Signs and Symptoms

Tennis elbow (lateral epicondylitis)

Risk factors

• Repeated flexion/extension of wrist
• Repeated pronation/supination of the forearm
• Overuse of finger extensor muscles

Golfer's elbow (medial epicondylitis)

Risk factors

• Constant over strain of wrist and finger flexors
• Patients commonly present with:
  • pain at the epicondylar region
  • pain in the forearm muscles
  • typically pain of gradual onset, worsened with use of the affected muscle
  • pain frequently elicited upon movement against resistance
  • occasional loss of grip strength due to pain
  • weakness and stiffness of the outer elbow

Differential Diagnoses

Consider the following differential diagnoses:

• humeral fracture
• radial head fracture
• osteoarthritis
• referred pain from cervical spine
• lateral elbow instability
• radial tunnel syndrome (compression of the posterior interosseous nerve):
  • difficult to differentiate from lateral epicondylitis
  • maximal tenderness 3-4cm distal and anterior to epicondyle
  • resisted wrist extension may not be painful, but resisted thumb and index finger extension may be painful
• fibromyalgia – there may be trigger point tenderness over the lateral epicondyle but no pain on resisted wrist and middle finger extension
• radial neuropathy
• rotary instability of the elbow
• posterior pinch syndrome or plica of the elbow
• myofascial pain syndrome
• osteochondritis dissecans (OCD)

Diagnosis of epicondylitis is made clinically:

• investigation is necessary when considering a differential diagnosis, e.g. X-ray for suspected fracture.

Tennis Elbow

Provide:

• Explanation of the condition and advice including:
  • rest
  • modification of activity
• NSAIDs
• Consider injections x 2 maximum (warn patient about possible lipoatrophy and skin depigmentation)
• Refer to community physiotherapy
• Consider epicondylar clasp - though no evidence regarding their effectiveness

Golfers Elbow

Provide:

• Explanation of the condition and advice including:
  • rest
  • modification of activity
• NSAIDs
• Consider injections x 2 maximum (warn patient about possible lipoatrophy and skin depigmentation) BEWARE ULNAR NERVE behind medial epicondyle
• Refer to community physiotherapy

Referral Criteria

Consider referral

• For persistent symptoms where conservative management has failed and the causative factors have been addressed.

Referral Information

• e-Referral Service
  • Specialty: Orthopaedics
  • Clinic Type: Shoulder and Elbow
  • Service: DRSS-Northern-Orthopaedics-Hand & Wrist- Devon ICB- 15N

Referral Form

DRSS Referral Form

Patient Information

Tennis and Golfer's elbow information

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: 28 September 2015