Synopsis
Differentiate lateral common-extensor and medial common-flexor tendinopathy from nerve, ligament and intra-articular elbow disease, prescribe progressive load rehabilitation, and reserve imaging, injection or surgery for clearly defined indications.
- 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.
Key red flags
Fever, joint warmth, effusion and severe pain through passive flexion-extension requires urgent evaluation for septic arthritis rather than tendon injection.
Investigation priorities
Reproduce tendon-origin pain and screen joint, ligament, nerve and cervical alternatives.
Management branches
Local epicondylar pain is reproduced by matching resisted wrist or forearm action without red flags.
- Map tenderness and reproduce symptoms with resisted extension laterally or flexion and pronation medially.
- Check passive elbow movement, collateral stability, distal motor and sensory function and the cervical spine before concluding tendinopathy.
Key medicines
Topical diclofenac gelUse 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.
Short oral naproxen course with protection when neededIf 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.