Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 41-04: Upper Extremity Musculoskeletal Injuries + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ +++ 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 (PRP) injections Becoming more commonly used in practice Still considered a second-line treatment Reviews suggest that PRP and autologous blood injections both have positive benefits in lateral epicondylitis Evidence continues to accumulate + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Condition is usually self-limited, resolving over a 12- to 18-month period without treatment +++ When to Refer ++ Patients not responding to 6 months of conservative treatment should be referred for surgical debridement or repair of the tendon + References Download Section PDF Listen +++ + +Amin NH et al. Medial epicondylitis: evaluation and management. J Am Acad Orthop Surg. 2015 Jun;23(6):348–55. [PubMed: 26001427] + +Kwapisz A et al. Platelet-rich plasma for elbow pathologies: a descriptive review of current literature. Curr Rev Musculoskelet Med. 2018 Dec;11(4):598–606. [PubMed: 30255288] + +Mattie R et al. Percutaneous needle tenotomy for the treatment of lateral epicondylitis: a systematic review of the literature. PM R. 2017 Jun;9(6):603–11. [PubMed: 27780771] + +Sayegh ET et al. Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta-analysis. Clin Orthop Relat Res. 2015 Mar;473(3):1093–107. [PubMed: 25352261] + +Sirico F et al. Local corticosteroid versus autologous blood injections in lateral epicondylitis: meta-analysis of randomized controlled trials. Eur J Phys Rehabil Med. 2017 Jun;53(3):483–91. [PubMed: 27585054]