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Lateral epicondylitis - E2.2

Definition of condition: Lateral epicondylitis is an inflammation of the common extensor origin at the lateral epicondyle.

Issue statement: The evidence for occupational risk factors (especially repetitive activities) producing elbow disorders is limited.  A careful history of the job tasks, load, posture and range of movements are needed to assess the degree of cumulative trauma and work related injury.

WCB-Alberta position

Work relationship criteria

The specific work related exposures causing lateral epicondylitis have not been adequately studied.

Work relationship can be established with a clear history of direct trauma to the lateral epicondyle, repetitive supination of the forearm or dorsiflexion of the wrist against resistance correlated with clinical findings of ligamentous strain or tear.

While the onset of lateral epicondylitis is usually insidious, there is minimal research on cumulative exposure-response.  One cohort study showed a clear increased risk for lateral epicondylitis among sausage makers, meat cutters and packers and there is substantial evidence of cumulative exposure-response in tennis players.

In cases where job duties do not support the injury, a good history about non-occupational activities is warranted.  More studies are needed to assess, one way or the other, the association between work and lateral epicondylitis.

Clinical criteria

The onset of lateral epicondylitis is usually insidious but may be provoked by acute trauma.  Symptoms include:

• pain in the lateral elbow with radiation into the extensor aspect of the forearm with extension of the wrist or forearm supination
• burning sensation that may radiate into the forearm
• possible loss of grip strength due to forearm pain with grip
• exacerbation of symptoms by gripping objects, especially with force, or frequent rotary motions

Signs include:

• point tenderness over the lateral epicondyle
• reproduction of pain with passive flexion of the wrist and fingers with the elbow extended; supination against resistance; wrist/finger extension against resistance; resisted lifting with forearm in neutral position
• weakness of wrist extension and/or grip due to pain
• normal elbow motion although painful at the end range of extension in severe cases

Diagnostic criteria

Lab Tests

• no specific findings
• not indicated unless a systemic disorder suspected

Imaging Studies

• plain films only to rule out fractures following significant trauma and calcific tendonitis in intractable lateral epicondylitis

Electrophysiologic Tests

• if history and physical exam are equivocal, may be ordered to rule out concomitant radial nerve entrapment

Strength and Flexibility Tests

• no specific findings
• may assist in assessing improvement and progression

Recommended management

Education

The primary treating physician should discuss the following with the patient:

• anatomy, natural history, and prognosis
• expected progress with treatment
• self care including exercises
• proper use of medication
• risk factor modification: avoid repetitive grip, dorsiflexion of the wrist and supination of the forearm against resistance

Prevention of reoccurence

Prevention of recurrence is a joint effort between the physician, the employee and the employer.  Components include:

• education of all parties as to preventive measures
• modification of tools and/or work activities
• compliance with limitations & restrictions
• avoidance of conditions predisposing to a recurrence may be required
• body mechanics retraining may be indicated in some circumstances
• include education related to home, social and sports activity as well as the work environment

Physical methods of treatment

Orthoses

• counterforce armband may produce an increase in wrist extension strength and grip strength
• volar supported wrist splint for 1-2 weeks (used primarily to remind patient to modify and restrict their activity)

Physical therapy

Examination of the cervical spine and shoulder to rule out referred causes of lateral elbow pain is required and needs to be documented.  Postural description should also be included.

• active assisted and non-resisted motion to recover ROM
• initially isokinetic strengthening with light weights and higher repetitions for endurance
• followed by a strengthening protocol utilizing fewer repetitions and gradually increasing weight

Further improvements in strength and flexibility are unlikely after one month of adequate physical therapy; special circumstances should exist to justify further treatment; modalities are not indicated after one month

Passive modalities are not indicated as there is no evidence of their effectiveness except for one:

• ice massage 4 times/day until acute pain is controlled

Inappropriate therapies include:

• prolonged wrist splinting
• manipulative therapy

Medical treatment

Medication

• ASA, acetaminophen, or NSAID may be used as needed for pain relief x 1-2 weeks (maximum)
• local corticosteroid injection for acute or non-responsive lateral epicondylitis may be warranted; no more than 3 should be given within a 9 month period

Surgical         

Orthopedic surgery may be indicated if lateral epicondylitis fails to resolve after a 6-12 month course of conservative treatment, or no improvement after 3 steroid injections

Fitness to work criteria

• no absence from work anticipated particularly if modified duties available
• 1-8 weeks expected duration of absence depending on job duties and if modified work is not available

Permanent clinical impairment criteria

As a general rule, in the absence of a loss of ROM, there is no assessable impairment. There may be permanent work restrictions.

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