An effective approach to diagnosis and surgical repair of refractory medial epicondylitis.

BACKGROUND: Medial epicondylitis of the elbow, an overuse injury characterized by angiofibroblastic tendinosis of the common flexor-pronator origin, generally responds to nonoperative treatment. Refractory cases may require surgical débridement and repair. This study discusses physical examination and imaging findings and an updated surgical technique used in patients with recalcitrant medial epicondylitis.

METHODS: The surgical records of 60 patients with refractory medial epicondylitis were reviewed. All received a course of nonoperative care. After 3 to 6 months of failed therapy, imaging was obtained, and surgical intervention was offered when indicated. This open procedure consisted of thorough débridement with repair and restoration of the flexor-pronator origin, using a suture anchor. Accelerated rehabilitation, emphasizing early motion, was used. One-year follow-ups were obtained. The Mayo Elbow Performance Score was calculated preoperatively and postoperatively.

RESULTS: Pronation weakness at 90° was a critical physical examination finding. Preoperative magnetic resonance images demonstrated pathologic partial tearing at the flexor-pronator origin. Ulnar neuritis was addressed in 20%. Postoperatively, the Mayo Elbow Performance Score significantly increased (preoperatively, 58 ± 7.7; postoperatively, 88 ± 7.8; P = 5.6E-34), and pain significantly decreased (preoperatively, 2.2 ± 0.3; postoperatively, 0.6 ± 0.5; P = 3.8E-33). There was one retear in a patient noncompliant with the postoperative protocol. He responded positively to reoperation.

CONCLUSION: Identification of weakness on pronation is a reliable physical examination finding for determining clinically significant pathologic changes in patients with medial epicondylitis. Débridement with restoration of the flexor-pronator origin is an efficacious procedure. In this large series of patients, surgical repair with aggressive rehabilitation was shown to be reliable and safe in restoring function and relieving pain in recalcitrant cases of medial epicondylitis.