Tennis Elbow
Definition: Tennis elbow is tendinosis (chronic symptomatic degeneration of the tendon) that affects the common attachment of the tendons of the extensor muscles of the forearm to the lateral epicondyle of the humerus. It is characterized by pain in the lateral elbow, pain with wrist extension, and reduced grip strength. Exacerbation factors include activities which involve excessive and repetitive use of the extensor muscles of the forearm.
Diagnosis: History
Symptoms often insidious onset, no clear precipitating event but can follow and injury/increased level of activity, pain or burning sensation, symptoms are usually exacerbated by repetitive wrist movements, occupational and recreational activities may provoke symptoms.
History of elbow pain and treatments tried
Severity, onset, duration and exacerbating features of pain.
Associated disturbed sleep, anxiety, and/or depression
Red flags such as trauma, joint swelling or systemic symptoms
Grip weakness
Diagnosis: Examination
Impact on daily function
Reduced grip strength
A full range of active and passive movement at the elbow and wrist joints is usually preserved.
Dorsiflex the wrist against resistance with the elbow flexed at 90 degrees — extending the elbow increases pain further.
Normal sensation
Resisted middle finger extension may be painful (Maudsley's test).
Check for Tinel's sign — tap lightly on the medial elbow over the ulnar nerve. It is positive if testing generates paraesthesia without pain.
Localized point of tenderness on palpation over and/or distal to the lateral epicondyle and along the common extensor tendon
Assess the neck and shoulder to exclude an alternative diagnosis, such as referred pain.
Red flag features - swollen, red, tender joint
Investigations are not usually required in Primary care
Differential Diagnosis
Trauma and intra-articular loose bodies
Malignancy
Radial tunnel syndrome
Posterior interosseous nerve entrapment syndrome
Osteochondritis dissicans of the capitellum
Posterolateral elbow instability
Elbow arthropathy
Synovitis
Cervical radiculopathy
Synovial fold syndrome
Rheumatoid arthritis/Septic arthritis
Frozen shoulder
Management
If no response to treatment after 6-12 months, consider referral to orthopaedic surgeon
If no response to initial treatment after 6 weeks, consider alternative diagnosis, physiotherapy referral, do not routinely offer corticosteroid injection.
If diagnosis uncertain, if there is refractory pain or severe functional impairment, or persistent symptoms despite 6 - 12 months of optimal management - refer to orthopaedic surgeon
Provide appropriate information or advice - NHS patient info etc.
Offer analgesia for symptom relief such as paracetamol or topical NSAIDs - consider oral NSAID if symptoms persist
Advise to discuss with place of employment or occupational health if work-related activities are exacerbating symptoms
Advice on use of heat/ice to help relieve pain, rest the arm and avoid any aggravating factors for 6 weeks while maintaining activities, consider the use of orthosis