Epicondylitis typically occurs during the 4th and 5th decades of life. Patients describe a history of activities contributing to overuse of the forearm muscles that originate at the elbow.
People with lateral epicondylitis experience tenderness approximately 1 cm distal and anterior to the lateral epicondyle. They report pain during resisted wrist and digit extension, and during passive wrist flexion with the elbow extended.
People with medial epicondylitis have tenderness along the medial elbow, approximately 5 mm distal and anterior to the medial epicondyle. Pain is exacerbated with resisted forearm pronation and resisted wrist flexion.
Most patients will have complete resolution of symptoms with arm rest and nonsteroidal anti-inflammatory drug therapy. Patients with continued symptoms may require further treatment, including physical therapy, injection therapy, or surgical debridement.
The principal complication is continued pain. All other complications may arise from interventions attempting to alleviate the pain.
Epicondylitis of the elbow is a condition associated with repetitive forearm and elbow activities. Both lateral epicondylitis (commonly known as tennis elbow) and medial epicondylitis (commonly known as golfer's elbow) are characterized by elbow pain during or following elbow flexion and extension. A combination of poor mechanics, microtears in areas of hypoperfusion, and a delayed healing response contribute to the pathophysiology of the condition.
History and exam
Key diagnostic factors
- history of repetitive recreational or occupational activity
- past medical history of epicondylitis
- elbow pain during or following flexion and extension
- exacerbation of pain with repetitive movement or occupational activity
- decreased grip strength
- pain at the lateral aspect of the elbow (lateral epicondylitis)
- tenderness over the common extensor tendon (lateral epicondylitis)
- positive extensor carpi radialis brevis stretch (lateral epicondylitis)
- pain during resisted wrist and digit extension (lateral epicondylitis)
- pain at the medial aspect of the elbow (medial epicondylitis)
- tenderness approximately 5 mm distal and lateral to the medial epicondyle (medial epicondylitis)
- increased pain with resisted forearm pronation or wrist flexion (medial epicondylitis)
Other diagnostic factors
- normal range of movement at elbow
- normal sensation
- Tinel sign negative
- weak wrist extension (lateral epicondylitis)
- increasing age (>40 years)
- past medical history of epicondylitis
- repetitive activities
- poor mechanics during activities
- improper equipment
- inadequate physical conditioning
- symptoms occurring on the same side as hand dominance
- female sex
1st investigations to order
- no initial tests (clinical diagnosis)
Investigations to consider
- elbow x-ray
- computed tomographic scan of the elbow
- magnetic resonance imaging (MRI) of the elbow
- electromyogram and nerve conduction studies
- MRI of the cervical spine
- ultrasound of the elbow
no response to initial treatment at 6 weeks
lateral epicondylitis refractory to treatment 6 to 12 months after initial presentation
medial epicondylitis refractory to treatment 6 to 12 months after initial presentation
Adam C. Watts, BSc, MBBS, FRCS (Tr and Ortho)
Consultant Hand and Upper Limb Surgeon
ACW has received payment for education from Medartis and Wright Medical. His institution has received funding for research from Chemedica, ZimmerBiomet, Wright Medical, Stryker and Lima.
Paul M. Robinson, FRCS (Tr&Orth), BMedSci, MBChB (Hons)
Consultant Trauma and Orthopaedic Surgeon
Peterborough City Hospital
North West Anglia NHS Foundation Trust
PMR declares that he has no competing interests.
Dr Adam C. Watts and Dr Paul M. Robinson would like to gratefully acknowledge Dr Len Funk, Dr Iain Macleod, Dr Daniel J. Soloman, and Dr Hugo B. Sanchez, previous contributors to this topic. LF, IM, DJS, and HBS declare that they have no competing interests.
Brent A. Ponce, MD
Division of Orthopedic Surgery
University of Alabama
BAP declares that he has no competing interests.
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