Lateral epicondylitis

• Lateral epicondylitis:

  • Also called tennis elbow
  • Tendinosis (chronic symptomatic degeneration of the tendon) affecting tendons of the extensor muscles of the forearm where they attach to the lateral epicondyle of the humerus
  • Usually occurs after minor or unrecognised trauma e.g. repetitive overuse of the extensor muscles causing microtears in the extensor tendons at their point of attachment on the lateral epicondyle
• Demographics:

  • Women and men affected equally
  • Peak incidence 35-54
  • Associated with activities that involve gripping something and repeatedly extending or twisting the forearm
• Lateral epicondylitis (tennis elbow) is the most common cause of persistent elbow pain

  Much more common than medial epicondylitis (golfer's elbow)
• Presentation:

  • Usually insidious onset with no clear precipitating event - but can follow injury or increased levels of activity
  • Pain or burning sensation in the lateral elbow with radiation down extensor aspect of forearm
  • Pain with wrist extension
  • Reduced grip strength
  • Exacerbated by excessive and repetitive use of the extensor muscles of the forearm
  • Dominant arm is involved in most patients
  • Can impact on daily functioning e.g. difficulty raising cup
• Examination:

  • Usually have full range of motion at elbow and wrist joint with normal sensation
  • Localised point tenderness on palpation over and/or distal to lateral epicondyle and along common extensor tendon
  • Pain on resisted wrist extension (Cozen's test)
  • Grip strength may be reduced
• Diagnosis:

  • Clinical diagnosis based on history and clinical findings
  • Investigations not usually needed
• Initial treatment:

  • Apply heat or ice
  • Rest arm and avoid aggravating activities for 6 weeks while maintaining activity where possible - may need occupational health assessment if work related
  • Consider forearm straps/wrist or elbow brace - limits excessive stress on tendons
  • Analgesia - paracetamol, topical NSAIDs (switch to oral if ineffective)
• If no response to initial treatment after 6 weeks:

  • Physiotherapy - stretching and strengthening exercises, massage, ultrasound therapy
  • Consider steroid injections but not routinely offered - provide short term relief for severe pain but no long-term benefit
• When to refer to orthopaedic surgeons:

  • Diagnosis uncertain - may need MRI
  • Refractory pain or severe functional impact
  • Symptoms persist despite 6-12 months of optimal management in primary care
  • Surgical options - debridement, release or repair of damaged tendons
• Prognosis:

  • Generally self-limiting
  • Improves in around 80-90% of people over 1-2 years