What special physical examination tests are used to evaluate lateral and medial epicondylitis (tennis elbow and golfer's elbow)?

Special Physical Examination Tests for Epicondylitis

The most clinically useful special tests for epicondylitis are Cozen's test for lateral epicondylitis (tennis elbow) and grip strength measurement comparing elbow flexion versus extension positions, both demonstrating high diagnostic accuracy. 1

Lateral Epicondylitis (Tennis Elbow) Testing

Primary Diagnostic Tests

Cozen's Test is the most validated special test for lateral epicondylitis, demonstrating 91% sensitivity 1. This test involves resisted wrist extension with the elbow extended, reproducing pain at the lateral epicondyle when positive.

Grip Strength Differential Testing shows excellent diagnostic performance with:

• Sensitivity: 78-83%
• Specificity: 80-90%
• Technique: Compare grip strength with elbow in flexion versus extension; a 5-10% difference between positions indicates lateral epicondylitis 1

Additional Clinical Tests

Chair Pick-Up Test (modified version using the ORI-TETS system) provides objective force measurements and demonstrates:

• Excellent interrater reliability (ICC 0.84-0.93)
• Strong negative correlation with pain scores (Spearman rho -0.87 to -1.0)
• Takes only 5 minutes to perform 2

However, international survey data reveals the chair pick-up test is not routinely used in clinical practice (70% of physiotherapists report infrequent use) 3, suggesting a gap between research validation and clinical adoption.

Medial Epicondylitis (Golfer's Elbow) Testing

Clinical Examination Approach

Polk's Test has been described as a novel method for differentiating medial from lateral epicondylitis, though it requires further academic validation 4. The test helps identify repetitive activities of daily living that may be hindering recovery.

Palpation and Resisted Testing remain the cornerstone:

• Direct palpation over the flexor-pronator origin (starting 4.2-4.6 mm anterior to the posterior ridge of the medial epicondyle) 5
• Resisted wrist flexion and forearm pronation with elbow extended
• Pain reproduction indicates medial epicondylitis 6

Critical Anatomical Considerations

When examining for medial epicondylitis, understanding the precise anatomy is essential for accurate diagnosis and to avoid confusing it with ulnar collateral ligament (UCL) pathology:

• Common flexor tendons originate 4-5 mm from the posterior ridge and extend 5-7 mm anteriorly
• MCL origin is more posterior, starting at 10.4 mm from the posterior ridge
• This anatomical separation allows clinical differentiation between epicondylitis and ligamentous injury 5

Imaging Correlation

While special tests guide clinical diagnosis, sonoelastography demonstrates the highest diagnostic accuracy when imaging is needed:

• Sensitivity: 75-100%
• Specificity: 85-96% 7

Standard grayscale ultrasound shows more variable performance (sensitivity 53-100%, specificity 42-90%) 1, and plain radiographs are not routinely indicated for epicondylitis diagnosis (71% of clinicians report infrequent use) 3.

Clinical Pitfalls to Avoid

1. Don't rely on cervical spine special tests (e.g., Spurling's test) for epicondylitis evaluation—these are not routinely used and may lead to diagnostic confusion 3

2. Distinguish medial epicondylitis from UCL injury by noting that epicondylitis pain is more anterior on the epicondyle, while UCL pathology presents more posteriorly 5

3. Avoid ordering plain radiographs as initial imaging for suspected epicondylitis—they rarely change management in uncomplicated cases 8

4. Consider bilateral comparison when grip strength testing is equivocal, as side-to-side differences provide more reliable diagnostic information 1

Practical Testing Algorithm

1. Start with palpation of the specific epicondyle (lateral or medial)
2. Perform Cozen's test for suspected lateral epicondylitis
3. Measure grip strength differential (flexion vs. extension) for objective confirmation
4. Use resisted wrist flexion/pronation for medial epicondylitis
5. Reserve imaging (preferably sonoelastography if available) for atypical presentations or treatment-resistant cases

The evidence demonstrates that physical examination tests alone provide sufficient diagnostic accuracy for most cases of epicondylitis, with imaging reserved for cases requiring differential diagnosis or surgical planning 1, 6.