Tennis elbow and Golfer's elbow

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

Toggle all

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 syndorme (compression of the posterior interosseous nerve):
- difficult to differentiate from lateral epicondivitis
- 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, eg 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
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

Please refer via DRSS using the e-Referral Service

- Specialty: Orthopaedics
- Clinic Type: Shoulder and Elbow
- Service: DRSS-Western-Orthopaedics Hand & Wrist- Devon CCG-15N / DRSS-Western-Orthopaedics-Shoulder & Elbow-Cornwall-Devon ICB-15N

Referral Form

DRSS referral form

Patient Information

Tennis Elbow information

Pathway Group

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

Publication date: 23 December 2014

(This guideline is currently under review)

Referral