What is the purpose and treatment approach of a positive Cozen test (lateral epicondylitis)?

Cozen Test for Lateral Epicondylitis: Purpose and Treatment Approach

The Cozen test is a diagnostic maneuver used to identify lateral epicondylitis (tennis elbow) by eliciting pain at the lateral epicondyle when the patient actively extends the wrist against resistance while the elbow is extended. 1

Purpose of the Cozen Test

The Cozen test serves several important clinical functions:

• High diagnostic sensitivity: The test has high sensitivity in diagnosing lateral epicondylitis, making it a valuable clinical tool 1
• Identifies pathology: Helps confirm the diagnosis of lateral epicondylitis, an enthesopathy associated with the origin of the extensor carpi radialis brevis (ECRB) muscle 2
• Differentiates from other conditions: Assists in distinguishing lateral epicondylitis from other causes of lateral elbow pain such as:
  • Entrapment syndromes
  • Cervical radiculopathy
  • Osseous pathology
  • Inflammatory conditions 1

Imaging After a Positive Cozen Test

When a Cozen test is positive, the following imaging approach is recommended:

1. Initial imaging: Radiographs should be the first imaging modality to rule out fractures or other bony abnormalities 3, 4
2. If radiographs are normal or indeterminate:
   • MRI without contrast or ultrasound is recommended for suspected tendon injury 3
   • These are considered equivalent alternatives, with selection based on availability and clinical context 3

Treatment Approach for Lateral Epicondylitis

Initial Management (0-6 weeks)

1. Conservative measures:
   • Rest and activity modification
   • Ice application
   • NSAIDs (oral or topical) at lowest effective dose for shortest duration
   • Eccentric strengthening exercises
   • Functional bracing/orthotics (tennis elbow brace) 4, 5

Intermediate Management (6-12 weeks)

If symptoms persist after initial management:

1. Continue eccentric exercises for at least 12 weeks 4
2. Consider corticosteroid injection (limited to 1-2 injections) 4, 5
   • Note: Biologics such as platelet-rich plasma may be superior to steroid injections for long-term management 6
3. Consider physical therapy modalities:
   • Manual therapy combined with exercise therapy
   • Ultrasound or extracorporeal shock wave therapy 4

Management of Persistent Symptoms (>3 months)

For refractory cases:

1. Reassessment with imaging:

   • Repeat radiographs
   • MRI if needed to evaluate for associated pathology 4

2. Consider surgical referral if symptoms persist despite 6+ months of conservative management 4

   • Surgical options include:
     • Open debridement
     • Percutaneous techniques
     • Arthroscopic procedures 4, 6
   • All surgical approaches are highly effective with no method clearly superior, though arthroscopic and percutaneous approaches may allow faster recovery 6, 7

Prevention of Recurrence

To prevent recurrence after successful treatment:

• Technique modification for athletes and manual laborers to minimize repetitive stress 4
• Equipment adjustments (larger grips, graphite shafts) to reduce stress on the elbow 4
• Strength and flexibility program focusing on forearm muscles 4
• Relative rest rather than complete immobilization 4

Important Clinical Considerations

• Lateral epicondylitis is self-limiting in approximately 90% of cases 1
• The goal of treatment should be to restore functional range of elbow motion (≥30° to 130°) 4
• Avoid multiple corticosteroid injections as they may lead to tendon weakening
• For persistent cases, rule out other conditions that may mimic lateral epicondylitis