Editors

HelenaLiira

Lateral and Medial Epicondylitis of the Elbow

The strain that triggers the symptoms must be identified. Epicondylitis usually recovers spontaneously once the strain is removed.
Topical anti-inflammatory drugs may be used in the treatment of acute pain Non-Steroidal Anti-Inflammatory Drugs (Nsaids) for Treating Lateral Elbow Pain. Physiotherapy may be considered in chronic cases Physiotherapy and Exercise for Epicondylitis.
Glucocorticoid injections should not be used in the treatment of epicondylitis. Even though the injections will alleviate acute pain they will markedly increase the recurrence of epicondylitis Corticosteroid Injections for Lateral Epicondylitis.

Lateral epicondylitis (tennis elbow) is caused by repetitive strain on the wrist and finger extensor muscles which results in irritation of the tendon insertion on the humerus. Likewise, medial epicondylitis is caused by strain on the flexor muscles.
Risk factors of lateral epicondylitis include handling of heavy tools and loads as well as work tasks including repetitive movements Work-Related Factors and Risk of Lateral Epicondylitis. Predisposing factors of medial epicondylitis include handling of loads, repetitive movements and use of vibrating tools Work-Related Factors and Risk of Medial Epicondylitis.
According to Health 2000 (a health survey carried out in Finland) the prevalence of epicondylitis shows no gender preference. The prevalence of lateral epicondylitis was 1.1% and that of medial epicondylitis 0.3%.
Smoking may increase the risk of both lateral and medial epicondylitis, and obesity is associated with medial epicondylitis.

The patient presents typically with pain that localises around the epicondyle, particularly whilst gripping something with the forearm extended.
Resisted isometric testing should be carried out with the forearm extended. Extension (lateral epicondylitis) and flexion (medial epicondylitis) of the wrist are resisted. Pain at the insertion site of the tendon constitutes a positive finding.
A measurement of hand grip power and pain during gripping may also be used as diagnostic tools, and they also serve as functional capacity indicators. Hand dominance has an effect on grip power, and a 10% side difference in grip power is normal.

Lateral epicondylitis
- Resisted extension of the wrist causes pain at the lateral epicondyle and
- the epicondyle is tender on palpation.
Medial epicondylitis
- Resisted flexion of the wrist causes pain at the medial epicondyle and
- the epicondyle is tender on palpation.

Local strain symptoms and tendinitides in the forearm
Arthrosis of the elbow joint and ulnar sulcus syndrome.
Proximal problems originating from the plexus or the cervical spine nerve root areas, e.g. disc prolapse and radicular compression
Nerve entrapment of the deep motor branch of the radial nerve (Frohse's syndrome) is rare and is associated with extension weakness of the fingers.
ENMG Clinical Neurophysiology in Diagnostics is necessary in some cases for the differential diagnosis.

Avoidance of lifting and gripping.
Safe analgesia: topical non-steroidal anti-inflammatory drugs Non-Steroidal Anti-Inflammatory Drugs (Nsaids) for Treating Lateral Elbow Pain or paracetamol.
There is scarce evidence on the benefit of oral anti-inflammatory drugs, and due to their possible adverse effects they are not recommended Non-Steroidal Anti-Inflammatory Drugs (Nsaids) for Treating Lateral Elbow Pain.

Glucocorticoid injections are not recommended for the treatment of epicondylitis because they increase the recurrence of the pain within a 3-12 month follow-up period despite providing good short-term (less than 6 weeks) pain relief Corticosteroid Injections for Lateral Epicondylitis.
Orthotic supports, such as adhesive tape or splints, may improve symptoms Orthotic Devices and Splints for Tennis Elbow and, if necessary, they may be used short term in order to alleviate pain.
Gradually increasing strengthening exercises may have some effect on both the symptoms and recovery of chronic epicondylitis, but scientific evidence is inconsistent Physiotherapy and Exercise for Epicondylitis.
Shock wave therapy has been studied in several comparative studies, but its effect in terms of pain and function in chronic epicondylitis has not been proven Shock Wave Therapy for Lateral Elbow Pain.
Ultrasound may improve symptoms of chronic epicondylitis. The treatment effect is very small, and study results are not totally consistent Ultrasound for Epicondylitis.
Topical application of nitric oxide ointment may be effective in the treatment of chronic epicondylitis.
Injection treatments (botulinum toxin or platelet-rich plasma) may reduce symptoms of lateral epicondylitis in chronic conditions.
There is no evidence from comparative studies on the effectiveness of surgery in the treatment of epicondylitis, and there are no clear indications for surgery Surgery for Lateral Elbow Pain.

Epicondylitis may be considered as an occupational disease in certain circumstances. In accordance with national legislation, the patient may be eligible for reimbursement payments.

Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol 2006 Dec 1;164(11):1065-74. [PubMed]
Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2003 Nov-Dec;31(6):915-20. [PubMed]
Wong SM, Hui AC, Tong PY, Poon DW, Yu E, Wong LK. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 2005 Dec 6;143(11):793-7. [PubMed],
Krogh TP, Bartels EM, Ellingsen T et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med 2013;41(6):1435-46. [PubMed]