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Key Features

Essentials of Diagnosis

  • Tenderness over the lateral or medial epicondyle

  • Diagnosis of tendinopathy is confirmed by pain with resisted strength testing and passive stretching of the affected tendon and muscle unit

  • Physical therapy and activity modification are more successful than anti-inflammatory treatments

General Considerations

  • Tendinopathy involving the wrist extensors, flexors, and pronators are very common complaints

  • The underlying mechanism is chronic repetitive overuse causing microtrauma at the tendon insertion

  • However, acute injuries can occur as well if the tendon is strained due to excessive loading

  • Lateral epicondylosis

    • Involves the wrist extensors, especially the extensor carpi radialis brevis

    • Usually caused be lifting with the wrist and the elbow extended

  • Medial epicondylosis

    • Involves the wrist flexors and most commonly the pronator teres tendon

    • Ulnar neuropathy and cervical radiculopathy should be considered in the differential diagnosis

Clinical Findings

Symptoms and Signs

  • Lateral epicondylosis

    • Pain with the arm and wrist extended

    • For example, common complaints include pain while shaking hands, lifting objects, using a computer mouse, or hitting a backhand in tennis ("tennis elbow")

    • Pain can be reproduced over the epicondyle with resisted wrist extension and third digit extension for lateral epicondylosis

  • Medial epicondylosis

    • Presents with pain during motions in which the arm is repetitively pronated or the wrist is flexed

    • This is also known as "golfer's elbow" due to the motion of turning the hands over during the golf swing

    • Pain can be reproduced with resisted wrist pronation and wrist flexion

    • On examination, tenderness directly over the epicondyle is present, especially over the posterior aspect where the tendon insertion occurs

    • The proximal tendon and musculotendinous junction can also be sore

  • Useful to check the ulnar nerve for tenderness as well as to perform a Spurling test for cervical radiculopathy

Diagnosis

Imaging

  • Radiographs

    • Often normal

    • A small traction spur may be present in chronic cases (enthesopathy)

  • Ultrasound and MRI

    • Indicated if patient does not improve after 3 months of conservative treatment

    • Can visualize the tendon and confirm tendinosis or tears

Treatment

Conservative measures

  • Patient education regarding activity modification and management of symptoms

  • Ice can help with pain

  • Physical therapy is mainstay of treatment

  • Counterforce elbow braces might provide some symptomatic relief

Medications

  • NSAIDs can help with pain

  • If the patient has severe or long-standing symptoms, injections can be considered

  • Corticosteroid injection resulted in improvement at 1 month as well as evidence of decreased tendon thickness and Doppler changes

  • Platelet-rich plasma injections showed no effects for lateral epicondylitis

Outcome

Prognosis

  • Condition is usually self-limited, resolving over a 12- to 18-month period without treatment

When to Refer

  • Patients ...

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