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Lateral & Medial Epicondylopathy Cheat Sheet (DRAFT) by

Presentation, Management

This is a draft cheat sheet. It is a work in progress and is not finished yet.


- Repetitve Wrist extension causes micro tearing of CEO
- Common tendon affected is ECRB (hypov­asc­ular)
- Chronic cases- inflam­matory cells are absent
- Failure of the natural healing process (angio­blastic degner­ation)


- Usually in 4th/5th decade of life
- Affects men and women equally
- Most of the time it presents in dominant arm

Risk Factors

- Repeated wrist extension and forearm supina­tio­n/p­ron­ation
- Occupa­tio­ns/­act­ivies: carpen­ters, brickl­ayers, seamst­resses, tailor, pianists, drummers, people who shake hands alot, tennis player­s.p­rol­onged keyboa­rd/­mouse usage
- Tennis rplayers - improper mechanics during backha­nds­/serves
- Ask about racquet: Heavy/­new­/ti­ghtly strung, excessive gripping, hitting wet/heavy tennis­balls


- Insidious after overuse activity - usually no trauma
- Pain over lateral aspect of elbow
- Provoked by activities that involve grippi­ng/­wrist extension
- Relieved by rest
- Usually localised - but consider peripheral neuropathy (radial tunnel) if distal symptoms (nocturnal pain more common in radial tunnel than LE)
- Pain on palpation of lateral epicondyle (over ECRB tendon 2nd one down)
- Pain on RROM - wrist extension
- +ve Cozen's, +ve long finger extension test
- Consider Anconeus TrPs
- Neurol­ogical exam normal unless radial tunnel syndrome( diminished sensit­ivity over dorsal aspect of the forear­m/thumb and weakness of thumb extension


Further imaging if red flags: F# , disloc­ation, infection, hx of trauma, neoplasm
US (can reveal asympt­omatic damage at ECBR) - can pick up calcific tendinitis


- Cx radicu­lopathy
- Radial Tunnel syndrome
- OA
- F#
- Infection
- Neoplasm
- Osteoc­hondral loose body
- Elbow synovitis
- Triceps tendinitis
- Sprain­/strain
- Myofascial pain syndrome
- inflam­matory Arthro­pathy


- Rest and avoidance of offending activity (wrist ext, pronat­ion­/su­pin­ation)
- Ice/Ice massage
- Change mechanics (2 handed backst­roke)
- EMT/mo­bil­isation of the elbow and wrist
- SMT of Cx Tx
- Deep friction massage of tendon
- STM and stretching of wrist extensors and supinator
- ECRB stretched by elbow extension, forearm pronation and wrist flexion
- Slow and progre­ssive (moderate effort and low reptit­iions) - assessed by night pain (increased = load is excessive)
Progre­ssion advances when patient tolerates a given level of tensile load
- Resistance training - isomet­rically then eccentric
- Tyler twist with theraband flexbar
- Scapular stability deficits
- Ultrasound treatment
- Oral/t­opical NSAIDs
- Cortic­ost­eriod injections
- Surgical consid­era­tio­n/poor prognosis of conser­vative care if: failure of conser­vative care, heavy manual labour, LE in dominant arm, high pain percep­tion, poor coping strats

Medial Epicon­dyl­opathy

- Pronator teres, FCR, Palmaris Longus, FDS, FCU
- Most frequent cause of medial elbow pain


- Repetitive flexion and pronation and valgus stress
- Injuries (trauma, excessive stretch, eccentric overload)
- Microt­earing - disorg­anised healing process, failure to regenerate
- FCR and pronator teres origin most commonly affected
- Affects men and women equally
4th and5th decade
Dominant arm mostly affected
athletes (golfers - top of their back swing until ball impact, baseball players (accel­eration phase of throwing), racquet sports , bowling, javelin throwing, football, archery, weight lifting
- Occupa­tions that require repetitive flexion and pronation
- Obesity
- Smoking
- Type II diabetes


- Dull pain over medial elbow
- Grip weakness
- Swelling often present
- TTP over <1 finger breadth distal and anterior to the centre of the medial epicondyle
- Pain during resisted forearm pronation + resisted wrist flexion + resisted elbow flexion (in chronic cases)
- Ulnar neuritis, Cubital tunnel syndrome and UCL instab­ility (moving valgus stress test) must be considered


- Only if unresp­onsive to conser­vative care/t­rauma (rule out avulsion f#)
- MRI for stress f#. infect­ions, tumours, ligame­ntous injuries and osteoc­hon­dritis dissecans
- US for ruling in medial epicon­dyl­opathy


- Cubital tunnel syndrome
- Little league elbow (children)
- Muscle strain
- Cx radicu­lopathy
- F#
- Infection
- Neoplasm
- Bursitis
- Flexion contra­cture
- Pronator Quadratus syndrome
- Intraa­rti­cular injury
- Osteoc­hon­dritis dissecans
- Anterior intero­sseous nerve entrapment
- Rheuma­tologic disease


- Prone to recurr­ence, prolonged discomfort present
- Rest , ice/ice massage NSAIDs for acute cases
- If chronic - bracings (counter force), eccentric rehab, activity modifi­cation
- Limita­tio­n/s­topping offending activity
- Cock up wrist splints for night time
- Myofas­cia­l/s­tre­tching of common flexor tendon
- Mobili­sat­ion­/ma­nip­ulation into ext if flexion contra­cture
- SMT/EMT of the Cx, elbow, wrist and shoulder
- Moderate efforts with low reps on rehab
- Stretching then streng­thening
- Reverse tyler twists
- Surgery if unresp­onsive to conser­vative care after 3-6 months