Epicondylitis

This tool provides information to facilitate the management of recent onset and persistent epicondylitis

Focused examination

1. Patient History 

  • Assess level of concern for major structural or other pathologies. If required, refer to an appropriate healthcare provider.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address prognostic factors that may delay recovery.

Major structural or other pathologies may be suspected with certain signs and symptoms (red flags):

  • History of significant trauma, history of inflammatory arthritis, history of unexplained, significant weight loss, fever, swollen joints, progressive, widespread neurological symptoms, severe, unremitting night-time pain, widespread, unexplained pain, unremitting pain when at rest

Examples of other conditions/co-morbidities:

  • Physical conditions: neck pain, headache

  • Psychological conditions: depression, anxiety

  • Co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization

2. Physical Examination

  • Assess levels of concern regarding major structural or other pathologies.

  • Assess for neurological signs.

  • Identify patient's baseline status relative to pain, function and disability; determine the patient's readiness to return to activities using appropriate assessments.

3. Management 

  • Offer information on nature, management, and the course of epicondylitis. See patient handouts below for more information to provide to patients.

  • Discuss the range of effective interventions with the patient and, together, select a therapeutic intervention.

  • Emphasize active rather than passive treatments.

Patient Handouts

CCGI_epicondylitis_patient handout.jpg
CCGI_epicondylitis_patient handout_FR.jpg
 

Management of recent-onset (0-3 months symptom duration) 

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

Consider an elbow brace worn over the common exterior tendon during the daytime for 6 weeks (for lateral epicondylitis)

​​Consider multimodal care

  • combination of manipulation or mobilization¹, deep tissue massage², forearm strengthening and stretching exercise³, and advice to stay active, and ergonomic and activity modification to avoid symptom provocation (10 sessions over 5 weeks)

Do not offer transcutaneous electrical nerve stimulation (TENS)⁴

Do not offer elbow brace added to multimodal physical therapy (for lateral epicondylitis)⁴

Management of persistent (3+ months symptom duration)

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

Consider home-based stretching and strengthening exercise⁵ ​

Consider multimodal care (if not provided within the acute period)

  • combination of manipulation or mobilization¹, deep tissue massage², forearm strengthening and stretching exercise³, and advice to stay active, and ergonomic and activity modification to avoid symptom provocation (10 sessions over 5 weeks)

Consider muscle energy technique⁶

Consider myofascial release to the forearm 

Consider an elbow brace worn over the common exterior tendon during the daytime for 6 weeks (for lateral epicondylitis)

Do not offer transcutaneous electrical nerve stimulation (TENS)⁴

Do not offer elbow brace added to multimodal physical therapy (lateral epicondylitis)⁴

*Interventions are recommended if guidelines used terms such as ‘recommended for consideration’ (e.g., ‘offer’, ‘consider’), ‘strongly recommended’, ‘recommended without any conditions required’, or ‘should be used’. Recommendations from low-quality evidence are not listed.

ᶧMultimodal care: treatment involving at least two distinct therapeutic modalities, provided by one or more health care disciplines.


¹Mobilization: a) Sustained Lateral Glide With Pain-Free Grip: a sustained lateral glide across the elbow joint while the patient performs a gripping action; b) Sustained Lateral Glide with Movement: If there is also reproduction of pain with elbow movement, perform the lateral glide while the movement is repeated; c) Sustained Posterior-Anterior Glide with Pain-Free Grip: In the event (a) and (b) are not effective, attempt a sustained posteror-anterior glide of the radio-humeral joint. Manipulation: patient seated with upper extremity in 90 degrees of abduction with internal rotation so that the olecranon faces up. Stabilize wrist in full flexion and pronation with one hand and place the other hand over the olecranon. Deliver a high-velocity low amplitude thrust at the end of range of elbow extension


²10 minutes of deep transverse friction massage followed by manipulation


³Exercise: supervised and home exercise including: progressive, slow, repetitive wrist and forearm stretches; 8-12 repetitions of progressive loaded exercise for wrist extension/flexion, supination/pronation, radial/ulnar deviation, pain-free grip, 3 sets, 2-3 times per week. Include work-specific tasks and activities before re-introduction into the workforce. Include other upper quadrant muscle deficiency, and correction of postural alignment and upper limb movements as clinically indicated

 

⁴There is no significant difference between the intervention of interest and the comparison intervention

 

⁵The program should consist of 15 repetitions of progressive incremental loading exercises for forearm extensors, 3 sets daily for 3 months; and/or 3 repetitions of wrist extensor stretches, twice daily for 6 weeks.

 

⁶The program should include 5 repetitions (twice per week for 4 weeks) of resisted forearm pronation from an initial maximally supinated position to passively stretch the pronator muscles

Care Pathway for the management of epicondylitis

(click here for French version)

Clinician Handout_epicondylitis_Page_3.jpg

4. Reevaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors that may delay recovery.

5. Referrals and Collaboration

  • Refer the patient to an appropriate healthcare provider for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms.