History and exam
Key diagnostic factors
common
presence of risk factors
Risk factors strongly associated with the development of epicondylitis include a history of repetitive recreational or occupational activity, increasing age, medical history of epicondylitis, inadequate physical conditioning, poor mechanics during an activity, and smoking.
elbow pain during or after flexion and extension
Without pain, epicondylitis should not be considered as a possible diagnosis.
exacerbation of pain with repetitive movement or occupational activity
Typically, repetitive motion or activity is a causative factor for either lateral or medial epicondylitis.
decreased grip strength
Grip strength may be decreased in either medial or lateral epicondylitis, and pain exacerbated.[36]
pain at the lateral aspect of the elbow (lateral epicondylitis)
Without pain, epicondylitis should not be considered as a diagnosis.
Pain is sharp and persistent, with either an acute or insidious onset.
tenderness over the common extensor tendon (lateral epicondylitis)
Pain typically localised to the extensor carpi radialis brevis.
Maximal tenderness occurs approximately 1 cm distal and anterior to the midpoint of the lateral epicondyle.
positive extensor carpi radialis brevis stretch (lateral epicondylitis)
Reproducible pain over the origin of the common extensor mass when the arm is placed in extension while the examiner maximally flexes the wrist.[35]
pain during resisted wrist and digit extension (lateral epicondylitis)
Reproducible pain over the origin of the common extensor mass when the arm is extended and the patient is asked to resist an applied force at the wrist.[35]
Extensor carpi radialis brevis strength reduced due to pain.
pain at the medial aspect of the elbow (medial epicondylitis)
Pain may radiate along the medial elbow in medial epicondylitis.
Pain is sharp and persistent, and may have an acute or insidious onset, but is more likely to be insidious with medial epicondylitis.
tenderness approximately 5 mm distal and lateral to the medial epicondyle (medial epicondylitis)
Over the pronator teres and flexor carpi radialis.
Pain may radiate along the medial elbow and be increased with resisted forearm pronation or wrist flexion.
increased pain with resisted forearm pronation or wrist flexion (medial epicondylitis)
Pain may radiate along the medial elbow and be increased with resisted forearm pronation or wrist flexion.[26]
Other diagnostic factors
common
normal range of movement at elbow
Typical finding, although there may be pain resulting in weak wrist extension with lateral epicondylitis.
normal sensation
Typically sensation is normal.
Tinel's sign negative
This is important to rule out other pathology, such as cubital tunnel or other neurological conditions.
The sign is elicited by tapping lightly on the medial elbow over the ulnar nerve. It is described as positive if testing generates paraesthesia without pain.[22]
uncommon
weak wrist extension (lateral epicondylitis)
May occur secondary to pain.
swelling
When symptoms are severe the patient's elbow may have mild swelling.
Risk factors
strong
medical history of epicondylitis
If the patient has a history of previous epicondylitis, there is a greater risk of recurrence.
repetitive activities
Both medial and lateral epicondylitis have been associated with repetitive wrist, elbow, and forearm activities, such as tennis, fencing, golf, rowing, baseball, hammering, typing, meat-cutting, plumbing, and painting.[4][10][11][12][13][14][15][16][17][18][19][20]
Shear valgus forces caused during these events lead to traumatic microtears in already hypovascular tissue. This contributes to pain and delayed healing.[3]
poor mechanics during activities
Poor motor mechanics have been associated with continued injury of both the common extensor mass and the common flexor mass during recreational activities.
An example, during recreational tennis, is when a player incorrectly performs a back-handed swing with either an extended elbow or a flexed wrist.[21][22][24]
Studies have demonstrated that patients with lateral epicondylitis are not able to correct their racket strokes mid-swing. This decreased elbow proprioception may contribute to poor mechanics and exacerbation of inflammation.[23]
inadequate physical conditioning
Both lateral and medial epicondylitis have been associated with repetitive activities requiring prolonged grip strength.[4][5]
It has been reported that inadequate physical conditioning and resultant fatigue could exacerbate tissue damage.
One study examining competitive rowing teams demonstrated that individuals not in proper rowing condition were at increased risk of developing injuries, including lateral epicondylitis.[20]
weak
improper equipment
Studies have tested the theory of a relationship between the grip size used in racket and ball sports and the development of lateral epicondylitis.
A method has been described to determine the proper grip size for an individual, by measuring the distance from the lateral palmar wrist crease to the medial tip of the ring finger.[33]
However, a study of collegiate tennis players determined that increasing grip size up to one quarter of an inch (6 mm) does not increase extensor carpi radialis brevis activity.[34]
obesity
symptoms occurring on the same side as hand dominance
Lateral epicondylitis is associated with hand dominance in both sexes.
Medial epicondylitis is associated with hand dominance in women but not in men.[5]
female sex
One meta-analysis found that women had a higher risk of sustaining lateral epicondylitis (odds ratio males:females = 0.77).[8]
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