Medial Epicondylitis Rehabilitation Protocol

This protocol provides a comprehensive outline for the physical therapy management of medial epicondylitis (golfer's elbow). It is designed to be a guideline and should be adapted based on individual patient presentation, severity of symptoms, and response to treatment. This protocol aims to reduce pain, inflammation, and restore full function of the elbow and wrist.

Pathophysiology

Medial epicondylitis is an overuse injury affecting the common flexor tendon origin at the medial epicondyle of the humerus. It most commonly involves the pronator teres, flexor carpi radialis, and flexor carpi ulnaris muscles. Repetitive wrist flexion, forearm pronation, and gripping activities place excessive stress on these tendons, leading to micro-tearing and inflammation. Risk factors include improper technique in sports (golf, baseball), repetitive work activities (typing, assembly line work), and poor ergonomic setups.

Symptoms typically include pain and tenderness over the medial epicondyle, pain radiating down the forearm, pain with wrist flexion and pronation against resistance, and potential weakness in grip strength. Chronic cases can develop tendinosis, a degenerative condition of the tendon with altered collagen structure and minimal inflammation.

Special Tests

• Resisted Wrist Flexion Test: The patient flexes their wrist against resistance applied by the examiner. A positive test reproduces pain at the medial epicondyle.
• Resisted Forearm Pronation Test: The patient pronates their forearm against resistance. A positive test reproduces pain at the medial epicondyle.
• Passive Wrist Extension Test: The examiner passively extends the patient's wrist with the elbow extended. A positive test reproduces pain at the medial epicondyle.
• Grip Strength Measurement: Using a dynamometer, grip strength is measured and compared to the contralateral side. Weakness may indicate involvement of the flexor muscles.

Phase I: Protection (Acute Phase - Day 1 to 2 Weeks)

The primary goals of this phase are to reduce pain and inflammation, protect the injured tissues, and prevent further damage. It is essential to respect pain levels and avoid activities that exacerbate symptoms.

• Pain Management:
  • Rest: Avoid activities that provoke pain.
  • Ice: Apply ice to the medial epicondyle for 15-20 minutes, several times per day.
  • Activity Modification: Modify or eliminate activities that aggravate the condition. This may involve adjusting work habits, sporting techniques, or daily tasks.
  • Support: Use an elbow brace or counterforce strap to reduce stress on the medial epicondyle. The strap should be positioned just distal to the medial epicondyle.
  • Medications: Over-the-counter pain relievers (NSAIDs) may be considered, as directed by a physician.
• Range of Motion (ROM):
  • Gentle active range of motion (AROM) exercises for the elbow, wrist, and hand, within a pain-free range. Examples include:
    • Elbow flexion and extension
    • Wrist flexion and extension
    • Wrist radial and ulnar deviation
    • Finger flexion and extension
• Isometric Exercises:
  • Isometric exercises for wrist flexion, extension, pronation, and supination performed in neutral positions with minimal resistance and no pain. Hold each contraction for 5-10 seconds. Gradually increase the hold time as tolerated.
• Patient Education:
  • Educate the patient about the condition, its causes, and the importance of activity modification and proper body mechanics.
  • Instruct on proper posture and ergonomics to prevent recurrence.

Phase II: Loading (Subacute Phase - Weeks 2 to 6)

The goals of this phase are to gradually increase strength, endurance, and flexibility, while continuing to manage pain and inflammation. Progression is guided by the patient's symptoms.

• Pain Management:
  • Continue ice/heat as needed for pain management.
• Range of Motion (ROM):
  • Continue AROM exercises.
  • Begin gentle stretching exercises for wrist flexors and pronators. Hold each stretch for 20-30 seconds, repeated 2-3 times.
• Strengthening Exercises:
  • Progress to isotonic exercises using light weights or resistance bands. Focus on controlled movements and proper form. Examples include:
    • Wrist flexion and extension with light weights
    • Forearm pronation and supination with light weights
    • Grip strengthening exercises (e.g., squeezing a stress ball)
  • Progress resistance gradually, increasing weight or resistance band tension as tolerated. Monitor for any increase in pain.
• Proprioception Exercises:
  • Begin incorporating proprioceptive exercises to improve joint awareness and coordination. Examples include:
    • Wrist circles with eyes open and closed
    • Reaching and pointing tasks with the affected arm
• Ergonomic Assessment and Modification:
  • Assess work or sporting activities for ergonomic risk factors.
  • Modify equipment, posture, or techniques to reduce stress on the elbow and wrist.

Phase III: Return to Function (Weeks 6+)

The goals of this phase are to restore full function, return to sport or work activities, and prevent recurrence. This phase involves progressive strengthening, endurance training, and activity-specific exercises.

• Strengthening Exercises:
  • Continue progressing strengthening exercises with increasing weight and resistance.
  • Incorporate sport- or work-specific exercises that mimic the demands of the patient's activities. Examples include:
    • Golf swings with proper technique
    • Simulated typing or assembly line tasks
• Endurance Training:
  • Increase the number of repetitions and sets of exercises to improve muscular endurance.
  • Implement activities that require sustained muscle contractions, such as carrying weights or performing repetitive tasks.
• Plyometric Exercises (if appropriate):
  • If the patient's activity requires explosive movements (e.g., throwing sports), begin incorporating plyometric exercises, such as medicine ball throws.
• Activity-Specific Training:
  • Gradually return to sport or work activities, starting with reduced intensity and duration.
  • Monitor for any recurrence of symptoms and adjust activity levels accordingly.
• Maintenance Program:
  • Develop a home exercise program to maintain strength, flexibility, and endurance.
  • Educate the patient on proper warm-up and cool-down techniques, as well as strategies for preventing recurrence.

Progression Criteria: Progression through each phase is dependent on the patient's pain levels, functional abilities, and response to treatment. Patients should be able to perform exercises without significant pain or increased inflammation before advancing to the next phase.

Disclaimer: This protocol is a general guideline and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare professional before starting any new exercise program.