How do you diagnose epicondylitis?

Diagnosis of Epicondylitis

The diagnosis of epicondylitis is primarily clinical, based on a thorough history and specific physical examination findings including localized tenderness over the affected tendon, pain with resisted wrist extension (lateral epicondylitis) or flexion (medial epicondylitis), and weakened grip strength. 1, 2

Clinical Examination Approach

History Elements

• Age: Most common in 40-60 year age group 3
• Occupational or recreational activities involving repetitive wrist extension/supination (lateral) or flexion/pronation (medial) 2, 3
• Symptom characteristics: lateral or medial elbow pain, pain with specific movements, grip weakness 2

Physical Examination

1. Palpation:

   • Localized tenderness over the affected epicondyle and tendon origin 1
   • Compare with contralateral side to note differences in tissue texture 1
   • Document pain response using numerical scale 1
   • Note any associated muscle guarding or spasm 1

2. Special Tests:

   • Lateral Epicondylitis:

     • Cozen's Test: Pain with resisted wrist extension (high sensitivity) 4
     • Maudsley's Test: Pain with resisted extension of the middle finger 4

   • Medial Epicondylitis:

     • Pain with resisted wrist flexion and pronation
     • Tenderness over the medial epicondyle 1

   • Polk's Test: Helps differentiate between lateral and medial epicondylitis by identifying specific painful movements 5

Diagnostic Imaging

Imaging is typically not required for initial diagnosis but may be useful in cases with uncertain diagnosis or when symptoms persist despite treatment:

1. Radiographs (X-rays):

   • Usually normal or nonspecific in epicondylitis 1
   • Helpful to rule out other pathologies (fractures, arthritis, calcifications) 1

2. MRI Elbow (if radiographs are normal/noncontributory):

   • High inter- and intraobserver reliability for diagnosis 1
   • Sensitivity: 90-100%, Specificity: 83% 1
   • Findings: intermediate to high T2 signal within the common extensor/flexor tendon, paratendinous soft tissue edema 1
   • Can identify associated injuries and facilitate surgical planning 1

3. Ultrasound Elbow:

   • Moderate agreement with MRI for diagnosis and grading of tendon tears 1
   • Sensitivity: 64-95%, Specificity: 85-98%, Accuracy: 73-96% 1
   • Newer techniques like sonoelastography and superb microvascular imaging show improved diagnostic accuracy 1

Differential Diagnosis

Important conditions to rule out include:

• Cervical radiculopathy
• Entrapment neuropathies (radial or ulnar nerve)
• Osteochondral injuries
• Collateral ligament tears
• Biceps tendinopathy
• Inflammatory arthritis
• Osseous pathology 2, 4

Common Pitfalls to Avoid

1. Misdiagnosis: Failing to consider other causes of elbow pain, particularly nerve entrapment syndromes or cervical radiculopathy 4

2. Overreliance on imaging: Remember that diagnosis is primarily clinical; imaging should be used to confirm diagnosis or rule out other pathologies, not as the initial diagnostic tool 1, 2

3. Incomplete examination: Not testing both epicondyles or comparing with the contralateral side 1

4. Overlooking occupational factors: Failing to identify repetitive activities that may contribute to the condition and its persistence 3

Epicondylitis is often self-limiting, with approximately 90% of cases resolving with conservative management, though this may take 3-6 months 4. Early diagnosis and appropriate activity modification are key to successful management.