Iontophoresis Protocol:

Golfer's Elbow
Medial Epicondylitis
3
ETIOLOGY PATIENT EVALUATION

Medial epicondylitis occurs at the common flexor tendon A. Subjective:

at the tenoperiosteal site or musculotendinous origin from Patient complaint
overuse or direct trauma. Muscles arising from the medi- Location
al epicondyle are the pronator teres, flexor carpi radialis, Onset and duration of symptoms
palmaris longus and the flexor carpi ulnaris. Arm sports
such as baseball pitching, golf, javelin throwing or tennis Description of symptoms (i.e. numbness, pain
serving often give rise to medial epicondylitis, in which [constant, dull, sharp] hypersensitivity, stiffness);
the elbow is extended with a sudden vagus force, while use pain scale
the wrist is in flexion. Pain is felt at the medial aspect of Pattern of when symptoms occur (AM, PM,
the forearm and usually does not radiate. after activity, etc.)
Self-help or other formal treatment
Medial epicondylitis may be tested for and confirmed by: Other medical problems
passively extending the wrist with over-pressure Concurrent medications and allergies
while maintaining the forearm in an extended,
supinated position, or, B. Objective (also compare with uninvolved elbow):
1. Inspection
resisting active wrist flexion while maintaining Carrying angle, arm posturing
the forearm in a pronated, extended position. Redness, swelling, warmth
Scars

2. Palpation:
Medial epicondyle, olecranon, groove,
Typical Dispersive olecranon process, lateral epicondyle, cubital
Pad Site (on biceps) fossa.
Soft tissue: muscles and tendons (medially,
posteriorly, laterally, anteriorly).

3. Mobility:
Typical Drug Active and passive ROM (flexion, extension,
Electrode Site supination, pronation)
(over medial epi-
condyle) 4. Muscle Testing:
Wrist flexors, extensors, supinators, pronators.
Elbow flexors and extensors.
Pronator
5. Provocation Tests:
Teres With the elbow extended and forearm supinat-
ed, passively extend the wrist while maintain-
ing elbow extension.
Flexor Carpi With the elbow extended, forearm pronated
Radialis and wrist in midposition, resist wrist flexion
while maintaining elbow extension.
Tinel sign: to rule out ulnar nerve neuroma or
Palmaris Longus
ulnar neuritis, tap the ulnar nerve, located in the
groove between the olecranon and medial epi-
condyle. Tingling in the ring and little finger
Flexor Carpi Ulnaris (ulnar nerve distribution) indicates a positive
sign.
(Objective continued)
6. Neurological:
Reflexes, sensation
7. Other Joints:
Test neck, shoulder, wrist and hand for
secondary involvement
8. Review x-ray films and physician's report
C. Assessment:
1. Problem list
2. Goals
3. Treatment:
Iontophoresis (medications, dosages,
electrode size)
Other modalities (e.g. ice or heat, stretching,
strengthening, massage, home program, activi-
ty or sport re-education to prevent re-injury,
etc.)
Oral or injectable medications (administered
by physician, e.g. NSAIDs, corticosteroids)
D. Plan:
1. Frequency and duration of treatment
2. Date(s) for assessment of progress
WHY IONTOPHORESIS IS
APPROPRIATE THERAPY
Iontophoretic drug delivery for the condition of medial
epicondylitis provides an alternative to hypodermic injec-
tion of corticosteroids, with increased comfort and
decreased systemic and localized side effects. It allows
short term administration and avoids the associated dis-
comfort of needle insertion at an already tender area of tis-
sue. Avoiding the use of a hypodermic needle prevents
further tissue trauma and eliminates the risk of infection at
the injection site. Also, the risk of potential necrosis
and/or tendon weakening associated with bolus injections
of corticosteroids is eliminated. Medial epicondylitis is
usually a very well localized condition, appropriate for
electrode placement over the affected site.
RE-EVALUATION
In addition to patient's subjective reports, check for:
decreased pain, decreased tenderness to palpation at the
medial epicondyle and muscles, decreased swelling, neg-
ative provocation tests, increased strength and endurance
of the forearm flexors and resolution of pain.
Distributed By:
Balego & Associates, Inc.
1-800-322-2781
Fax: 651-633-0024
www.BalegoOnline.com
IOMED, Inc., 1993. Printed in USA. 3/03. All rights reserved.
IONTOPHORESIS PROCEDURE
IMPORTANT: See iontophoresis system and electrode
instruction guides for indications, contraindications, warnings,
precautions and directions for use.
1. Clean skin is absolutely necessary to minimize or elim-
inate skin irritation. Clean both electrode sites vigor-
ously with an alcohol wipe prior to applying electrodes
to remove dry skin, salts and oils. Excess hair may be
trimmed with scissors or electric clippers. Do not
shave skin. Doing so may result in excessive irritation
or burns.
2. Prepare electrodes according to package instructions.
3. Place the drug electrode over the involved medial
epicondyle at its most tender point.
4. The dispersive pad may be placed proximal or distal
to the drug electrode, over a major muscle (e.g.
biceps). Never tape, bind or compress either electrode
in any way. Properly prepared drug electrodes and dis-
persive pads do not require added fixation on properly
prepared skin.
5. Do not allow the patient to extend or flex the arm or
to press on or lean against the electrodes during treat-
ment. This prevents circuit breaks and minimizes the
possibility of excessive skin irritation or burns.
6. Treat for 40 milliampere-minutes according to the
package instructions.
7. Treat every other day. Usually, no more than six treat-
ments are required, but there is no contraindication for
additional treatments.
REFERENCES
1. Hartley, A. 1990. Practical Joint Assessment. Mosby Year
Book. St. Louis.
2. Hoppenfeld, S. 1976. Physical Examination of the Spine
and Extremities. Appleton-Century-Crofts. New York.
3. Saunders, H.D. 1985. Evaluation, Treatment and Prevention
of Musculoskeletal Disorders. W.B. Saunders. Minneapolis.
4. Warwick, R. and Williams, P. 1983. Gray's Anatomy, 35th
British Ed. W.B. Saunders. Philadelphia.
Edited By: For:
Rebecca Stephenson, PT IOMED, Inc.
Stephenson Physical Therapy 2441 South 3850 West, Suite A
335 Main Street Salt Lake City, Utah 84120 USA
Medfield, MA 02052 Ph. 800.621.3347 Fax 800.318.7793