Higher incidence in athletes >35 yr, especially those participating in racquet sports; higher activity level (sports or occupational).

Poor technique; inadequate fitness level.

Repetitive eccentric overload of ECRB and/or the EDC, typically from tennis backhand, leading to degenerative histological changes within the tendon.

Early reports consistently described this process as inflammatory in nature; however, recent studies have confirmed the presence of fibroblasts, vascular hyperplasia, and disorganized collagen (angiofibroblastic hyperplasia) with a paucity of acute or chronic inflammatory cells, supporting the use of the term “tendinopathy” instead of “tendonitis.”

Lateral elbow pain typically with activities.

Occasional swelling and weakness of wrist extensors.

Numbness and parasthesias are uncommon.

Focal tenderness to palpation of common extensors overlying the lateral epicondyle and extending 1-2 cm distally.

Typically pain is elicited with resisted wrist extension while the elbow is in full extension, pain with the elbow flexed may indicate more advanced disease.

Pain may also be elicited with resisted supination.

Care should be taken to fully examine the shoulder as well, since it is not uncommon to uncover associated rotator cuff weakness.

Initially pain after activities, which is self-remitting.

Without treatment pain typically progresses to pain during activities only and may begin to affect activities of daily living and eventually become constant as well as disturb sleep.

Flexibility: stretching exercises for spine, shoulder (including scapula stabilizers: pectoralis, latissimus, rhomboids, trapezius), arm (biceps, triceps), forearm (wrist flexors and extensors).

Strength: progressive resistive exercise for the shoulder, elbow, wrist, and grip.

Proper technique: strike the ball in front of the body with the wrist and elbow extended, allowing the upper arm and torso not the wrist extensors to provide stroke power.

Equipment: lightweight racquet of low vibration material (graphite, epoxies); appropriate grip size (handle circumference should be equal to the measured distance from the tip of the ring finger to the proximal palmar crease, along its radial border); low string tension.

Protect, rest, ice, compression, elevation, medications, modalities (PRICEMM).

Rehabilitation exercises to include: stretching of wrist flexors and extensors; strengthening of wrist, elbow, and shoulder muscles especially rotator cuff (see 22.2)

Modalities to the affected area (ice, heat, ultrasound, electrical stimulation) with the goal of allowing individual to participate in rehabilitation program; general body conditioning.

Control of force loads as patient returns to activities: counterforce brace (forearm strap); improved sports technique; consider developing a two-handed backhand stroke; control intensity, duration and frequency of activities; appropriate equipment/racquet (see above).

Consider steroid injection if pain continues to limit participation in rehabilitation program (see 2.7).

Consider surgery for failure to respond to an appropriate rehabilitation program of 6 months or greater or an unacceptable quality of life.

Alternative modalities for resistant cases have been investigated and include botulinum toxin A, extracorporal shock wave therapy, acupuncture, and autologous blood injections.

Higher incidence in athletes >35 yr.

Golfers, tennis players, and throwing sports.

Repetitive eccentric overload of common flexors and pronator teres typically occurring in trail arm during a golf swing, forehand in racquet sports, or throwing arm.

Degenerative histological changes within the tendon, angiofibroblastic hyperplasia (see 6.1).

Medial elbow pain typically with activities.

Occasional swelling and weakness of wrist flexors and pronator.

Numbness and parasthesias are uncommon.

Focal tenderness to palpation of over the tip of the medial epicondyle extending distally 1-2 cm.

Often increased pain with resisted wrist flexion and pronation.

May also be associated rotator cuff weakness.

Check for positive Tinel’s sign at the cubital tunnel to rule out associated ulnar nerve entrapment (see 15.10).

Initially pain after activities, which is self-remitting; progresses to pain during activities only.

Without treatment, pain may begin to affect daily living and eventually become constant as well as disturb sleep.

Calcification or exostosis at the epicondyle or at the tendon attachment.

Calcification within the UCL, may suggest concomitant instability.

Flexibility: stretching exercises for spine, shoulder (including scapula stabilizers: pectoralis, latissimus, rhomboids, trapezius), arm (biceps, triceps), forearm (wrist flexors and extensors).

Strength: progressive resistive exercise for the shoulder, elbow, wrist, and grip.

Proper technique: for racquet sports, see discussion of lateral epicondylitis, 7.1.