1. LATERAL & MEDIAL EPICONDYLOSIS (TENDINOPATHY)
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.
Tendinopathies involving the wrist extensors, flexors, and pronators are very common complaints. The underlying mechanism is chronic repetitive overuse causing microtrauma at the tendon insertion, although acute injuries can occur as well if the tendon is strained due to excessive loading. The traditional term “epicondylitis” is a misnomer because histologically tendinosis or degeneration in the tendon is seen rather than acute inflammation. Therefore, these entities should be referred to as “tendinopathy” or “tendinosis.” Lateral epicondylosis involves the wrist extensors, especially the extensor carpi radialis brevis. This is 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.
For lateral epicondylosis, the patient describes 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”). 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. For either, 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. To confirm that the pain is due to tendinopathy, pain can be reproduced over the epicondyle with resisted wrist extension and third digit extension for lateral epicondylosis and resisted wrist pronation and wrist flexion for medial epicondylosis. The pain is also often reproduced with passive stretching of the affected muscle groups, which can be performed with the arm in extension. It is useful to check the ulnar nerve (located in a groove at the posteromedial elbow) for tenderness as well as to perform a Spurling test for cervical radiculopathy.
Radiographs are often normal, although a small traction spur may be present in chronic cases (enthesopathy). Diagnostic investigations are usually unnecessary, unless the patient does not improve after up to 3 months of conservative treatment. At that point, a patient who demonstrates significant disability due to the pain should be assessed with an MRI or ultrasound. Ultrasound and MRI can visualize the tendon and confirm tendinosis or tears.
Treatment is usually conservative, including patient education regarding activity modification and management ...