Referral

Tennis and Golfer’s Elbow

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Scope

This referral guidance covers the diagnosis and management of lateral and medial epicondylitis (tennis elbow and golfers elbow respectively) in adults across both primary and secondary care.

Definition:
  • lateral epicondylitis (also known as tennis elbow):
    • tendinopathy of the common extensor muscle origin of the lateral elbow
    • pain is worsened by active and resisted movements of the extensor forearm muscles and resisted dorsiflexion of the wrist, middle finger or both
  • medial epicondylitis (also known as golfer's elbow):
    • tendinopathy of the common flexor muscle origin of the medial elbow
    • worsened with affected muscle use, eg forearm rotation or grasping, opening a jar
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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