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.
- 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.
Key red flags
Fever, joint warmth, effusion and severe pain through passive flexion-extension requires urgent evaluation for septic arthritis rather than tendon injection.
A fall, deformity, focal bony tenderness, mechanical block or inability to extend requires radiographs for fracture, dislocation or intra-articular injury.
Progressive finger or wrist weakness, persistent sensory change or muscle wasting requires localisation of radial, posterior interosseous, ulnar or cervical nerve disease.
Night pain unrelated to load, a mass, weight loss or previous malignancy requires imaging for tumour or destructive disease.
Medial pain with valgus instability in an overhead athlete may represent ulnar collateral-ligament injury rather than common-flexor tendinopathy.
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.
- Explain the usual gradual course and agree temporary changes in repetition, grip and force while retaining tolerable activity.
- Begin a progressive exercise plan and define grip, work or sporting outcomes for review over six to twelve weeks.