Epicondylosis, Lateral & Medial

For further information, see CMDT Part 41-04: Upper Extremity Musculoskeletal Injuries

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

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

• 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

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

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