Differential Diagnosis for Golfer's Elbow (Medial Epicondylitis)
Primary Diagnosis
- Medial epicondylitis (golfer's elbow) is a degenerative tendinopathy of the common flexor-pronator origin at the medial epicondyle, affecting 1-3.8% of the general population, most commonly between ages 40-60 1
Differential Diagnoses with Physical Exam Findings
Medial Compartment Pathologies
- The American College of Radiology recommends pain with valgus stress testing of the elbow as a diagnostic criterion for UCL injury 3
- Medial joint line tenderness (distinct from epicondyle) is a diagnostic finding for UCL injury 3
- A positive moving valgus stress test in throwing athletes is indicative of UCL injury 3
- The Journal of the American College of Radiology suggests that ulnar nerve subluxation with elbow flexion/extension is a diagnostic finding for cubital tunnel syndrome 4
Intra-articular Pathologies
- Mechanical symptoms such as locking, clicking, or catching are indicative of intra-articular pathology, including osteochondral lesions (capitellum or medial trochlea) 3, 2
- Limited range of motion and effusion may be present in osteochondral lesions 3, 2
- Pain with passive range of motion (differentiates from tendinopathy) is a diagnostic finding for intra-articular loose bodies 2
Relevant Workup
Initial Imaging
- The American College of Radiology recommends plain radiographs of the elbow as the most appropriate initial imaging study to rule out osseous pathology 3, 2, 1
- Standard AP and lateral views can identify intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification within tendons, and occult fractures 2, 1
Advanced Imaging (When Radiographs Normal/Nonspecific)
- MRI elbow without contrast is indicated for suspected tendon tear, nerve entrapment, or soft tissue pathology with normal radiographs 3, 2, 1
- T2-weighted MR neurography is the reference standard for imaging ulnar nerve entrapment, showing high signal intensity and nerve enlargement 3, 4
- MR arthrography elbow (3T) is the most accurate for UCL tears, with 81% sensitivity, 91% specificity, and 88% accuracy 3, 5, 6
Electrodiagnostic Studies
- EMG and nerve conduction studies are indicated when neurologic symptoms suggest cubital tunnel syndrome, pronator syndrome, or posterior interosseous nerve syndrome 2
Key Clinical Pearls
Red Flags Requiring Further Investigation
- Night pain or pain at rest suggests inflammatory or neoplastic process 2
- Mechanical symptoms (locking, catching) indicate intra-articular pathology 3, 2
- Neurologic symptoms (paresthesias, weakness) require nerve evaluation 2