The "forgotten sister" of lateral epicondylitis

While tennis elbow (lateral epicondylitis) receives ample clinical and research attention, golfer’s elbow (medial epicondylitis) remains underdiagnosed — despite affecting a diverse population that goes far beyond golfers. Computer professionals, weight-training practitioners (biceps curls, rows), manual workers, and even musicians suffer from pain on the inside of the elbow that worsens when forcefully closing the hand, rotating the forearm, or lifting objects with the palm up.

Medial epicondylitis is a tendinopathy of the flexor-pronator muscles that originate at the medial epicondyle of the humerus. The pronator teres, flexor carpi radialis, and palmaris longus are the main muscles involved. Medical acupuncture with dry needling of these muscles and their trigger points — combined with electroacupuncture for pain neuromodulation — offers an effective approach that treats the muscular cause without the risks of corticosteroid injection.

Mechanism of pain in medial epicondylitis

  1. Overload of the flexor-pronators

    Repetitive movements of wrist flexion and forearm pronation — present in typing, weight training (biceps curls, rows), throwing, and manual work — overload the tendinous origin at the medial epicondyle. Repetitive microlesions accumulate faster than the tissue can repair.

  2. Degenerative, not inflammatory, tendinopathy

    Despite the suffix "-itis", chronic epicondylitis is predominantly degenerative (tendinosis), not inflammatory. Histologically, one finds collagen disorganization, abnormal neovascularization, and increased substance P — which explains why anti-inflammatories and ice offer only partial and temporary relief.

  3. Trigger points in the wrist flexors

    Trigger points in the pronator teres, flexor carpi radialis, and palmaris longus refer pain to the medial side of the elbow and forearm, mimicking and amplifying the tendinous pain. These trigger points maintain chronic muscle tension that overloads the tendon — creating a vicious cycle of pain and dysfunction.

  4. Concomitant ulnar neuropathy

    The ulnar nerve passes through the cubital tunnel, immediately posterior to the medial epicondyle. Inflammation and edema associated with medial epicondylitis can compress the ulnar nerve, causing tingling in the 4th and 5th fingers. This association occurs in up to 50% of chronic cases and should be actively investigated.

  5. Neuromodulation by electroacupuncture

    Electroacupuncture at the trigger points of the flexors and at the medial epicondyle modulates nociceptive transmission via segmental inhibition and release of endogenous opioids. The 2 Hz frequency stimulates release of enkephalins and beta-endorphins, promoting prolonged analgesia and reduction of central sensitization.

Epidemiology of medial epicondylitis

0.4–1%
OF THE GENERAL POPULATION
is affected by medial epicondylitis — less common than the lateral form, but frequently more persistent and with greater functional impact
Frequent
ASSOCIATED ULNAR NEUROPATHY
clinical series describe frequent coexistence of ulnar neuropathy at the cubital tunnel in chronic cases — always investigate tingling in the 4th and 5th fingers
75%
IN THE DOMINANT ARM
medial epicondylitis predominates on the dominant side, reflecting asymmetric functional overload in manual activities
Most
RESOLVE WITHOUT SURGERY
most patients respond to conservative treatment (dry needling, eccentric exercises, activity modification), with surgery rarely indicated

Identifying medial epicondylitis

Critérios clínicos
07 itens

Golfer's elbow — typical pattern

  1. 01

    Pain on the inside of the elbow when shaking hands forcefully

  2. 02

    Worsens with resisted forearm rotation (pronation)

  3. 03

    Pain when lifting objects with the palm up

  4. 04

    Grip weakness — difficulty opening jars or gripping objects

  5. 05

    Pain radiating along the medial forearm to the wrist

  6. 06

    Worsens with biceps curls, rows, or pulling exercises at the gym

  7. 07

    Tingling in the 4th and 5th fingers (when associated with ulnar neuropathy)

Myths and facts about golfer's elbow

Myth vs. Fact

MYTH

Only golfers get golfer's elbow

FACT

Despite the name, medial epicondylitis is more common in non-golfers. Office professionals (typing and mouse use), weight-training practitioners (biceps curls, rows, close-grip bench press), manual workers, and throwers are high-risk populations. The popular name persists by tradition, but "medial epicondylitis" is the correct term.

MYTH

Corticosteroid injection is the best treatment

FACT

Corticosteroid injections offer short-term relief, but follow-up studies in elbow tendinopathies show that long-term outcomes can be inferior to those of exercise treatment or even the natural course. Repeated corticosteroids can weaken the tendon. Dry needling with medical acupuncture addresses trigger points without the deleterious effects of corticosteroids on tendinous tissue.

MYTH

If the pain is in the elbow, the problem is in the elbow

FACT

Pain at the medial epicondyle may have a referred-pain component from trigger points in the pronator teres, flexor carpi radialis, and even the triceps (medial head). Treating only the medial epicondyle with local therapies, without assessing trigger points in the forearm muscles, explains many cases of "refractory epicondylitis" that actually have an undiagnosed myofascial cause.

The ulnar nerve as a key piece of the diagnosis

Treatment protocol

Assessment and differential diagnosis
1st visit

Resisted wrist flexion and resisted pronation tests to confirm medial epicondylitis. Tinel test at the cubital tunnel for ulnar neuropathy. Palpation of trigger points in the pronator teres, flexor carpi radialis, and palmaris longus. Exclusion of medial ligamentous instability.

Dry needling of the flexor-pronators
Sessions 1–4

Needling of trigger points in the pronator teres (main target), flexor carpi radialis, and palmaris longus. 2 Hz electroacupuncture at the medial epicondyle and at distal trigger points. Load guidance: avoid biceps curls, heavy rows, and forced pronation during initial treatment.

Progressive eccentric exercises
Sessions 3–6

Introduction of eccentric exercises of the wrist flexors — the gold standard for tendinous rehabilitation. Gradual load progression. Dry needling of proximal muscle chains (medial triceps, subscapularis) if they contribute to dysfunction.

Functional return and prevention
Sessions 7–10

Progressive return to activities that provoked pain — with emphasis on ergonomics and correct technique. Adjustment of grip in weight training (prefer neutral grip, avoid forced supination). Ergonomic guidance for mouse and keyboard use. Maintenance sessions as needed.

Clinical pearl: the forgotten pronator teres

Frequently asked questions

FREQUENTLY ASKED QUESTIONS · 03

Frequently Asked Questions

Training with active medial epicondylitis pain perpetuates the injury. In the initial treatment phase, it is necessary to modify exercises: avoid biceps curls, rows with supinated grip, and close-grip bench press. Exercises with neutral grip (parallel dumbbells) are generally tolerated. Progressive reintroduction of movements is done as pain decreases, guided by the physician.

A forearm brace can relieve pain by redistributing the load on the tendinous origin, but it is palliative — it does not treat the cause. In combination with dry needling and eccentric exercises, it can be useful in the acute phase to allow essential activities. Its isolated use is not sufficient for resolution of the picture.

With adequate treatment (dry needling, eccentric exercises, activity modification), most patients report significant improvement in 4–6 weeks. Chronic cases with associated ulnar neuropathy may take 8–12 weeks. Adherence to home exercises and modification of habits are decisive for the recovery time.