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Last reviewed: 10 Nov 2023
Last updated: 26 May 2022



History and exam

Key diagnostic factors

  • history of repetitive recreational or occupational activity
  • past medical history of epicondylitis
  • smoking
  • 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)
More key diagnostic factors

Other diagnostic factors

  • normal range of movement at elbow
  • normal sensation
  • Tinel sign negative
  • weak wrist extension (lateral epicondylitis)
  • swelling
Other diagnostic factors

Risk factors

  • increasing age (>40 years)
  • past medical history of epicondylitis
  • repetitive activities
  • poor mechanics during activities
  • improper equipment
  • inadequate physical conditioning
  • smoking
  • obesity
  • symptoms occurring on the same side as hand dominance
  • female sex
More risk factors

Diagnostic investigations

1st investigations to order

  • no initial tests (clinical diagnosis)
More 1st investigations to order

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
More investigations to consider

Emerging tests

  • ultrasound of the elbow

Treatment algorithm


initial presentation


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

Wrightington Hospital

Appley Bridge




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.

Peer reviewers

Brent A. Ponce, MD

Associate Professor

Division of Orthopedic Surgery

University of Alabama




BAP declares that he has no competing interests.

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