01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Ask which action provokes pain: lifting a kettle, shaking hands, using tools, typing with sustained wrist posture, racquet sport, throwing or golf. Define a recent load increase, direct trauma, clicking, locking, instability and neck or hand symptoms. Lateral pain is more common and usually relates to the common extensor origin; medial symptoms arise around the flexor-pronator origin. Neither term means that inflammation of the bony epicondyle is the whole disorder, and the alternative term tendinopathy better reflects the usual chronic matrix process.
Inspect for swelling, bruising and wasting. Palpate precisely while comparing the other side. Lateral tendinopathy reproduces familiar pain with resisted wrist extension, gripping or sometimes resisted middle-finger extension; medial tendinopathy with wrist flexion and pronation. Keep the elbow position consistent and distinguish pain from true weakness. Check full flexion, extension and forearm rotation, joint effusion and stability. Test finger and wrist motor function, sensory territories and reflexes, then examine the cervical spine when symptoms radiate.
A typical pattern needs no imaging. Plain radiographs are appropriate after trauma, with bony tenderness, range loss, locking, arthritis suspicion or atypical persistence. Ultrasound can show tendon thickening or tearing and guide a procedure, but structural change also occurs without pain. MRI is reserved for a specific unresolved question such as ligament injury, intra-articular disease, tumour or surgical planning. Electrodiagnostic studies are not tendinopathy tests; use them when nerve symptoms or weakness need localisation.
Explain that most episodes improve but recovery may take months. Relative load modification means changing grip size, wrist position, repetition, force and breaks while retaining tolerable use. It does not mean immobilising the arm until asymptomatic. A counterforce strap or wrist support can be trialled for a specific task if it reduces symptoms, then discontinued if it does not. Ergonomic change must address actual load rather than simply supplying equipment.
Exercise should be progressive and reproducible. Start with comfortable isometric wrist extension for lateral disease or flexion and pronation for medial disease, then add slow isotonic loading through increasing range. Progress weight, repetitions and speed before recreating high-force gripping, throwing or racquet tasks. Mild pain during loading can be acceptable when it settles and function advances; a strong next-day flare means reduce dose, not abandon the programme. Shoulder and scapular capacity may also matter in athletes and manual workers.
A short topical NSAID trial may help symptoms, while oral NSAIDs are reserved for selected patients after risk review. Evidence for routine corticosteroid injection is unattractive because early relief can be followed by recurrence and poorer longer-term outcome; if used after shared discussion, it should be accurately targeted, limited and linked to active rehabilitation. Autologous blood, platelet-rich plasma, dry needling, shockwave and other procedures have variable evidence and should not be described as universal standards.
Surgery is uncommon. Before referral, confirm that a sufficiently long, progressed and adhered-to programme has occurred and reconsider radial tunnel syndrome, ulnar neuropathy, collateral-ligament disease, cervical radiculopathy and joint pathology. Specialist discussion may include debridement or release for persistent lateral disease, but outcome is not guaranteed and return to heavy work remains staged. Progressive neurological loss or instability requires a different and potentially earlier pathway.
Modify plans for comorbidity. Diabetes and smoking may slow tendon recovery. Older adults with new pain after a fall need fracture exclusion before loading. Anticoagulation heightens bruising and procedural bleeding but should never be stopped without the responsible prescriber. In pregnancy, favour activity modification and rehabilitation, consider topical rather than systemic exposure where appropriate, and observe MHRA restrictions on systemic NSAIDs from 20 weeks and in the final trimester.
Key points
- Lateral epicondylitis causes point tenderness at or just distal to the lateral epicondyle with pain on gripping and resisted wrist extension; medial disease reproduces pain with resisted wrist flexion or pronation.
- First-line investigation is a focused history and examination because the diagnosis is clinical; routine radiographs, ultrasound and MRI are unnecessary in a typical presentation.
- Map the exact tender point, test elbow movement and stability, and examine radial, posterior interosseous, ulnar and cervical nerve function before prescribing a tendon pathway.
- First-line management is education, temporary adjustment of provocative work or sport and progressive forearm loading, not prolonged rest or an immediate procedure.
- Begin isometric or low-load wrist work when irritable, then progress concentric and eccentric resistance, grip endurance and the actual occupational or sporting movement over weeks.
- Topical NSAID can be considered for short-term relief; an oral NSAID needs individual gastrointestinal, kidney, cardiovascular, pregnancy and anticoagulation assessment.
- Corticosteroid injection may improve pain briefly but carries recurrence and tissue risks; it should not be routine first-line treatment or repeated automatically.
- Refer persistent disabling pain after well-delivered rehabilitation when diagnosis is uncertain, nerve or ligament disease is suspected, or the patient is considering operative options.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Repetitive extensor loading
Lateral disease follows repeated gripping, wrist extension and forearm rotation at work, sport or home, often after a sudden increase rather than years of exposure alone.
Repetitive flexor-pronator loading
Medial disease arises from forceful wrist flexion, pronation, throwing or golf-related demand concentrated at the common flexor origin.
Age and recovery factors
Midlife tendon matrix change, smoking, diabetes, obesity and insufficient recovery can lower capacity, while complete rest causes further deconditioning.
Acute overload
A single forceful lift or racquet stroke may trigger symptoms in a previously vulnerable enthesis but should prompt fracture or ligament assessment when bruising or instability follows.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Tendinopathic matrix change
Collagen disorganisation, increased ground substance and neovascular signalling develop at the tendon origin; this is not simply an acute inflammatory epicondyle process.
- 2Load-pain sensitisation
Gripping and resisted wrist action reproduce local nociception when demand exceeds current capacity, and pain inhibition further reduces measured strength.
- 3Lateral extensor origin
Extensor carpi radialis brevis is commonly involved near the lateral epicondyle, explaining pain with resisted wrist extension or middle-finger loading.
- 4Medial flexor-pronator origin
Pronator teres and wrist-flexor origin load concentrates near the medial epicondyle, anatomically close to the ulnar nerve and collateral ligament.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
The patient's familiar pain is reproduced at the common extensor origin rather than several centimetres down the radial tunnel.
Gripping or resisted wrist extension with the elbow positioned consistently produces lateral pain, while passive joint movement is largely preserved.
Tenderness at the flexor-pronator origin and pain on resisted wrist flexion or pronation supports medial epicondylitis.
Effusion, loss of passive movement, crepitus or locking requires assessment for arthritis, loose body, fracture or synovial disease.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
First-line focused clinical examinationFirst stepFirst line - Why
- Reproduce tendon-origin pain and screen joint, ligament, nerve and cervical alternatives.
- Interpretation and limitations
- Local tenderness plus pain with matching resisted loading supports the diagnosis; true weakness or sensory change demands neurological localisation.
- 02
Plain elbow radiographs - Why
- Assess trauma, focal bony tenderness, motion loss, locking, arthritis, calcification or atypical chronic pain.
- Interpretation and limitations
- Normal films are expected in uncomplicated tendinopathy; incidental enthesophytes do not prove the source of symptoms.
- 03
Ultrasound for a defined tendon question - Why
- Characterise thickening, tear or adjacent structures when persistent symptoms or a procedure make anatomy relevant.
- Interpretation and limitations
- Correlate abnormality with the exact painful site because asymptomatic structural change is common and operator skill affects accuracy.
- 04
MRI for complex differential or surgery - Why
- Evaluate collateral ligament, cartilage, marrow, tumour or deeper tendon anatomy when findings will alter specialist management.
- Interpretation and limitations
- Do not use MRI as routine first-line confirmation; reports can medicalise incidental age-related change.
- 05
Nerve-conduction and electromyography - Why
- Localise significant motor deficit or persistent sensory symptoms suggesting ulnar, radial or cervical pathology.
- Interpretation and limitations
- Normal studies do not diagnose tendinopathy, and early or intermittent compression can remain clinically important despite a non-diagnostic result.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Radial tunnel syndrome
Pain is usually several centimetres distal to the lateral epicondyle and may worsen with resisted supination; posterior interosseous involvement produces motor weakness without cutaneous numbness.
Cubital tunnel syndrome
Medial discomfort with ring-and-little-finger paraesthesia, intrinsic weakness or symptoms during prolonged elbow flexion suggests ulnar neuropathy.
Elbow osteoarthritis or loose body
Crepitus, terminal range loss, effusion or locking points to an intra-articular process rather than an isolated painful tendon origin.
Collateral-ligament injury
Trauma, throwing-related instability and pain on valgus or varus stress requires ligament assessment, especially at the medial elbow.
Cervical radiculopathy
Neck provocation, dermatomal sensory disturbance, reflex change or weakness beyond the painful muscle group indicates a proximal neurological source.
Additional chapter-specific clues
Distal lateral tenderness, pain on resisted supination or finger-extension weakness shifts concern toward radial tunnel or posterior interosseous disease.
Ring-and-little-finger paraesthesia, first dorsal interosseous wasting or weakness of finger abduction is not explained by flexor tendinopathy alone.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01First-lineMake a clinical load diagnosisFirst stepFirst lineLocal epicondylar pain is reproduced by matching resisted wrist or forearm action without red flags.+
- 1Map tenderness and reproduce symptoms with resisted extension laterally or flexion and pronation medially.
- 2Check passive elbow movement, collateral stability, distal motor and sensory function and the cervical spine before concluding tendinopathy.
- 3Explain the usual gradual course and agree temporary changes in repetition, grip and force while retaining tolerable activity.
- 4Begin a progressive exercise plan and define grip, work or sporting outcomes for review over six to twelve weeks.
02Stepwise rehabilitationRestore forearm capacityPain limits loading but no fracture, unstable ligament or neurological deficit is present.+
- 1Start with isometric or light slow wrist loading in the symptomatic tendon direction and monitor the next-day response.
- 2Progress concentric and eccentric resistance, range, grip endurance and proximal upper-limb control.
- 3Add task-specific speed, torque and repeated work only after basic strength and symptom recovery improve.
- 4Use a brace or topical analgesia as a temporary aid, discontinuing anything that does not improve function.
03ReassessmentInvestigate a non-improving patternSymptoms remain disabling despite adherence or develop locking, instability, distal tenderness or neurological features.+
- 1Repeat localisation and check for radial tunnel, cubital tunnel, cervical root, collateral ligament and intra-articular disease.
- 2Order radiographs first for bone or joint features and select ultrasound, MRI or electrodiagnosis for a specific remaining question.
- 3Review work demands, exercise dose and smoking or metabolic factors rather than declaring all rehabilitation failed.
- 4AlternativeRefer to the appropriate elbow, hand or neurology service when the alternative diagnosis or operative decision requires it.
04ProceduralUse interventions selectivelyPersistent functional limitation remains after a credible active programme and the diagnosis is well localised.+
- 1Discuss that corticosteroid may provide short-term relief but recurrence and tissue effects limit routine use.
- 2Avoid serial injections and unproven procedures presented as guaranteed tendon healing.
- 3Seek specialist assessment before surgery, including reconsideration of nerve and ligament disorders.
- 4Plan staged rehabilitation and work return after any procedure rather than assuming pain relief instantly restores capacity.
Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
Topical diclofenac gel
Use 2–4 g of 1.16% diclofenac gel over the painful epicondylar area on each occasion, up to three or four occasions daily for a short course within the label maximum.Avoid broken skin and NSAID hypersensitivity, wash hands after application, account for concomitant oral NSAIDs and pregnancy, and stop for rash or systemic adverse effects.
Short oral naproxen course with protection when needed
If benefits outweigh risks, use naproxen 250–500 mg orally twice daily with food for the shortest effective period and add omeprazole 20 mg orally once daily during treatment when gastroprotection is indicated.Review gastrointestinal bleeding, kidney disease, hypertension, heart failure, cardiovascular risk, older-age frailty, anticoagulants and antiplatelets; avoid combined NSAIDs and observe pregnancy restrictions from 20 weeks.
Corticosteroid tendon-origin injection
If exceptionally chosen after shared decision, use one small accurately localised dose under a trained service protocol and avoid intratendinous placement; do not schedule automatic repeats.Explain skin depigmentation, fat atrophy, post-injection flare, tendon injury and rare infection; exclude sepsis, assess anticoagulation and diabetes, and avoid masking neurological or ligament disease.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Persistent load intolerance
Pain can continue for many months, limiting grip, manual work and sport, particularly when rehabilitation repeatedly alternates between overload and complete rest.
Deconditioning and fear
Avoidance reduces tendon and forearm capacity and can make ordinary lifting feel threatening even after tissue irritability begins to settle.
Injection-related harm
Repeated corticosteroid may cause skin depigmentation, fat atrophy, tendon weakening and poorer long-term recurrence patterns despite short-term pain reduction.
Missed nerve or ligament disease
Assuming all epicondylar pain is tendinopathy can delay treatment of posterior interosseous palsy, ulnar neuropathy, instability or intra-articular pathology.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Measure pain-free grip or a standardised lifting task, work tolerance and sport-specific load rather than pain score alone.
- Review exercise technique, resistance and next-day response every few weeks and progress only one major load variable at a time.
- Recheck finger and wrist power, sensory symptoms and muscle bulk if weakness or paraesthesia emerges.
- Monitor topical or oral NSAID adverse effects and discontinue when the medicine no longer enables useful activity.
- After injection, document duration of functional improvement and screen for skin change, infection and recurrent pain before considering anything further.
- Escalate new locking, instability, range loss or unremitting night pain to targeted imaging and specialist review.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Tenderness location is diagnostic work
True lateral-origin pain is close to the epicondyle; pain clearly distal should trigger radial tunnel assessment rather than another tendon injection.
Pain is not always weakness
A painful effort can look weak, so compare technique and distal motor patterns before diagnosing a tendon tear or nerve palsy.
Rest changes symptoms, not capacity
Avoidance may settle pain temporarily but leaves the tendon unprepared for return to gripping, torque or repeated work.
Medial anatomy raises stakes
The ulnar nerve and medial collateral ligament lie close to the flexor origin, making neurological and valgus testing essential.
Early relief can mislead
A steroid response does not prove the diagnosis, and short-term benefit can coexist with higher recurrence and lower later function.
Load progression is the treatment
Successful return requires strength, endurance, speed and task exposure to advance sequentially rather than merely waiting for tenderness to disappear.
11Common pitfallsFrequent interpretation and management errors.
- 01
Calling all lateral elbow pain tennis elbow without mapping tenderness or testing radial and cervical nerves.
- 02
Ordering routine MRI before a structured clinical assessment and a credible rehabilitation attempt.
- 03
Prescribing rest alone and then returning the person directly to the original high-force workload.
- 04
Using repeated corticosteroid injections because each produces brief relief despite recurrent disability.
- 05
Missing valgus instability or ulnar neuropathy in a patient labelled with medial epicondylitis.
- 06
Failing to ask about actual occupational load, grip size, repetition and recovery when planning return to work.