Epicondylitis: lateral, internal, medial and others

General information

Epicondylitis of the elbow joint is an inflammatory process affecting the epicondyles of the humerus and occurs as a result of stress on the muscles. As the disease progresses, degenerative-dystrophic changes occur in the tendon attachment zone. There may be small tears in the muscles and their tendons, periostitis . Two forms of the disease are identified, differing in the location of pain. The so-called medial epicondylitis (or “golfer’s elbow”) is an internal form that occurs against the background of prolonged monotonous hand movements in people of certain professions. Lateral epicondylitis (or “tennis elbow”) is an external form that develops as a result of significant stress on the limb.
Because this form often develops in people who play tennis professionally, it is also called “tennis elbow syndrome.” ICD-10 code: medial epicondylitis - M77.0, lateral epicondylitis - M77.1. There are many reasons leading to the development of such damage to the shoulder, elbow, and knee joint - from severe overloads to injuries. The medical literature notes that this disease occurs quite often (5-10% in the general population). Due to the predominance of right-handers, the right hand is mainly affected.

How the symptoms of this disease manifest themselves and which treatment methods are the most effective will be discussed in this article.

Epicondylitis

External epicondylitis is one of the most common diseases of the musculoskeletal system. Its true incidence is unknown due to the high frequency of mild forms for which patients do not seek medical help. In the English-language literature, the term “tennis elbow” is used to refer to this disease, due to the high frequency of this pathology in tennis players. This is due to the fact that when playing tennis, especially with an incorrectly selected racket and defects in the backhand technique, the extensor tendons of the hand are overloaded, with the subsequent development of the characteristic symptoms of external epicondylitis. In Russia, tennis is not yet a popular sport, and in the vast majority of patients, overload of the proximal attachment zones of the forearm muscles is associated with more prosaic reasons (professional activity, carrying heavy loads, performing repairs, home canning). The disease affects middle-aged people (40–60 years old). The process involves predominantly the dominant limb (right hand). The pathogenesis of the disease is the occurrence, as a result of overload, of microtraumatization of tendon tissue with the subsequent development of an inflammatory reaction. In some cases, the disease is preceded by direct trauma. The pre-existing condition of the ligamentous apparatus is also important. Thus, hypermobile individuals (with signs of congenital weakness of the ligamentous apparatus) have a tendency to develop this disease; They also have a more severe course. History The disease can begin after an episode of overload (in the variants mentioned), and repeated movements of the hand in the position of abduction and flexion at the elbow joint are important. However, pain in the elbow joint often occurs against the background of the normal rhythm of life. In the latter case, we are talking about gradual involutive changes in the musculoskeletal system, which are manifested by degenerative processes in the area of ​​the epicondyles of the humerus without visible external causes. Once present, the pain caused by epicondylitis can last for weeks or months. Clinical picture With lateral epicondylitis, patients complain of pain in the elbow joint, provoked by the load associated with extension of the fingers and supination of the hand. In this case, the load can be very small, for example, an attempt to take an object from the table (even as small as a cup of tea). The pain is well localized - patients confidently point to the outer (with external epicondylitis) or inner (with internal epicondylitis) surface of the elbow joint. The pain may radiate distally along the outer or inner surface of the forearm or up to the lower third of the shoulder. There is no pain at rest. An important sign that allows you to distinguish epicondylitis from damage to the elbow joint itself is the absence of pain during active and passive flexion and extension of the elbow joint. Diagnosis The diagnosis of epicondylitis is based solely on clinical examination. Strictly localized tenderness of the external or internal epicondyle is determined (simultaneous involvement of both structures does not occur). In some cases, the painful area includes adjacent areas of the tendons. Additional information supporting the diagnosis is obtained using active motion resistance tests. In the case of lateral epicondylitis, this is resistance to extension of the hand (Fig. 2); with medial epicondylitis, pain is provoked by resistance to flexion in the wrist joint. An attempt to move is made in the wrist joint, but pain occurs at the site of muscle attachment in the elbow joint (external or internal epicondyle) (Fig. 2). The list of diseases with which the differential diagnosis of epicondylitis is made includes lesions of the elbow joint itself (arthritis, aseptic necrosis of the articular surfaces) and tunnel syndromes of this area (pronator teres syndrome - entrapment of the median nerve, cubital tunnel syndrome - entrapment of the ulnar nerve). Differential diagnosis of epicondylitis and damage to the elbow joint is not difficult. In the case of arthritis, the pain is reproduced by movements in the elbow joint; often with arthritis, a flexion contracture is formed. The pain is localized not in the area of ​​the epicondyle, but in the projection of the joint itself. Neurological causes of pain are accompanied by signs of damage to peripheral nerves - impaired sensitivity and weakness of the corresponding muscles. When developing the clinical picture of epicondylitis in young people, it is advisable to search for signs of systemic pathology in the patient - joint hypermobility, the presence of other non-inflammatory lesions of connective tissue structures, which would allow classifying this pathology as a manifestation of a systemic disease - hypermobility syndrome. Instrumental and laboratory methods are usually not used in the diagnosis of epicondylitis. Only in cases of obvious trauma can conventional radiography exclude bone damage (possible fracture of the lateral epicondyle), and normal laboratory tests (acute phase indicators) exclude inflammatory joint disease. In case of chronic or often recurrent epicondylitis (which is extremely rare), on the x-ray one can see changes typical of chronic enthesopathies - loosening of the cortical layer, cyst-like restructuring of the bone tissue in the area of ​​the affected enthesis and ossification of the enthesis in the form of a “spur”. The affected structures in epicondylitis are so superficial that the use of soft tissue imaging methods (ultrasound, magnetic resonance imaging) does not provide any additional useful information. Treatment Treatment of epicondylitis is exclusively conservative. In the case of minor pain (when the patient is more concerned about the cause of his discomfort than the pain itself), treatment may be limited to a protective regime for the affected limb - “do not make movements that cause pain.” If epicondylitis occurs in a person engaged in physical labor or an athlete, the logical advice is to take a break from physical activity (stop training) until the symptoms disappear completely, followed by a gradual increase in the volume of exercise. In these cases, it is advisable to establish the cause of the overload - improper working conditions or inconvenient tools. If the patient really plays tennis, then recommend that he use a lighter weight racket. However, these tips do not apply to all patients. As a rule, people seek medical help who have a long history of pain and who, despite a gentle regimen, are tired of waiting for an independent recovery. In case of severe pain, short-term immobilization is used - a light splint on a scarf. When epicondylitis develops after injury, local cold is effective - applying ice to the painful area several times a day. The effectiveness of therapeutic exercises aimed at stretching connective tissue structures has been shown - in the case of external epicondylitis, these are daily courses of short-term hyperextension in the wrist joint. Since the main cause of pain in epicondylitis is an inflammatory reaction, the use of anti-inflammatory therapy is pathogenetically justified. Due to the superficial location of the epicondyles, a good effect can be expected from the local use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the form of ointments and gels. One of the most effective products from this group is Nurofen Gel. The main active ingredient of Nurofen Gel is ibuprofen, which provides its analgesic and anti-inflammatory activity. The gel is applied in a 3–5 cm strip to the painful area and rubbed in thoroughly until completely absorbed. Frequency of application 3-4 times a day. Nurofen Gel has a rapid effect by suppressing the synthesis of inflammatory mediators directly in the lesion, which in epicondylitis is located directly under the skin. The drug extremely rarely causes side effects, mainly in the form of skin hyperemia caused by individual sensitivity to ibuprofen. This reaction quickly disappears when you stop using the drug. With epicondylitis, we are talking about suppressing inflammation in a very small structure, and therefore oral, and even more so parenteral, NSAIDs, in which the drug is distributed throughout the body, are inappropriate. In comparative studies, the effectiveness of oral NSAIDs did not differ from the effect of placebo. In case of persistent pain syndrome that does not respond to local use of NSAIDs, the method of choice is local injection of microcrystalline glucocorticosteroids (GCS) mixed with an anesthetic. Of the GCS drugs available to the doctor, betamethasone dipropionate can be considered the most suitable. The use of triamcinolone preparations is extremely undesirable, since if it gets under the skin, it can cause severe degenerative changes (depigmentation, cicatricial adhesion of the skin to the epicondyle). The use of a suspension of hydrocortisone or methylprednisolone is possible, but in this case the patient must be warned about the mandatory increase in pain in the first day after the injection due to the development of severe microcrystalline inflammation (tissue reaction to the injected drug crystals). Due to the distinct localization of the process in the area of ​​the epicondyle, the choice of injection site is not a problem. This is the point of maximum pain, which can be located both in the center of the epicondyle and along its edges. The scheme and the administration of GCS itself for external epicondylitis are shown in Figures 3 and 4. In some cases, it is necessary to infiltrate additional painful points, determined by palpation, in the projection of the adjacent tendons. Adding an anesthetic (2% lidocine) to the GCS preparation allows literally 1-2 minutes after the injection to assess the correctness of the diagnosis and the accuracy of the injection itself - the pain should disappear. If it persists somewhere, then the rest of the suspension is introduced into this zone. Since the enthesis in the area of ​​the external epicondyle is a very dense tissue, the injection must be performed with high pressure on the piston, which requires fixing the needle (0.6–0.4 mm–25 mm) with the fingers of the other hand. This also limits the total volume of the administered suspension - the syringe contains 1.5–2 ml of a mixture of GCS and anesthetic. 0.5–0.7 ml of suspension is injected into one point. The procedure is carried out once, in rare cases it is necessary to re-administer after 7-10 days. Injections are not repeated more than 2 times. Certain inconveniences arise when it is necessary to carry out infiltration in the area of ​​the internal epicondyle with the patient sitting. With medial epicondylitis, it is much more convenient to place the patient on the couch with his stomach down and his arms extended along the body (Fig. 5). In this position, the entire internal area of ​​the elbow joint is easily accessible to the doctor, and accidental injury to the ulnar nerve (passing between the internal epicondyle and the olecranon process) is practically excluded. In the vast majority of cases, the above treatment methods have an effect - pain completely disappears within 2-3 weeks with conservative treatment and 2-3 days after GCS injection. Relapses are possible; to prevent them, it is important to explain to the patient the need to adhere to an optimal motor regimen that eliminates overload of the entheses involved in the process. However, in some patients, the pain caused by epicondylitis is persistent. The pain is difficult to respond to even GCS infiltration (the effect is limited to a few days). Factors of poor prognosis (frequent relapses, incomplete relief of pain) are bilateral lesions, the presence of systemic weakness of the ligamentous apparatus (articular hypermobility) and the simultaneous identification of signs of asthenic-depressive syndrome (fibromyalgia). In the latter case, the complex of treatment measures must include the use of antidepressants (amitriptyline). In persistent cases of epicondylitis, the use of a relatively new treatment method - extracorporeal shock wave therapy - is indicated. This method is based on the impact of high-energy ultrasound on the affected structure. Also described are individual cases of successful surgical treatment of epicondylitis - excision of detectable enthesis ossification. Thus, epicondylitis of the elbow joint is a common form of soft tissue periarticular pathology that is relatively easy to diagnose and treatable (except for rare persistent cases). The capabilities available to modern medicine make it possible to cure the vast majority of patients.

References 1. Astapenko M.G., Eryalis P.S. Extra-articular diseases of soft tissues of the musculoskeletal system. – M.: Medicine, 1975; 65–68. 2. Bunchuk N.V. Diseases of extra-articular soft tissues. In a manual of internal medicine. Rheumatic diseases. Ed. V.A. Nasonova, N.V. Bunchuk. –M. Medicine.1997 – P. 418–19. 3. Doherty M.B., Doherty D. Clinical diagnosis of joint diseases. – Minsk. Tivali, 1993. 4. Hotchkiss R. Epicondilitis – lateral and medial. Hand clin., 2000;16; 505–8. 5. Speed ​​CA. Corticosteroid injections in tendon lesions. BMJ, 2001; 323; 382–6. 6. Smidt N. Corticosteroid injection, physiotherapy or “wait–and–see” policy for lateral epicondilitis: a randomized controlled trial. Lancet, 2002, 309; 657–62. 7. Melikian EY Extracorporal shock wave treatment for tennis elbow. A randomized dowble–blind trial. J Bone Joint Surg Br 2003; 85; 852–5.

Pathogenesis

During the development of the disease, periosteal inflammation occurs, subsequently leading to the appearance of microtraumas in the area of ​​muscle attachment. Local inflammation of the nerves innervating the epicondyles may also develop. Factors that provoke the development of these processes are microtrauma or muscle failure. In addition, local disorders in the tendons, collagen degeneration of cartilage tissue, degeneration of fibrils and fibrocytes can be provoking phenomena.

The pathophysiology of the disease is associated with professional activities and activities that require constant forceful supination and pronation of the forearm. During the development of the process, the development of subperiosteal hemorrhages, calcification , and degenerative changes in tendon tissue may be noted.

Physiotherapy

Physiotherapeutic treatment is carried out:

• magnetic therapy;
• phonophoresis;
• cryotherapy;
• mud therapy;
• paraffin therapy;
• Bernard currents;
• electrophoresis with anti-inflammatory drugs (with acetylcholine, potassium iodide, novocaine);
• shock wave therapy.

These procedures improve metabolic processes in tendon and muscle tissue, restore blood microcirculation in muscle tissue, and eliminate pain and inflammation.

The painful area is cooled. Use cold accumulators or irrigation with chlorethyl. You can use ice cubes wrapped in a towel. The procedure is carried out once a day.

Massage

Perform a massage every day for 15 minutes. Knead the points where muscle tightness is located. The course is 12 days. Massage should not cause discomfort to the patient.

If all of the above procedures do not bring positive dynamics and the expected result, the disease progresses, then surgical treatment is used.

Classification

According to the characteristics of the course of the disease, the following forms are distinguished:

• Acute - in this case, first there are complaints of muscle tension and slight soreness, after which constant severe pain appears.
• Subacute – pain is felt during exercise, and disappears at rest.
• Chronic – pain manifests itself for three or more months, with remission followed by relapse.

According to the location of the disease, the following are distinguished:

• Lateral epicondylitis (external) - an inflammatory process develops in the tendons that attach to the epicondyle on the outside of the bone. External epicondylitis is diagnosed more often than internal epicondylitis. Often treatment for such a disease is required for those who play tennis.
• Medial epicondylitis of the elbow joint - inflammation develops in the area of ​​attachment to the internal epicondyle. The medial type of the disease can occur as a result of playing golf, shot throwing, javelin, etc. However, this type of disease develops not only in athletes, but also in tailors, typists, surgeons, etc. Due to the connection of this type of disease with certain activities, it develops more often in women .

Therapy

Treatment of epicondylitis
It is necessary to treat lateral and medial epicondylitis together.

It all depends on the stage of development of the disease, the cause of its occurrence, changes in the tendons and muscles in the area of ​​the hand and elbow, and the level of dysfunction of the joint.

The treatment helps relieve pain symptoms, relieve muscle strain, and eliminate inflammation. Drug therapy and folk remedies are used. In order to unload the muscles, use:

Gentle treatment and bandage

Treatment involves temporary cessation of professional activities that led to the development of epicondylitis. A special bandage is also used to immobilize the joint.

It allows you to immobilize the sore limb and relieve severe pain. Professional athletes regularly wear a brace to prevent overload of the joint.

Load Relief Clamp

A bandage is a special device that is attached to the upper part of the forearm. It prevents inflamed muscles from contracting and thereby relieves stress on them. The orthopedic bandage is worn only while awake; it is removed while sleeping.

The principle of its use is simple. The bandage firmly fixes the elbow joint, preventing excessive range of motion. Its choice must be approached thoroughly; it is better that the bandage is selected by an orthopedist, taking into account the anatomical features of the joint.

Gymnastics

It helps restore motor functions of the elbow joint. Gymnastics involves performing simple movements that stimulate muscle function. Exercises are performed aimed at stretching the tendons with maximum abduction of the hand.

Variant of gymnastics with a ball

Wrist trainers are used to help perform three-dimensional exercises. Exercises begin with exercise machines of maximum rigidity. Exercises are selected in such a way that the muscles are not overstrained.

Causes

• Epicondylitis of the elbow joint develops as a result of prolonged monotonous load on the muscles of the forearm. This disease is typical for people of certain professions - athletes, massage therapists, carpenters, milkmaids, masons, typists, etc.
• The occurrence of the disease can also be associated with sudden overload during heavy physical activity - for example, when lifting heavy weights.
• Epicondylitis is sometimes a consequence of prolonged carrying of heavy objects in the hand - suitcases, bags, etc. This leads to significant static muscle tension.
• The cause of the disease can be injury, as well as congenital weakness of the ligament apparatus.

Conservative treatment

Treatment with drugs can be carried out as monotherapy or represent a preparatory stage before physiotherapeutic procedures, as well as surgery. For this purpose, non-steroidal anti-inflammatory medications are used in the form of capsules, tablets, ointments or creams.

In case of severe inflammation, glucocorticoid hormones are prescribed, which have a more pronounced anti-inflammatory effect. The duration of therapy is determined by a decrease in the intensity of the inflammatory reaction, as well as the disappearance of clinical symptoms of the disease and restoration of the functional state of the elbow.

Symptoms of epicondylitis of the elbow joint

Symptoms of the disease depend on the location of the inflammatory process.

Lateral epicondylitis (“tennis elbow”) is manifested by the following symptoms:

• Pain on the outside of the elbow that radiates to the outside of the forearm.
• Increased pain in the elbow with movement, especially with external rotation of the forearm and its extension. The pain also becomes stronger during palpation of the external epicondyle of the humerus. At rest, the unpleasant sensations subside.
• The patient cannot hold objects in his hands.
• Due to atrophy of the forearm extensor muscles, the fingers may go numb, and at the same time pain in the shoulder develops.

Medial epicondylitis is manifested by the following symptoms:

• Pain on the inside of the elbow, which radiates to the flexor muscles of the forearm.
• The pain becomes worse during movement when the forearm bends inward.

Very often, symptoms can be pronounced and significantly affect the patient’s performance. However, sometimes they are weak. In this case, the disease may go away on its own over time. As a result, the person does not seek help, and the process can become chronic.

Eliminating pain

To relieve pain, tablets are prescribed: analgin, ketanov, renalgin. Local treatment is also carried out, using injections of glucocorticoids, such as Diprospan, Betamethasone.

Anti-inflammatory drugs are prescribed in the form of tablets or ointments, which contain Indomethacin, Diclofenac, Ibuprofen. Apply compresses with Dimexide.

Anesthetic injection into the elbow

For pain relief and improvement of local tissue trophism, blockades are made at the attachment point of the hand and fingers with lidocaine or novocaine in combination with hydrocortisone.

4 blockades with an interval of two days will be enough. Injections of B vitamins are prescribed.

Tests and diagnostics

The diagnosis is made on the basis of a survey, examination of the patient and a number of studies. The disease is not characterized by changes in laboratory tests.

Initially, the doctor collects anamnesis, asking the patient a series of questions.

Next, an examination is carried out, during which the specialist examines the affected area, determining whether there is swelling, redness, discomfort, or pain. A number of functional tests are also carried out - for example, the patient is asked to shake hands, raise a glass of water, etc.

In addition, the doctor may prescribe additional research methods: manual muscle testing, radiography, MRI, ultrasound, etc.

Treatment of epicondylitis with folk remedies

During the main treatment of the disease, treatment with folk remedies can also be practiced. However, their use should be agreed with your doctor. Under no circumstances should you replace basic treatment with traditional medicine.

Treatment of medial epicondylitis with folk remedies involves applying compresses, lotions, baths, and treating the affected area with homemade ointments.

• Horse sorrel tincture . Pour the dried horse sorrel root into a 1 liter jar so that half the jar is filled. Pour in vodka and leave for 10 days. Make compresses before going to bed, placing a cloth soaked in the tincture on the affected area.
• Ointment with propolis . Mix 50 g of propolis with the same amount of oil and dissolve in a water bath. Cool the resulting ointment and apply it to the affected area before going to bed, rub in and place polyethylene on top. Place a warm scarf on top.
• Blue clay compress . It is necessary to dilute the clay to the consistency of thick sour cream. Place it on the affected area in an even layer, cover with gauze and insulate it. This compress can be done several times a day, using fresh clay each time.
• Birch leaf compress . Take a handful of green birch leaves, wash them and pour boiling water over them. After half an hour, drain the liquid and apply wet leaves to the affected area and leave for 30 minutes. At night, fresh birch leaves are applied to the elbow without soaking them in boiling water. You can secure them with an elastic bandage without tightening it on the joint.
• Pine bath . Boil a handful of pine needles or cones for 10 minutes, then leave for another hour. After this, the warm product can be used for a bath.
• Sea salt bath . 3 tbsp. l. sea ​​salt pour 1 liter of warm water. Soak your elbow in the bath for half an hour. It is advisable to do this procedure before going to bed and not wash off the salt after it is finished.
• Oat straw bath . Pour 1 kg of oat straw with water and boil for 10 minutes. When the product has cooled sufficiently, dip your elbow into it and hold until the broth has cooled completely.

Prevention

To prevent the development of epicondylitis, you must adhere to the following rules of prevention.

• Avoid monotonous movements that increase the load on the joint, or try to limit them.
• When playing sports, you should wear an elastic bandage or elbow pad, which will help distribute the pressure on the muscles and secure the tendons.
• It is important to warm up before training to warm up your muscles.
• Physical exercise should be done taking into account age, body type, and physical fitness.
• People whose professional activities increase the risk of disease need to take breaks more often, choose a comfortable position and try to avoid prolonged monotonous movements.
• Take periodic massage courses that have a positive effect on the muscles.
• Treat all chronic diseases in a timely manner, follow all doctor’s recommendations during the recovery period after joint injuries.
• Practice balanced nutrition to prevent deficiencies of minerals and vitamins.
• See a doctor if joint pain occurs.

Diet

Diet for sore joints

• Efficacy: therapeutic effect after 2-3 months
• Terms: 2-6 months
• Cost of products: 1700-1800 rubles. in Week

It is important to have enough foods containing vitamin D and calcium in your diet. It is recommended to eat more cottage cheese, dairy products, and fatty fish.

You should minimize your consumption of foods containing sugar and also reduce the amount of salt you consume.

Tendinitis treatment - international experience

In an independent study by The American Journal of Sports Medicine, shock wave therapy was found to be more effective and safer than traditional conservative treatment for calcific tendonitis of the shoulder, providing a clear reduction in calcium deposits and a faster return of patients to sports or normal daily activities. activities. Below is the research report. Purpose: to determine the effectiveness of shock wave therapy for the treatment of calcific tendonitis of the shoulder, based on 2-3 years of observation. Methods: Thirty-seven patients (39 shoulders) with calcific tendinitis of the shoulder were treated with shock wave therapy (1000 pulses 14 kV) and followed for 24 to 30 months. The control group, which received traditional sham treatment with a sham electrode, consisted of 6 patients (6 shoulders) with a mean follow-up of 6 months. Evaluation included use of the 100-point Constant scoring system and shoulder radiographs.

Research results:

Group A - Research group (Shock wave therapy) - Group B - Control group (Traditional treatment)

The symptom recurrence rate for the study group was 6.5%. The breakdown of calcium deposits was complete in 57.6% of the study group, partial in 15.1%, and unchanged in 27.3%. Calcium fragmentation was noticed by 16.7% of patients in the control group; in the rest, 83.7% of patients in the control group had calcium deposits that remained unchanged. Over the course of 2 years, no recurrence of calcium deposits was observed in the study group. Conclusion: Shockwave therapy is a safe and effective atraumatic treatment for patients with calcific tendinitis of the shoulder. The full report can be viewed at: https://ajs.sagepub.com/content/31/3/425

Results of conservative treatment in our clinic.

You can also familiarize yourself with the international experience of treatment using shock wave therapy in the following materials:

1. CALCIFIED SHOULDER TENDINITIS
2. CLINICAL RESULTS OF EXTRACORPORAL LITHOTRIPSY FOR CALCIFIED SHOULDER TENDINITIS
3. TEN YEARS OF EXPERIENCE IN SHOCK WAVE THERAPY FOR RADIATION AND ELBAR DISORDERS OF THE EPICONDYLAR DISORDERS

Features of the treatment of certain types of tendinitis

• Patellar tendinitis or "jumper's knee".

• Quadriceps tendonitis. Degenerative changes can occur in the area where the quadriceps tendon attaches to the superior pole of the patella.

• Post-tibial tendonitis. Tibialis posterior tendonitis, or post-tibial tendinitis, is a strain of the tibialis posterior tendon.

To search for additional materials, use the following terms in the search module: tendinitis conservative treatment, tendinitis photo, tendinitis of the knee joint, patellar tendinitis, supraspinatus tendinitis, Achilles tendonitis, tendinitis of the shoulder joint, tendinitis of the shoulder treatment, tendonitis reviews, Moscow, Dolgoprudny, Khimki, Mytishchi, Altufyevo, Bibirevo, Medvedovo, Otradnoe, Timiryazevskaya.

List of sources

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• Makarchik A.V. Ulnar epicondylitis. Treatment with medical physical factors / A. V. Makarchik. – Gomel: State Institution “RSPC RMiECH”, 2019. – 11 p.
• Kirillova E. R., Khabirov R. A., Schneider L. L., Ananicheva G. V. Approaches to pathogenetic therapy of epicondylitis of the elbow joint. Practical medicine. 2013;(1):109-112.
• Popelyansky Ya.Yu. Orthopedic neurology: vertebroneurology Text. / Ya.Yu. Popelyansky. Kazan, 1997. - T. 1. - P. 433 - 435.