Lateral epicondylitis results from inflammation and microtearing of fibers in the extensor tendons of the forearm. Symptoms include pain at the lateral epicondyle of the elbow, which can radiate into the forearm. Diagnosis is by examination and provocative testing. Treatment is with rest, NSAIDs, and physical therapy.

Theories about the pathophysiology of lateral epicondylitis include nonathletic and occupational activities that require repetitive and forceful forearm supination and pronation, as well as overuse or weakness (or both) of the extensor carpi radialis brevis and longus muscles of the forearm, which originate from the lateral epicondyle of the elbow. For example, during a backhand return in racket sports such as tennis, the elbow and wrist are extended, and the extensor tendons, particularly the extensor carpi radialis brevis, can be damaged when they roll over the lateral epicondyle and radial head. Contributing factors include weak shoulder and wrist muscles, a racket strung too tightly, an undersized grip, hitting heavy wet balls, and hitting off-center on the racket.

In resistance trainees, injuries often are caused by overuse (too much activity or doing the same movements too often) or by muscle imbalance between the forearm extensors and flexors. Nonathletic activities that can cause or contribute to lateral epicondylitis include those involving grasping and twisting the elbow (eg, turning a screwdriver).

With time, subperiosteal hemorrhage, calcification, spur formation on the lateral epicondyle, and, most importantly, tendon degeneration can occur.

Symptoms and Signs

Pain initially occurs in the extensor tendons of the forearm and around the lateral elbow when the wrist is extended against resistance (eg, as in using a manual screw driver or hitting a backhand shot with a racket). In resistance trainees, lateral epicondylitis is most noticeable during various rowing and chin-up exercises for the back muscles, particularly when the hands are pronated. Pain can extend from the lateral epicondyle to the mid forearm.

Diagnosis

• Provocative testing

Pain along the common extensor tendon when the fingers are extended against resistance and the elbow is held straight is diagnostic. Alternatively, the diagnosis is confirmed if the same pain occurs during the following maneuver: The patient sits on a chair with the forearm on the examination table and the elbow held flexed (bent) and the hand held palm downward; the examiner places a hand firmly on top of that of the patient, who tries to raise the hand by extending the wrist.

Treatment

• Rest, ice, NSAIDs, extensor muscle stretches
• Modification of activity
• Later, resistive exercises

Treatment involves a 2-phased approach. Initially, rest, ice, NSAIDs, and stretching of the extensor muscles are used. Occasionally a corticosteroid injection into the painful area around the tendon is needed. When the pain subsides, gentle resistive exercises of the extensor ( see Sidebar 2: Sports Injury: Exercises to Strengthen the Wrist Extensors) and flexor (see Sidebar 3: Sports Injury: Exercises to Strengthen the Wrist Flexors) muscles in the forearm are done followed by eccentric and concentric resistive exercises. Activity that hurts when the wrist is extended or pronated should be avoided. Use of a tennis elbow brace is often advised. Adjusting the fit and type of racket used can also help prevent further injury.

Although surgery is not usually needed, surgical techniques to treat lateral epicondylitis involve removing scar and degenerative tissue from the involved extensor tendons at the elbow. Surgery is usually considered only after at least 9 to 12 mo of unsuccessful conservative treatment.

Sidebar 2
Exercises to Strengthen the Wrist Extensors
These exercises should be done only after the pain has subsided. Sit on a chair next to a table. Place the forearm on the table, palm facing down and elbow bent, with the wrist and hand hanging over the edge. Hold a light weight in the hand. Slowly raise and lower the hand by bending and straightening the wrist, keeping the forearm planted firmly on the table. Do 3 sets of 10 repetitions with 1 min of rest between repetitions. As the exercise becomes easier, increase the weight. Next, While standing and with both arms held out in front of the body palms downward, wind up a 450-g (1-lb) weight that is attached by a rope to a piece of wood with the diameter of a broomstick (the rope will be attached to the center of the device with the hands grasping on either side). The weight should almost touch the ground when the rope is unrolled. Roll the weight up and down 5 or 6 times by using the strength of the forearm extensor muscles (ie, the rotation of the stick is upward and toward the body); stop if pain is felt. Repeat the exercise every other day. Gradually increase the weight. Do not increase the number of times that the weight is rolled up. As heavier weights are used and as tissues become stronger, frequency should decrease to once every 7 to 10 days. Adapted from Mirkin G, Shangold M: The Complete Sports Medicine Book for Women. New York, Simon & Schuster, 1985, p. 109; used by permission of The Miller Press.

Sidebar 3
Exercises to Strengthen the Wrist Flexors
Sit on a chair next to a table. Place the forearm on the table, palm facing up, with the wrist and hand hanging over the edge. Hold a light weight in the hand. Slowly raise and lower the hand by bending and straightening the wrist. The set should last about 90 to 120 sec for rehabilitation and about 50 to 70 sec for general strength and conditioning. Rest 1 min, then do additional sets until the forearms feel fatigued and worked. Repeat every 2 days while rehabilitating but only once every 7 to 10 days with normal or strong forearms and when using heavier weights and greater intensity of effort. If pain is felt, stop the exercise immediately, and try it again the next day. As the exercise becomes easier, increase the weight. For rehabilitation, frequency should decrease as the muscles become stronger and heavier weights are used.

Last full review/revision April 2009 by Brian D. Johnston; Paul L. Liebert, MD

Content last modified February 2012