and older children, and MRI more likely in smaller hospitals and younger children. [111] (10.1177/2325967119s00071)
• [L4] The outcome of non-operative treatment is usually satisfactory as even a fibrous union is compatible with excellent function. [112] (10.1016/0020-1383(88)90109-x)
• [L4] [114] (10.1016/j.jseint.2024.08.004)
• [L4] Nonoperative treatment may be appropriate for minimally displaced cases. [116] (10.1177/23259671251365974)
• [L4] [118] (10.1177/2325967120976573)
• [L2] Therefore, ultrasonography is recommended as an initial imaging method for the diagnosis of clinical medial epicondylitis. [120] (10.1016/j.apmr.2007.09.048)
• [L2] Although conservative treatment without prohibiting tennis play resulted in an 83% rate of spontaneous bone union, elbow pain persisted in 50% of subjects at re-examination. [125] (10.1016/j.jse.2014.06.044)
• [L2] The prognosis for medial epicondylitis in this population was good with a 3-year recovery rate at 81%. [126] (10.1097/01.jom.0000085888.37273.d9)
• [L4] The delayed neuropathy of the ulnar nerve appears to be associated with a complete recovery in children, as long as it is promptly treated. [127] (10.1016/j.jse.2012.11.009)

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