Lateral Epicondyle Tendinopathy Toolkit: Section B - Clinical Assessment

Original Editor - Kim Jackson uploaded for the BC Tendinopathy Task Force Dr. Joseph Anthony, Paul Blazey, Dr. Allison Ezzat, Dr. Angela Fearon, Diana Hughes, Carol Kennedy, Dr. Alex Scott, Michael Yates and Alison Hoens

Top Contributors - Nupur Smit Shah, Cindy John-Chu, Kim Jackson, Rishika Babburu and Vidya Acharya  

Introduction[edit | edit source]

The purpose of this document is to summarize the clinical assessment of the patient diagnosed with lateral epicondyle tendinopathy. Initially, the assessment consists of history, objective and subjective examination, chief complaints in order to confirm the diagnosis. The toolkit will even include differential diagnosis, the process of identifying causes/risk factors of lateral epicondyle tendinopathy and functional examination.

Risk factors[edit | edit source]

There are potential risk factors associated with developing lateral epicondyle tendinopathy LET. These can be further classified as non-modifiable and modifiable risk factors

Non-Modifiable Risk Factors[edit | edit source]

These are the factors which cannot be changed

  • Age
    • Typically occurs > 40 years [1]
  • Gender
    • Weak evidence for female >male[1][2]
  • Metabolic Disorder
    • Generally, metabolic factors are weakly associated with LET compared to mechanical overuse (modifiable) factors.[3]
      • Diabetes[1][3]/Hyperglycemia[3]
      • Cardiovascular disease risk factors[4]
  • Familial Disorder
    • Genetics – variants in connective tissue health more likely to be susceptible to LET[5]
  • Systemic Inflammatory Disease
    • Spondyloarthropathy (SpA) is generally associated with enthesis disorders, more commonly in the load bearing tendons of lower limbs compared to upper limbs.
    • SpA (SCREEND’EM)[6] – acronym for a useful screening tool to assist in identifying individuals that would benefit from further medical investigation for SpA.

Modifiable Risk Factors[edit | edit source]

These are the factors which can be worked on and measures can be taken to change them. They are the exposures /behavior's which lowers or increases the person's risk of lateral elbow epicondylitis.

  • Lifestyle
    • Smoking – current and past history[1]
  • Active Group – Overuse from repetitive and forceful recreational and occupational activity.
    • Sport[1]Only 10% of LET are associated with racquet sport.[5]
      • Grip strength weakness
      • Equipment (eg improper tennis grip size)
      • Technique (eg poor backhand swing)
    • Occupation[1]
      • Repetition, Ergonomics, Tools (forceful grip, vibration)
  • Inactive/Sedentary Group
    • More likely to have overuse response to unaccustomed loads from ADLs, or decline in tendon load capacity (age, activity, or lifestyle factors).
  • Previous shoulder injury
    • Rotator cuff weakness ipsilateral side

History[edit | edit source]

Lateral elbow pain which is related to over use. It is not always associated with sport and can occur through any activity that involves wrist extension, pronation or supination.[7]

Subjective Symptoms[edit | edit source]

Symptoms provoked by activity. Symptoms are usually localized to lateral elbow, or referred along the extensor/supinator muscle groups of the forearm. Extensor weakness and reduced grip strength may be present and could be linked to pain provocation.

Biopsychological factors[edit | edit source]

Persistent LET pain may involve behavioral and psychosocial factors contributing to nervous system sensitivity (peripheral and central). There is evidence that psychological variables (catastrophization, signs of distress) can increase LET symptoms. In patients with psychosocial drivers, treatment programs should consider providing pain neuroscience education, as well as addressing cognitive and behavioral barriers.[8]

Objective Signs[edit | edit source]

During the assessment it is important to record clinical observations not only symptoms. Below we discuss objective signs relevant to LET.

Upper Quadrant Screening Exam[edit | edit source]

Upper quadrant musculoskeletal conditions are defined as pain in the arm , shoulder and neck and they are not due to trauma or underlying systemic disease.[9]

Upper quadrant Screening Exam Contributing Factors
Cervical Radiculopathy, Neuropathy
Shoulder Rotator cuff weakness myofascial trigger points (MTrP), Neuropathic tender points
Elbow , Forearm Grip weakness MTrP, Neuropathic tender points
Abnormal Neural Tension(Neurodynamics) Peripheral nerve – Radial bias

Palpation[edit | edit source]

Palpation is an important part of the assessment process and can used to determine any abnormalites such as swelling, pain or tenderness, and skin temperature.

In LET, palpation is primarily performed at the extensor carpi radialis brevis tendon insertion at the lateral epicondyle. It may also include the extensor carpi radialis longus and extensor digitorum communis insertion.

Mills Test[edit | edit source]

The Mills test is performed to provide a passive stretch of the extensor group[10]

  • Start position
    • Shoulder neutral, elbow 90 degrees, forearm pronated, wrist fully flexed.
  • Technique
    • Operator gradually passively extends elbow towards zero degrees, maintaining forearm pronation or wrist flexion. Monitor pain over lateral elbow.

Maudsley Test[edit | edit source]

The Maudsley test is an isometric resistance test for the extensor muscle group.[10]

  • Start Position
    • Shoulder neutral, elbow 90 degrees , forearm pronated and wrist in neutral position.
  • Technique
    • The therapist resist middle finger extension. Monitor pain over lateral elbow.

Cozen's Test[edit | edit source]

The Cozen's test is an isometric resistance test for the extensor muscle group.[10]

  • Start Position
    • Shoulder neutral, elbow 90 degrees , forearm pronated, wrist neutral. Combined resistance of wrist extension, radial deviation.
  • Technique
    • The patient is asked to move the wrist to dorsal flexion and the therapist provides resistance to this movement. The test is positive if pain is elicited over the lateral elbow.

Thomsen Test[edit | edit source]

The Thomsen test is an isometric resistance test for the extensor muscle group. It is a variation of cozen's test.[11]

  • Start position
    • Shoulder 60 degrees flexion, elbow 0 degrees, forearm pronated, wrist extended 30 degrees.
  • Technique
    • Isometrically resist wrist extension at the dorsum of hand. A positive is recognised if pain is observed at the lateral elbow.

Imaging[edit | edit source]

Imaging such as ultrasound (US) and magnetic resonance imaging (MRI) may be useful, particularly for patients whose symptoms are inconsistent with LET and are not responding to conservative interventions, to ascertain whether there are structural changes in tendon consistent with LET. Imaging may also assist to ‘rule out’ the tendon as a source of pathology, and investigate for other intra/extra articular conditions.[1]

Differential Diagnosis[edit | edit source]

It can be difficult to accurately diagnose LET as there are many other conditions with similar clinical symptoms. Below is a list of other possible causes and conditions:

  • Articular
    • Intra-articular synovial plica of radial-capitular joint[11]
    • Radio-capitular arthritis[11]
    • Osteochondritis dessicans[11]
  • Instability
    • Posterolateral rotary instability due to laxity of collateral ligaments[11]
  • Neural
    • Radial tunnel entrapment of posterior interosseous nerve (Arcade of Froshe)[12]
    • Cervical radiculopathy
    • Abnormal neural tension neurodynamics (radial nerve bias)[11]

Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Watts A, Robinson P. Epicondylitis. BMJ Best Practice. (2021). Available from: [cited 2022Nov4].
  2. Shiri R, et al. Prevalence and determinants of lateral and medial epicondylitis: A population study. Amer Jour Epidemiology. (2006). 164(11):1065-1074.
  3. 3.0 3.1 3.2 Park HB, Gwark JY, Im JH, Na JB. Factors associated with lateral epicondylitis of the elbow. Orthopaedic Journal of Sports Medicine. 2021 May 12;9(5):23259671211007734.
  4. Otoshi K, Takegami M, Sekiguchi M, Onishi Y, Yamazaki S, Otani K, Shishido H, Fukuhara S, Kikuchi S, Konno S. Chronic hyperglycemia increases the risk of lateral epicondylitis: the Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS). Springerplus. 2015 Dec;4(1):1-9.
  5. 5.0 5.1 Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.
  6. Zytoon A, et al. Ultrasound assessment of elbow enthesitis in patients with seronegative arthropathies. Jour Ultrasound. (2014). 17:33-44.
  7. Van Rijn R, et al. Associations between work-related factors and specific disorders at the elbow: a systematic literature review. Rheumatology (Oxford) 2009;48(5):528-36.
  8. Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. Journal of physiotherapy. 2015 Oct 1;61(4):174-81.
  9. Campbell KE, Parent EC, Crumback DJ, Hebert JS. Predicting upper quadrant musculoskeletal injuries in the military: a cohort study. Medicine and science in sports and exercise. 2021 Sep 20.
  10. 10.0 10.1 10.2 Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. British journal of sports medicine. 2017 May 1;51(9):743-8.
  11. 11.0 11.1 11.2 11.3 11.4 11.5 Karanasios S, Korakakis V, Moutzouri M, Drakonaki E, Koci K, Pantazopoulou V, Tsepis E, Gioftsos G. Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)–A systematic review. Journal of Hand Therapy. 2021 Feb 27.
  12. Hegmann KT, Thiese MS, Kapellusch J, Merryweather A, Bao S, Silverstein B, Wood EM, Kendall R, Foster J, Drury DL, Garg A. Association between epicondylitis and cardiovascular risk factors in pooled occupational cohorts. BMC musculoskeletal disorders. 2017 Dec;18(1):1-0.