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Management of medial epicondylitis inthe throwing athlete
MANAGEMENT OF MEDIAL EPICONDYLITIS IN THE THROWING ATHLETE GERARD T. GABEL, MD
Mediai epicondylitis in the throwing athlete is typically a result of repetitive loading of the flexor pronator mass or because of acute overload of the flexor pronator mass. It manifests itself as pain with or after a period of throwing and is typically associated with a more prolonged, frequent, or strenuous regimen. The mechanics in throwing include elbow extension, forearm pronation, and wrist palmar flexion in motion progressed from the acceleration phase to the release phase. The active contraction with forearm pronation and wrist palmar flexion, combined with extension at the elbow, results in an eccentric load being applied to the flexor pronator mass. The additional concern of valgus stress being applied with the throwing mechanism simply exacerbates this mechanical predisposition to overload of the flexor pronator mass. KEY WORDS: medial epicondylitis, repetitive loading, flexor pronator mass
Copyright © 2001 by W.B. Saunders Company
Isolated medial epicondylitis, ie, without medial collateral ligament ~ or ulnar neuropathy involvement, is relatively uncommon in the throwing athlete but can be managed discretely when these elements are not concomitantly involved. The classification of medial epicondylitis 2 is shown in Table 1 with type I medial epicondylitis having no concomitant ulnar neuropathy, type IIA having mild ulnar neuropathy, and type IIB having moderate to severe ulnar neuropathy. A subset that is seen frequently in the throwing athlete would be the associated medial collateral ligament injury that is reviewed to a limited degree in this article and fully reviewed in the medial collateral ligament reconstruction article in this journal. Also, management of ulnar neuropathy of the elbow in the throwing athlete with or without medial epicondylitis will similarly be reviewed in the article on ulnar neuropathy of the elbow in this issue of the journal. The diagnosis of medial epicondylitis consists of medial elbow discomfort with direct tenderness over the anterior aspect of the medial epicondyle and resisted pronation or wrist palmar flexion tenderness. The examination of the ulnar nerve and valgus stress examination should be negative to affirm a diagnosis of isolated medial epicondylitis. The evaluation should include plain radiographs, which may or may not show medial compartment concerns. Epicondylar calcification is seen in less than 10% of patients and is not prognostic. Magnetic resonance imaging evaluation may be considered and typically will show increased signal intensity at the origin of the flexor pronator mass. Conservative management includes modification
From the Baylor College of Medicine, Houston, TX.
Address reprint requests to Gerard T. Gabel, MD, Baylor College of Medicine, Smith Tower, SMTH 2625, 1 Baylor Plaza, Houston, TX 77030. Copyright © 2001 by W.B. Saunders Company 1060-1872/01/0904-0003535.00/0
doi:10.1053/otsm.2001.26785
T A B L E 1. Medial Epicondylitis Classification Type
Diagnosis
I IIA
Isolated medial epicondylitis Medial epicondylitis with minimal or mild associated ulnar neuropathy Medial epicondylitis with moderate or severe associated ulnar neuropathy
lIB
of the throwing program, prudent use of a corticosteroid injection, 3 counterforce bracing, and a flexor pronator strengthening program.
ANATOMY The relevant anatomy of type I medial epicondylitis relates specifically to the medial conjoint tendon. Like lateral epicondylitis in which the extensor mechanism coalesces into a lateral conjoint tendon, in medial epicondylitis, the pronator teres, flexor carpi radialis, and the palmaris longus and digital flexors form a tendinous origin that begins in the midforearm approximately 10 to 12 cm distal to the medial epicondyle (Fig 1). The tendons form a V-shaped structure with the pronator teres muscles belly radially, flexor carpi radialis muscles, belly centrally, and palmaris longus and flexor digitorum sublimis muscle belly medially. As the tendons extend proximally, they thicken to form a very discrete structure, which coalesces at a level 2 cm distal to the medial epicondyle, becoming a formal medial conjoint tendon. The medial conjoint tendon is located on the anterior and inferior medial epicondyle immediately anterior to the anterior oblique ligament. The orientation of the medial conjoint tendon is relatively vertical, extending directly anterior from the medial epicondyle to the superficial fascia of the flexor pronator mass. The identification of the medial conjoint tendon is critical not only from the perspective of the
Operative Techniques in Sports Medicine, Vol 9, No 4 (October), 2001: pp 205-210
205
MCT PT
I
PL & FDS
Fou / ,/
!
Humerus
\ PT /
F~CTpL
& FDS
tm !:
m
........
MCT
m
AOL ,/Y
RadiusU I n ~ PL & FDS
(FCU removed)
! : :i:;!:i!::i:iii?!!i!i:~
Ii;:ii
Fig 1. (Top left) Cross-sectional anatomy of the medial conjoint tendon (MCT) at the proximal and midportion of the medial conjoint tendon. Note the true conjoint nature at a proximal level and the double septum configuration distally. The anterior oblique ligament (AOL) is perpendicular and posteromedial to the medial conjoint tendon. (Bottom left) Longitudinal anatomy of the medial conjoint tendon. Note the anterior/medial origin of the medial conjoint tendon (MCT) at the medial epicondyle, as well as the flexor pronator muscle attachments to the medial conjoint tendon. This produces the only dynamic valgus stabilizing mechanism at the elbow, the flexor pronator mass/medial conjoint tendon mechanism. Abbreviation: AOL, anterior oblique ligament.
surgical management of medial epicondylitis, but also in using the medial conjoint tendon as a landmark for avoiding injury to the anterior oblique ligament. It is also useful for defining the origin and insertion of the anterior oblique ligament, if needed, because the medial conjoint tendon lies immediately anterior to the ligament throughout its course. If corticosteroid injections are used in the management of medial epicondylitis in the throwing athlete, care should be taken to place the corticosteroid injection on the anterior margin of the medial conjoint tendon to avoid any potential corticosteroid effect on the more posteriorly located anterior oblique ligament. 206
INDICATIONS The indication for surgical intervention to allow the throwing athlete to resume a preinjury level of competition would be the failure of conservative management. 4-7 The patient should be advised of the potential that even with surgical management, the results may not allow resumption of the same level of competition. Although valgus stability at the elbow is enhanced by active contraction of the biceps and triceps increasing the joint reactive force, the only anatomic dynamic valgus stabilizer is the flexor pronator attachment to the medial GERARD T. GABEL
epicondyle through the medial conjoint tendon. Because of this, the management of isolated medial epicondylitis in the throwing athlete is placed into 2 subgroups. One subgroup is a recreational athlete without considerable ongoing valgus load and the other is the high-level athlete who will continue to experience considerable valgus loads at the elbow. In the former patient group, ie, the lower valgus load setting, medial conjoint tendon debridement, and segmental resection yields predictably good results; however, if segmental resection of the tendon is performed, the notable contribution to valgus stability on the part of the flexor pronator mass is lost. In the second subgroup, the athlete with continued valgus loads, debridement, and anatomic repair of the medial conjoint tendon is recommended to retain the dynamic valgus contribution of the flexor pronator mass via the medial conjoint tendon. SURGICAL
TECHNIQUE
Medial Conjoint Tendon Debridement and Repair
A general endotracheal anesthetic is used without paralyzing agents to allow for identification of any ulnar nerve activity intraoperatively. The patient is maintained in a supine position with an arm table positioned midway at the shoulder. A nonsterile tourniquet applied high is satisfactory in isolated medial epicondylitis, but if an ulnar nerve transposition may be entertained, a sterile tourniquet should be used. A longitudinal incision starting immediately anterior to the proximal margin of the medial epicondyle and extending distally for 3 to 4 cm is created (Fig 2). The posterior branch of the medial antibrachial cutaneous nerve is identified in the subcutaneous fat at this level, and it is gently retracted throughout the procedure. The superficial flexor pronator fascia and flexor pronator mass are exposed to allow visualization from the proximal edge of the flexor pronator mass to the level of the cubital turmel. The margin of the medial conjoint tendon is identified either by palpation or by longitudinally
Fig 2. Surgical incision for isolated medial epicondylitis. The incision is placed longitudinally oriented slightly anterior to the medial epicondyle (ME) to minimize a risk of a tender scar over the epicondylar prominence. Note the anticipated course of the posterior branch of the medial antebrachial cutaneous nerve (MABCN)
MANAGEMENTOF MEDIALEPICONDYLITIS
Fig 3. Exposure of the flexor pronator mass. The medial conjoint tendon can be palpated in most patients as of a longitudinal structure immediately deep to the superficial flexor pronator fascia in the midportion of the flexor pronator mass. Alternately, a longitudinal incision at the midpoint may be created to expose the medial conjoint tendon (arrows).
incising the superficial flexor pronator fascia at its midpoint (Fig 3). The medial conjoint tendon is carefully exposed with a No. 15 blade or tenotomy scissors to elevate the pronator teres off of its anterior margin and the palmaris longus and sublimus muscle bellies off of its posterior margin (Fig 4). The surgeon should take care with the posterior exposure so as not to violate the anterior oblique ligament, which is located immediately adjacent to the medial conjoint tendon. It should be noted that the medial conjoint tendon is oriented vertically, whereas the anterior surface of the anterior oblique ligament presents a coronal plane, creating a 90 ° angle between the medial conjoint tendon and the anterior margin of the anterior oblique ligament (Fig 5). It is recommended that the dissection at the posterior deep margin of the medial conjoint tendon be
Fig 4. Medial conjoint tendon (MCT) exposure. The tendon may be as wide as 4 to 5 mm and, at this level, is a truly conjoint structure with no septation. Exposure with knife or tenotomy scissors is performed for the first few centimeters of the medial conjoint tendon to isolate the tendon. Abbreviations: ME, medial epicondyle; PL, Palmaris Longus; FDS, fascio-dermal sling.
207
Fig 5. The medial conjoint tendon (MCT) and anterior oblique ligament (AOL) are fully exposed. Note the AOL immediately posterior to the MCT. At this level, a freer elevator may be used to reflect the muscle fibers off of these structures to minimize the risk of injury to the AOL ligament. Abbreviation: ME, medial epicondyle.
Fig 7. Medial conjoint tendon (MCT) repair is most easily performed with suture anchors, either a single large suture anchor as shown in this case if the medial epicondyle (ME) can accommodate it, or 2 smaller suture anchors, for a total of 4 sutures/2 knots. Abbreviation: AOL, anterior oblique ligament.
performed either with tenotomy scissors or simply a freer elevator. This allows for complete exposure of the medial conjoint tendon while minimizing risk to the anterior oblique ligament. Palpation is performed either digitally or with a freer elevator to allow identification of the plane of the anterior oblique ligament and the interval between the anterior oblique ligament and medial conjoint tendon. At this time, a No. 15 blade is used to elevate, starting posterior medially at the anterior oblique-medial conjoint tendon interval and extending anteriorly to elevate the entirety of the medial conjoint tendon off of the medial epicondyle. The medial conjoint tendon, once elevated, is
easily isolated from the anterior oblique ligament (Fig 6). At this point, the degenerative tendinitis, which is typically found, is debrided back to normal-appearing tissue. This may result in removal of as much as i cm of the medial conjoint tendon. The medial epicondylar origin of the medial conjoint tendon is freshened up with a rongeur. Repair of the medial conjoint tendon is most effectively performed with suture anchors, either 2 small doublestrand suture anchors or, if the epicondyle will accommodate, 1 larger 4-strand suture anchor (Fig 7). The sutures are passed through the deep surface of the conjoint tendon
Fig 6. Medial conjoint tendon (MCT) elevation is performed over the proximal 2 to 3 cm of the MCT (the conjoint tendon proximal margin is in the pick-ups). Note the small rim of degenerative tissue at the proximal aspect of the MCT. In the subgroup of patients in whom MCT resection may be elected, the elevated MCT is excised at a point 2 to 3 cm from its origin with tenotomy scissors, effectively lengthening it. Abbreviations: ME, medial epicondyle; AOL, anterior oblique ligament. Dotted lines indicate the course of AOL. 208
Fig 8. Completion of the medial conjoint tendon (MCT) repair. The sutures are passed deep to superficial and tied on the superficial surface of the tendon. The knots do not need to be buried because closure of the superficial fascia over the repair prevents any postoperative irritation from the knots themselves. Abbreviation: ME, medial epicondyle. GERARD T. GABEL
and tied superficially to complete the repair of the medial conjoint tendon (Fig 8). The superficial flexor pronator fascia is approximated with 3-0 Vicryl suture with the knot buried. This allows for complete coverage of the medial conjoint tendon repair and the suture anchor knots. In addition, it minimizes the risk of flexor pronator muscle herniation postoperatively (Fig 9). The wound is irrigated and closed with a subcuticular 4-0 Vicryl suture, and the skin is approximated with Steri-strips. A bulky dressing is applied, followed by an application of a single sugar-tong splint holding the forearm and wrist in neutral. Medial collateral ligament reconstruction is specifically addressed in a separate section of this issue. Operative repair or reconstruction of the anterior oblique ligament is easily performed in association with medial conjoint tendon debridement and repair because the exposure of the medial conjoint tendon requires discrete identification of the anterior oblique ligament. In addi-
tion, elevation of the medial conjoint tendon allows for full exposure of the anterior oblique ligament from its epicondylar origin to its ulnar insertion. Either a tunnel technique or suture anchors m a y be used for separate stabilization of the proximal portion of the anterior oblique ligament at the medial epicondyle. The surgeon should take care to avoid respective hardware or tunnel placement in a manner that would interfere with anatomic positioning of either the medial conjoint tendon or the anterior oblique ligament origin. Medial Conjoint Tendon Debridement and S e g m e n t Resection
In the subgroup of patients who do not expose the elbow to a frequent and high level of valgus load, medial conjoint tendon debridement and segment resection can be entertained. The resection of 2 to 3 cm of the proximal medial conjoint tendon, in effect, lengthens the medial conjoint tendon and diminishes the stress concentration that the medial conjoint tendon experiences at its origin. This should be avoided in the high level throwing athlete because of concerns with the loss of the dynamic valgus stability imparted by the flexor pronator mass and the medial conjoint tendon. The surgical technique is identical to debridement and repair except that once the medial conjoint tendon is isolated, the procedure includes not only debridement of the involved portion of the tendon, but, also resection of the proximal 2 to 3 cm of the medial conjoint tendon (see Figure 6). Closure and splinting, as well as the postoperative program, are similar to debridement and repair. Rehabilitation
Fig 9. (A) Note the coverage of the medial conjoint tendon (MCT) by the flexor pronator muscles after release of the retractors before the repair. (B) The flexor pronator (FP) fascia is closed over the repair to protect the repair and minimize irritation from subcutaneous knots and minimize the risk of flexor pronator muscle hernation postoperatively. Abbreviation: ME, medial epicondyle.
MANAGEMENTOF MEDIALEPICONDYLITIS
The patient is seen in the office at 10 days postoperative for wound examination and application of a well-padded munster cast, again with the forearm and wrist in neutral. Gentle elbow range of motion as allowed by the munster cast (typically 45 ° to 120 °) is performed for an additional 2 weeks. At this time, the cast is removed and a wrist splint, at neutral, is applied, and a noncomposite gentle range of motion program is initiated. Because the medial conjoint tendon components cross 3 joints (elbow, forearm, and wrist), relaxation of the tendon at 1 joint can allow for range of motion at another joint without considerably loading the medial conjoint tendon. Elbow range of motion is therefore performed with the forearm passively positioned in pronation and the wrist palmar flexed. Forearm and wrist range of motion is performed with the elbow at 90 °. This noncomposite program is maintained for 3 weeks, after which a composite range of motion program with full elbow extension, forearm supination, and wrist dorsiflexion is initiated. A gentle flexor pronator strengthening program is started at 6 to 8 weeks. A graduated resumption of pitching activities may be started when good flexor pronator strength is restored and pitching is pain free, typically at 3 to 4 months. Full reintegration into a preinjury throwing program usually requires 6 to 9 months. 209
RESULTS
REFERENCES
In the absence of c o n c o m i t a n t disease, the results of m e dial conjoint t e n d o n d e b r i d e m e n t a n d t e n d o n repair are typically good, w i t h the majority of patients (greater t h a n 75%) r e s u m i n g the p r e i n j u r y level of competition. Because the original injury w a s a consequence of the mechanics of the n o r m a l t h r o w i n g routine, there is a risk of recurrence or the potential for the athlete not to regain his or her f o r m e r level of proficiency. The patient s h o u l d be a d v i s e d of this before a n y surgical intervention. In the case of the recreational athlete, the loads are typically less intense a n d less frequent, a n d these patients will overall h a v e a generally i m p r o v e d p r o g n o s i s c o m p a r e d w i t h the high-level t h r o w i n g athlete.
1. Jobe FW, Stark H, Lombardo SJ: Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am 68:1158-1163, 1986 2. Gabel GT, Morrey BF: Operative treatment of medical epicondylitis. Influence in concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am 77:1065-1069, 1995 3. Stahl S, Kaufman T: Ulnar nerve injury at the elbow after steroid injection for medial epic0ndylitis. J Hand Surg Br 22:69-70, 1997 4. Gabel GT, Nirschl RP: Medial epicondylitis, in: Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, Saunders, 2001 5. Kurvers H, Verhaar J: The results of operative treatment of medial epicondylitis. J Bone Joint Surg Am 77:1374-1379, 1995 6. Ollivierre CO, Nirschl RP, Pettrone FA: Resection and repair for medial tennis elbow. A prospective analysis. Am J Sports Med 23:214221, 1995 7. Vangsness CT, Jobe FW: Surgical management of medial epicondylitis. J Bone Joint Surg Br 73:409-411, 1991
210
GERARD T. GABEL
Mediai epicondylitis in the throwing athlete is typically a result of repetitive loading of the flexor pronator mass or because of acute overload of the flexor pronator mass. It manifests itself as pain with or after a period of throwing and is typically associated with a more prolonged, frequent, or strenuous regimen. The mechanics in throwing include elbow extension, forearm pronation, and wrist palmar flexion in motion progressed from the acceleration phase to the release phase. The active contraction with forearm pronation and wrist palmar flexion, combined with extension at the elbow, results in an eccentric load being applied to the flexor pronator mass. The additional concern of valgus stress being applied with the throwing mechanism simply exacerbates this mechanical predisposition to overload of the flexor pronator mass. KEY WORDS: medial epicondylitis, repetitive loading, flexor pronator mass
Copyright © 2001 by W.B. Saunders Company
Isolated medial epicondylitis, ie, without medial collateral ligament ~ or ulnar neuropathy involvement, is relatively uncommon in the throwing athlete but can be managed discretely when these elements are not concomitantly involved. The classification of medial epicondylitis 2 is shown in Table 1 with type I medial epicondylitis having no concomitant ulnar neuropathy, type IIA having mild ulnar neuropathy, and type IIB having moderate to severe ulnar neuropathy. A subset that is seen frequently in the throwing athlete would be the associated medial collateral ligament injury that is reviewed to a limited degree in this article and fully reviewed in the medial collateral ligament reconstruction article in this journal. Also, management of ulnar neuropathy of the elbow in the throwing athlete with or without medial epicondylitis will similarly be reviewed in the article on ulnar neuropathy of the elbow in this issue of the journal. The diagnosis of medial epicondylitis consists of medial elbow discomfort with direct tenderness over the anterior aspect of the medial epicondyle and resisted pronation or wrist palmar flexion tenderness. The examination of the ulnar nerve and valgus stress examination should be negative to affirm a diagnosis of isolated medial epicondylitis. The evaluation should include plain radiographs, which may or may not show medial compartment concerns. Epicondylar calcification is seen in less than 10% of patients and is not prognostic. Magnetic resonance imaging evaluation may be considered and typically will show increased signal intensity at the origin of the flexor pronator mass. Conservative management includes modification
From the Baylor College of Medicine, Houston, TX.
Address reprint requests to Gerard T. Gabel, MD, Baylor College of Medicine, Smith Tower, SMTH 2625, 1 Baylor Plaza, Houston, TX 77030. Copyright © 2001 by W.B. Saunders Company 1060-1872/01/0904-0003535.00/0
doi:10.1053/otsm.2001.26785
T A B L E 1. Medial Epicondylitis Classification Type
Diagnosis
I IIA
Isolated medial epicondylitis Medial epicondylitis with minimal or mild associated ulnar neuropathy Medial epicondylitis with moderate or severe associated ulnar neuropathy
lIB
of the throwing program, prudent use of a corticosteroid injection, 3 counterforce bracing, and a flexor pronator strengthening program.
ANATOMY The relevant anatomy of type I medial epicondylitis relates specifically to the medial conjoint tendon. Like lateral epicondylitis in which the extensor mechanism coalesces into a lateral conjoint tendon, in medial epicondylitis, the pronator teres, flexor carpi radialis, and the palmaris longus and digital flexors form a tendinous origin that begins in the midforearm approximately 10 to 12 cm distal to the medial epicondyle (Fig 1). The tendons form a V-shaped structure with the pronator teres muscles belly radially, flexor carpi radialis muscles, belly centrally, and palmaris longus and flexor digitorum sublimis muscle belly medially. As the tendons extend proximally, they thicken to form a very discrete structure, which coalesces at a level 2 cm distal to the medial epicondyle, becoming a formal medial conjoint tendon. The medial conjoint tendon is located on the anterior and inferior medial epicondyle immediately anterior to the anterior oblique ligament. The orientation of the medial conjoint tendon is relatively vertical, extending directly anterior from the medial epicondyle to the superficial fascia of the flexor pronator mass. The identification of the medial conjoint tendon is critical not only from the perspective of the
Operative Techniques in Sports Medicine, Vol 9, No 4 (October), 2001: pp 205-210
205
MCT PT
I
PL & FDS
Fou / ,/
!
Humerus
\ PT /
F~CTpL
& FDS
tm !:
m
........
MCT
m
AOL ,/Y
RadiusU I n ~ PL & FDS
(FCU removed)
! : :i:;!:i!::i:iii?!!i!i:~
Ii;:ii
Fig 1. (Top left) Cross-sectional anatomy of the medial conjoint tendon (MCT) at the proximal and midportion of the medial conjoint tendon. Note the true conjoint nature at a proximal level and the double septum configuration distally. The anterior oblique ligament (AOL) is perpendicular and posteromedial to the medial conjoint tendon. (Bottom left) Longitudinal anatomy of the medial conjoint tendon. Note the anterior/medial origin of the medial conjoint tendon (MCT) at the medial epicondyle, as well as the flexor pronator muscle attachments to the medial conjoint tendon. This produces the only dynamic valgus stabilizing mechanism at the elbow, the flexor pronator mass/medial conjoint tendon mechanism. Abbreviation: AOL, anterior oblique ligament.
surgical management of medial epicondylitis, but also in using the medial conjoint tendon as a landmark for avoiding injury to the anterior oblique ligament. It is also useful for defining the origin and insertion of the anterior oblique ligament, if needed, because the medial conjoint tendon lies immediately anterior to the ligament throughout its course. If corticosteroid injections are used in the management of medial epicondylitis in the throwing athlete, care should be taken to place the corticosteroid injection on the anterior margin of the medial conjoint tendon to avoid any potential corticosteroid effect on the more posteriorly located anterior oblique ligament. 206
INDICATIONS The indication for surgical intervention to allow the throwing athlete to resume a preinjury level of competition would be the failure of conservative management. 4-7 The patient should be advised of the potential that even with surgical management, the results may not allow resumption of the same level of competition. Although valgus stability at the elbow is enhanced by active contraction of the biceps and triceps increasing the joint reactive force, the only anatomic dynamic valgus stabilizer is the flexor pronator attachment to the medial GERARD T. GABEL
epicondyle through the medial conjoint tendon. Because of this, the management of isolated medial epicondylitis in the throwing athlete is placed into 2 subgroups. One subgroup is a recreational athlete without considerable ongoing valgus load and the other is the high-level athlete who will continue to experience considerable valgus loads at the elbow. In the former patient group, ie, the lower valgus load setting, medial conjoint tendon debridement, and segmental resection yields predictably good results; however, if segmental resection of the tendon is performed, the notable contribution to valgus stability on the part of the flexor pronator mass is lost. In the second subgroup, the athlete with continued valgus loads, debridement, and anatomic repair of the medial conjoint tendon is recommended to retain the dynamic valgus contribution of the flexor pronator mass via the medial conjoint tendon. SURGICAL
TECHNIQUE
Medial Conjoint Tendon Debridement and Repair
A general endotracheal anesthetic is used without paralyzing agents to allow for identification of any ulnar nerve activity intraoperatively. The patient is maintained in a supine position with an arm table positioned midway at the shoulder. A nonsterile tourniquet applied high is satisfactory in isolated medial epicondylitis, but if an ulnar nerve transposition may be entertained, a sterile tourniquet should be used. A longitudinal incision starting immediately anterior to the proximal margin of the medial epicondyle and extending distally for 3 to 4 cm is created (Fig 2). The posterior branch of the medial antibrachial cutaneous nerve is identified in the subcutaneous fat at this level, and it is gently retracted throughout the procedure. The superficial flexor pronator fascia and flexor pronator mass are exposed to allow visualization from the proximal edge of the flexor pronator mass to the level of the cubital turmel. The margin of the medial conjoint tendon is identified either by palpation or by longitudinally
Fig 2. Surgical incision for isolated medial epicondylitis. The incision is placed longitudinally oriented slightly anterior to the medial epicondyle (ME) to minimize a risk of a tender scar over the epicondylar prominence. Note the anticipated course of the posterior branch of the medial antebrachial cutaneous nerve (MABCN)
MANAGEMENTOF MEDIALEPICONDYLITIS
Fig 3. Exposure of the flexor pronator mass. The medial conjoint tendon can be palpated in most patients as of a longitudinal structure immediately deep to the superficial flexor pronator fascia in the midportion of the flexor pronator mass. Alternately, a longitudinal incision at the midpoint may be created to expose the medial conjoint tendon (arrows).
incising the superficial flexor pronator fascia at its midpoint (Fig 3). The medial conjoint tendon is carefully exposed with a No. 15 blade or tenotomy scissors to elevate the pronator teres off of its anterior margin and the palmaris longus and sublimus muscle bellies off of its posterior margin (Fig 4). The surgeon should take care with the posterior exposure so as not to violate the anterior oblique ligament, which is located immediately adjacent to the medial conjoint tendon. It should be noted that the medial conjoint tendon is oriented vertically, whereas the anterior surface of the anterior oblique ligament presents a coronal plane, creating a 90 ° angle between the medial conjoint tendon and the anterior margin of the anterior oblique ligament (Fig 5). It is recommended that the dissection at the posterior deep margin of the medial conjoint tendon be
Fig 4. Medial conjoint tendon (MCT) exposure. The tendon may be as wide as 4 to 5 mm and, at this level, is a truly conjoint structure with no septation. Exposure with knife or tenotomy scissors is performed for the first few centimeters of the medial conjoint tendon to isolate the tendon. Abbreviations: ME, medial epicondyle; PL, Palmaris Longus; FDS, fascio-dermal sling.
207
Fig 5. The medial conjoint tendon (MCT) and anterior oblique ligament (AOL) are fully exposed. Note the AOL immediately posterior to the MCT. At this level, a freer elevator may be used to reflect the muscle fibers off of these structures to minimize the risk of injury to the AOL ligament. Abbreviation: ME, medial epicondyle.
Fig 7. Medial conjoint tendon (MCT) repair is most easily performed with suture anchors, either a single large suture anchor as shown in this case if the medial epicondyle (ME) can accommodate it, or 2 smaller suture anchors, for a total of 4 sutures/2 knots. Abbreviation: AOL, anterior oblique ligament.
performed either with tenotomy scissors or simply a freer elevator. This allows for complete exposure of the medial conjoint tendon while minimizing risk to the anterior oblique ligament. Palpation is performed either digitally or with a freer elevator to allow identification of the plane of the anterior oblique ligament and the interval between the anterior oblique ligament and medial conjoint tendon. At this time, a No. 15 blade is used to elevate, starting posterior medially at the anterior oblique-medial conjoint tendon interval and extending anteriorly to elevate the entirety of the medial conjoint tendon off of the medial epicondyle. The medial conjoint tendon, once elevated, is
easily isolated from the anterior oblique ligament (Fig 6). At this point, the degenerative tendinitis, which is typically found, is debrided back to normal-appearing tissue. This may result in removal of as much as i cm of the medial conjoint tendon. The medial epicondylar origin of the medial conjoint tendon is freshened up with a rongeur. Repair of the medial conjoint tendon is most effectively performed with suture anchors, either 2 small doublestrand suture anchors or, if the epicondyle will accommodate, 1 larger 4-strand suture anchor (Fig 7). The sutures are passed through the deep surface of the conjoint tendon
Fig 6. Medial conjoint tendon (MCT) elevation is performed over the proximal 2 to 3 cm of the MCT (the conjoint tendon proximal margin is in the pick-ups). Note the small rim of degenerative tissue at the proximal aspect of the MCT. In the subgroup of patients in whom MCT resection may be elected, the elevated MCT is excised at a point 2 to 3 cm from its origin with tenotomy scissors, effectively lengthening it. Abbreviations: ME, medial epicondyle; AOL, anterior oblique ligament. Dotted lines indicate the course of AOL. 208
Fig 8. Completion of the medial conjoint tendon (MCT) repair. The sutures are passed deep to superficial and tied on the superficial surface of the tendon. The knots do not need to be buried because closure of the superficial fascia over the repair prevents any postoperative irritation from the knots themselves. Abbreviation: ME, medial epicondyle. GERARD T. GABEL
and tied superficially to complete the repair of the medial conjoint tendon (Fig 8). The superficial flexor pronator fascia is approximated with 3-0 Vicryl suture with the knot buried. This allows for complete coverage of the medial conjoint tendon repair and the suture anchor knots. In addition, it minimizes the risk of flexor pronator muscle herniation postoperatively (Fig 9). The wound is irrigated and closed with a subcuticular 4-0 Vicryl suture, and the skin is approximated with Steri-strips. A bulky dressing is applied, followed by an application of a single sugar-tong splint holding the forearm and wrist in neutral. Medial collateral ligament reconstruction is specifically addressed in a separate section of this issue. Operative repair or reconstruction of the anterior oblique ligament is easily performed in association with medial conjoint tendon debridement and repair because the exposure of the medial conjoint tendon requires discrete identification of the anterior oblique ligament. In addi-
tion, elevation of the medial conjoint tendon allows for full exposure of the anterior oblique ligament from its epicondylar origin to its ulnar insertion. Either a tunnel technique or suture anchors m a y be used for separate stabilization of the proximal portion of the anterior oblique ligament at the medial epicondyle. The surgeon should take care to avoid respective hardware or tunnel placement in a manner that would interfere with anatomic positioning of either the medial conjoint tendon or the anterior oblique ligament origin. Medial Conjoint Tendon Debridement and S e g m e n t Resection
In the subgroup of patients who do not expose the elbow to a frequent and high level of valgus load, medial conjoint tendon debridement and segment resection can be entertained. The resection of 2 to 3 cm of the proximal medial conjoint tendon, in effect, lengthens the medial conjoint tendon and diminishes the stress concentration that the medial conjoint tendon experiences at its origin. This should be avoided in the high level throwing athlete because of concerns with the loss of the dynamic valgus stability imparted by the flexor pronator mass and the medial conjoint tendon. The surgical technique is identical to debridement and repair except that once the medial conjoint tendon is isolated, the procedure includes not only debridement of the involved portion of the tendon, but, also resection of the proximal 2 to 3 cm of the medial conjoint tendon (see Figure 6). Closure and splinting, as well as the postoperative program, are similar to debridement and repair. Rehabilitation
Fig 9. (A) Note the coverage of the medial conjoint tendon (MCT) by the flexor pronator muscles after release of the retractors before the repair. (B) The flexor pronator (FP) fascia is closed over the repair to protect the repair and minimize irritation from subcutaneous knots and minimize the risk of flexor pronator muscle hernation postoperatively. Abbreviation: ME, medial epicondyle.
MANAGEMENTOF MEDIALEPICONDYLITIS
The patient is seen in the office at 10 days postoperative for wound examination and application of a well-padded munster cast, again with the forearm and wrist in neutral. Gentle elbow range of motion as allowed by the munster cast (typically 45 ° to 120 °) is performed for an additional 2 weeks. At this time, the cast is removed and a wrist splint, at neutral, is applied, and a noncomposite gentle range of motion program is initiated. Because the medial conjoint tendon components cross 3 joints (elbow, forearm, and wrist), relaxation of the tendon at 1 joint can allow for range of motion at another joint without considerably loading the medial conjoint tendon. Elbow range of motion is therefore performed with the forearm passively positioned in pronation and the wrist palmar flexed. Forearm and wrist range of motion is performed with the elbow at 90 °. This noncomposite program is maintained for 3 weeks, after which a composite range of motion program with full elbow extension, forearm supination, and wrist dorsiflexion is initiated. A gentle flexor pronator strengthening program is started at 6 to 8 weeks. A graduated resumption of pitching activities may be started when good flexor pronator strength is restored and pitching is pain free, typically at 3 to 4 months. Full reintegration into a preinjury throwing program usually requires 6 to 9 months. 209
RESULTS
REFERENCES
In the absence of c o n c o m i t a n t disease, the results of m e dial conjoint t e n d o n d e b r i d e m e n t a n d t e n d o n repair are typically good, w i t h the majority of patients (greater t h a n 75%) r e s u m i n g the p r e i n j u r y level of competition. Because the original injury w a s a consequence of the mechanics of the n o r m a l t h r o w i n g routine, there is a risk of recurrence or the potential for the athlete not to regain his or her f o r m e r level of proficiency. The patient s h o u l d be a d v i s e d of this before a n y surgical intervention. In the case of the recreational athlete, the loads are typically less intense a n d less frequent, a n d these patients will overall h a v e a generally i m p r o v e d p r o g n o s i s c o m p a r e d w i t h the high-level t h r o w i n g athlete.
1. Jobe FW, Stark H, Lombardo SJ: Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am 68:1158-1163, 1986 2. Gabel GT, Morrey BF: Operative treatment of medical epicondylitis. Influence in concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am 77:1065-1069, 1995 3. Stahl S, Kaufman T: Ulnar nerve injury at the elbow after steroid injection for medial epic0ndylitis. J Hand Surg Br 22:69-70, 1997 4. Gabel GT, Nirschl RP: Medial epicondylitis, in: Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, Saunders, 2001 5. Kurvers H, Verhaar J: The results of operative treatment of medial epicondylitis. J Bone Joint Surg Am 77:1374-1379, 1995 6. Ollivierre CO, Nirschl RP, Pettrone FA: Resection and repair for medial tennis elbow. A prospective analysis. Am J Sports Med 23:214221, 1995 7. Vangsness CT, Jobe FW: Surgical management of medial epicondylitis. J Bone Joint Surg Br 73:409-411, 1991
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GERARD T. GABEL