the journal of the canadian chiropractic association
Conservative management of a case of medial epicondylosis in a recreational squash player
Karen Hudes, BSc, BS, DC*
A search of the literature for “epicondylitis” yields a plethora of information mainly regarding lateral elbow pain. There is much less information regarding pain of the medial elbow. This outcome is likely due to the fact that lateral epicondylitis is diagnosed between three and ten times more frequently than the medial version.1,2,3 One review reports that of all diagnoses of epicondylitis, medial epicondylitis makes up 9.8% to 20% of all cases.2 In general, lateral epicondylitis is thought to be due to repetitive trauma injuries whereas medial epicondylitis occurs due to valgus stress placed on the elbow as well as forceful work.4,5 The term “epicondylitis” has been abandoned by many researchers as it implies an ongoing inflammatory process. Studies of the histological nature of these conditions have shown that the condition on the lateral side of the elbow, and likely the medial side as well, is actually “a degenerative or failed healing tendon response characterized by the increased presence of fibroblasts, vascular hyperplasia, and disorganized collagen.”1,6 The term epicondylosis, which is a more appropriate term in light of these findings, will therefore be used for the remainder of this paper, although a search of the literature using the term “medial epicondylosis” does not yield many articles.
The incidence of presentation of peripheral conditions to chiropractors is reported as 17.1% of chief complaints.7 According to the National Board of Chiropractic Examiners 2005 Job Analysis of Chiropractic, the chief presenting complaint on initial visit of 8.3% of chiropractic patients in 2003 was in an upper extremity. The prevalence of medial epicondylosis is 0.4% according to the literature.8 Studies have noted that the dominant arm is involved in 82% of cases, the mean age was 45 years, and 51% of sufferers are female.9,10 Gender association in medial epicondylosis remains controversial with some studies reporting a gender bias towards females and another refuting it.8,9 Prevalence seems to be higher in the following categories: age range of 45–65, current and former smokers, high body mass index, larger waist circumference, higher waist to hip ratio, and type 2 diabetes.8 Despite the common name of “golfers elbow” it is reported in one study that 90–95% of those affected were not atheletes.1 Grip strength measures, which are generally negatively affected with lateral epicondylosis, do not seem to be as reliable a measure of pain or disability in medial epicondylosis.11 The prognosis for medial epicondylosis is reported as an 81% resolution over a three year period.4
Medial epicondylosis exhibits characteristic pain along the medial aspect of the elbow, which is exacerbated by resisted wrist flexion and/or forearm pronation.5 The vast majority of cases of medial epicondylosis can be treated using conservative methods, although severe cases of prolonged duration (over 6 to 12 months) may require a surgical consultation regarding release of the common flexor origin.9The purpose of this paper is to present a case of medial epicondylosis in a 35 year old male recreational squash player that was managed using conservative method