Case Report: Application of extracorporeal shockwave therapy in medial epicondylitis with concomitant ulnar nerve instability: a case series with long-term follow-up

BackgroundMedial epicondylitis is an overuse syndrome characterized by degeneration of the flexor-pronator tendons in the elbow, resulting from repetitive forced wrist flexion and forearm pronation. Due to its anatomical location, medial epicondylitis patients may also feature ulnar nerve instability, which can exacerbate symptoms and negatively impact treatment outcomes. Although conservative treatments remain the cornerstone of care for managing medial epicondylitis, the optimal treatment method remains an open question.ObjectiveTo evaluate the effects of a combined extracorporeal shockwave therapy (ESWT) protocol on pain, symptom severity, and functional outcomes in medial epicondylitis patients with concomitant ulnar nerve instability.DesignRetrospective case series study with two-year post-treatment follow-up.SettingCenter for Rehabilitative Medicine “Sport and Anatomy”, University of Pisa.InterventionsPatients underwent a combined ESWT using the Duolith SD1 ultra device (Storz Medical AG., Switzerland), consisting of sequential focal (0.15–0.20 mJ/mm2, 5–6 Hz, 1,000 shocks) and radial (1.3–1.8 mJ/mm2, 14 Hz, 2,000 shocks) shockwave application per session. Each patient received three to five weekly sessions.ParticipantsMedial epicondylitis patients with concomitant ulnar nerve involvement who underwent a combined ESWT protocol between September 2019 and May 2023.Main outcome measuresPain severity and upper limb disability were assessed with the numerical rating scale, the shortened Disabilities of the Arm, Shoulder and Hand questionnaire, and the Ulnar Neuropathy at the Elbow Questionnaire. Patient treatment satisfaction was evaluated with the Roles and Maudsley score.ResultsOf the reviewed 15 consecutive medical charts, only three subjects fulfilled the inclusion criteria. Two patients showed a marked decrease in pain and improved functionality scores at all time points; one patient remained unchanged throughout the study; no adverse effects were observed.ConclusionsThis retrospective study suggests that ESWT may be efficacious and safe for treating medial epicondylitis patients with concurrent ulnar nerve instability. Prospective studies with a larger sample size are needed to warrant the present results.