Extensor tendinopathy is traditionally known as 'tennis elbow', and flexor tendinopathy as 'golfer's elbow' because the corresponding muscle groups can be overused in these sports.
The two share similar pathology as overuse injuries of the common extensor or flexor tendons.
Around the site of insertion, the tendons can develop micro-tears resulting from overuse of a structure that is not accustomed to the repetitive load to which it has been exposed. Histological studies have shown tissue to be characterised by disorganised, immature collagen.1
These conditions are often diagnosed as tendinitis. Despite this, and the common term epicondylitis, it has been suggested that the tendon undergoes a degenerative rather than an inflammatory process.2 Tendinosis may therefore be a more appropriate term.
Patients may present with pain around the medial or lateral epicondyles. Aggravating factors include lifting and carrying, and activities that require heavy or repetitive loading of the flexor or extensor tendons of the wrist and hand.
The initial onset may coincide with a change in activity that places more load on the forearm flexors and extensors than usual. This may be a functional activity, such as cleaning or moving heavy boxes, or sport-related. Onset is usually gradual and some patients may have experienced their symptoms for years.
The relevant epicondyle may be tender to palpate. Testing resisted extension or flexion of the wrist is usually provocative of symptoms in the corresponding pathologies.
Testing of resisted middle finger extension, stressing the extensor digitorum tendon, may also provoke symptoms in tennis elbow. Pain may also be felt in the flexor or extensor muscles of the forearm.
It is important to rule out radicular elbow pain of cervical origin, peripheral nerve pathology and any infection or degenerative pathology.
Advice on activity modification, including using alternative grips, changing routines at work and pacing activities, forms the mainstay of initial treatment.
If there is a long wait for physiotherapy, it may be helpful for the GP to offer this advice at an early stage. Pain relief may be beneficial - NICE recommends NSAIDs and paracetamol with or without codeine.3
Suggesting the use of an orthosis, such as an elbow clasp, available in high street chemists, can help to ease symptoms by offloading the tension on the common extensor tendons.
If pain is limiting work and functional tasks, a corticosteroid injection may improve symptoms in the short term. Evidence shows poor prognosis for long-term outcome with corticosteroid injection, but in extreme cases, it may provide symptomatic relief in the first six weeks and a window of opportunity to commence physiotherapy with adequate pain relief.
Although physiotherapy is not as effective as corticosteroid injection in the short term, it has better outcomes after six weeks.4
Physiotherapists can advise on activity modification and pacing of activities. They may use a range of soft tissue techniques to provide pain relief. Some physiotherapists may choose to use ultrasound treatment to aid tendon healing.
The main body of evidence suggests that eccentric loading exercises (weight-lowering phase) are useful in managing tendinopathies. This is because tendons adapt to alterations in the mechanical load being applied by changing their structure and composition.5
Teaching a patient the correct exercise at the correct frequency can facilitate tendon healing. Using a small weight or exercise band forms a key part of management. For those whose goal is to return to sport or a manual job, training the flexors or extensors for these specific tasks can be important to help the patient return to their desired level of function.
When to refer
GPs should consider referring patients who have not responded to analgesia in six to 12 weeks or are struggling to modify their daily activities to prevent exacerbation of their symptoms. Patients who have been treated with a corticosteroid injection will have a better long-term outcome if referred to a physiotherapist.
GPs and physiotherapists working together
By having a mutual understanding of the pathology involved in tennis elbow and golfer's elbow, GPs and physiotherapists can present a united, evidence-based management plan to their patients.
Effective communication between a GP and physiotherapist regarding pain relief will help to reduce the impact of symptoms.
GPs who provide early advice to patients on activity modification will aid the physiotherapy management of these patients, who should present with less pain and will therefore be able to participate more effectively in an exercise-based programme of rehabilitation.
- Dr Jansen is a locum GP in Alaska, US; Mr Turpin is a senior physiotherapist, Royal Bournemouth and Christchurch NHS Foundation Trust
1. Kraushaar BS, Nirschl RP. J Bone Joint Surg (Am) 1999; 81-A: 259-78.
2. Ahmad Z, Siddiqui N, Malik SS et al. Bone Joint J 2013; 95-B: 1158-64.
3. NICE 2012.Clinical Knowledge Summaries: Tennis Elbow.
4. Bisset L, Beller E, Jull G. BMJ 2006; 333(7575): 939.
5. Mafulli N, Longo UG. Rheumatology 2008; 47: 1444-5.