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

Assessment

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)

Investigations

Diagnosis of epicondylitis is made clinically:

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

Management

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

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 CCG-15N

Referral Forms

DRSS referral form

Supporting Information

Patient Information

Tennis Elbow information

Pathway Group

This guideline has been signed off on behalf of the Western Locality of NEW Devon CCG.

Publication date: 23 December 2014

(This guideline is currently under review)

 

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