About Epicondylitis

Epicondylitis, commonly referred to as “tennis elbow” (lateral epicondylitis) or “golfer’s elbow” (medial epicondylitis), is a common musculoskeletal condition affecting adults who engage in repetitive or sustained upper-limb activities. It is characterized by localized pain and tenderness at the lateral or medial epicondyle of the humerus and is frequently aggravated by gripping, lifting, or resisted wrist and forearm movements.

Epicondylitis is best understood as a load-related tendinopathy rather than an acute inflammatory condition. Its etiology is multifactorial and may involve repetitive mechanical loading, insufficient load tolerance of the tendon, suboptimal movement patterns, and inadequate conditioning of the forearm musculature. Symptoms often develop gradually and may fluctuate over time, influenced by activity demands, occupational exposures, and individual capacity to adapt to load.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Epicondylitis Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent

Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
Key Aspects:
- Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
- Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time.
- Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
- Patient understanding and agreement:
  - Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
  - Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
  - Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
- Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.

3. Health History

Apply cultural awareness and trauma-informed care principles.
Sociodemographic information: Age, gender, sex, race/ethnicity.
Main complaint: Location of elbow pain (medial or lateral), onset (gradual or sudden), duration, severity, and symptom behaviour. Identify aggravating and easing factors (e.g., gripping, lifting, repetitive wrist or forearm use).
Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
Health, lifestyle, and history: Past medical conditions, medications (including opioids, anticoagulants, corticosteroids etc.), supplements, injuries, comorbidities, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
Work, sport, and activity exposure: Occupational demands, repetitive tasks, forceful gripping, sustained postures, tool use, sports or recreational activities, recent changes in workload or technique, and hand dominance.
Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, social isolation.
Previous care and responses: Prior treatments (e.g., exercise, manual therapy, injections, bracing, medication), perceived benefit, adverse effects, and adherence.
Beliefs, expectations, and understanding: Understanding of their condition, expectations of care, concerns about prognosis, work participation, or long-term impact.
Screen for flags: Identify red flags, orange flags, and psychosocial (yellow) factors that may influence care planning.

Outcomes Assessments:

Pain: Use pain scales (e.g., NRS) and diagrams.
Function and Participation: Evaluate impact on daily activities (PSFS, WHODAS, PRTEE, QuickDASH).
Recovery: Use self-rated recovery scales.
Quality of life: Assess using tools such as SF-12.
Work/school status: Monitor return to activities.
Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).
Patient feedback: Gatherand integrate patient experience and satisfaction.

4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

Acute traumatic injury: Suspected fracture or dislocation following trauma, marked deformity, significant swelling, inability to move the elbow, or severe pain.
Suspected septic process: Rapid onset of swelling, erythema, warmth, fever, or systemic symptoms suggestive of septic olecranon bursitis or joint infection.
Neurovascular compromise: Progressive neurologic deficits, loss of distal pulses, or signs of compartment syndrome.

ACTION: Refer to appropriate medical provider:

Inflammatory or systemic disease: Suspicion of inflammatory arthritis (e.g., rheumatoid arthritis, gout) based on multi-joint involvement, morning stiffness, or systemic features.
Ligamentous injury or instability: Suspected ulnar collateral ligament injury, particularly in throwing athletes or following acute valgus stress.
Intra-articular pathology: Locking, catching, or inability to fully extend or flex the elbow suggestive of osteochondral defects or loose bodies.
Persistent or worsening symptoms: Progressive pain, swelling, or functional loss that is disproportionate to findings or not responding to appropriate conservative care.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.
Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

Triage: Ensure primary management by medical/psychiatric providers.
Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
Social: Lack of family/social support, limited connections.
Socioeconomic: Employment status, financial stress, litigation/compensation.
Environmental/cultural: Social inequality, unsafe/unsupportive environments.
Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers:

Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).
Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

7. Physical Examination

The physical examination should be focused, hypothesis-driven, and informed by the health history and identified risk factors.

Observation: Inspect the upper limb for asymmetry, swelling, discoloration, muscle wasting, or protective postures. Observe functional movements involving gripping, lifting, or forearm rotation.
Range of motion (ROM): Assess active, passive, and resisted wrist, elbow, and shoulder ROM. Note pain reproduction, movement limitations, or compensatory patterns.
Palpation: Palpate the lateral and medial epicondyles and surrounding soft tissues for localized tenderness, thickening, temperature changes, or swelling. Assess adjacent regions (forearm, wrist, shoulder) as clinically indicated.
Grip strength: Evaluate grip strength and pain response during gripping tasks, particularly in functional or provocative positions.
Neurological examination: Perform a focused neurologic examination if symptoms suggest neural involvement, including assessment of sensation, reflexes, and myotomes. Consider screening for cubital tunnel syndrome or radial tunnel syndrome when indicated.
Special/Orthopedic Tests: Use condition-specific tests selectively to support clinical reasoning (e.g., pain reproduction with resisted wrist extension for lateral symptoms or resisted wrist flexion for medial symptoms).
Advanced Diagnostics: Imaging is not routinely indicated for suspected epicondylitis. Radiography may be considered in cases of trauma, suspected fracture, or atypical presentation. Advanced imaging should be reserved for refractory cases or when alternative pathology is suspected.

8. Clinical Presentation for Epicondylitis

Epicondylitis typically presents as localized, activity-related elbow pain that is mechanically provoked.

Common features include:

Reduced tolerance to load rather than constant pain at rest.
Pain localized to the lateral or medial elbow, aggravated by gripping, lifting, or repetitive wrist and forearm movements.
Functional difficulty with everyday tasks (e.g., opening jars, carrying objects, tool use, work- or sport-specific activities).

Presentation may vary by symptom location:

Lateral elbow presentations may include:

Lateral elbow pain with decreased strength or pain during resisted gripping.
Pain reproduced with resisted wrist extension.
Pain at the lateral elbow with isolated resisted extension of the middle finger.

Medial elbow presentations may include:

Medial elbow pain aggravated by resisted wrist flexion and forearm pronation.

Additional considerations:

Localized tenderness near the epicondyle is common.
Functional limitations may reflect compensatory movement patterns or concurrent impairments at the wrist, shoulder, or cervical region.
Symptom impact and care-seeking behaviour may be influenced by occupational demands, psychosocial factors, and prior experiences with care.

9. Conservative Treatment Considerations for Epicondylitis

Conservative Treatment Considerations for Epicondylitis (Lucado 2022, Hoogvliet 2013)

Management should be individualized, multimodal, and focused on improving load tolerance, function, and participation. No single intervention is universally effective.

Applies to both lateral epicondylitis (LE) and medial epicondylitis (ME)

Education/self-management: activity modification, pacing, graded return to valued activities, and aligning expectations with a load-related tendinopathy framework.
Therapeutic exercise: progressive, symptom-guided loading of the involved musculature (isometric, concentric, and/or eccentric).
Multimodal care: combine exercise with other conservative interventions as clinically indicated (e.g., manual therapy, taping, supports).

Lateral epicondylitis (LE)

Manual therapy (local and regional): elbow mobilization/manipulation to reduce pain and improve pain-free grip strength; regional techniques (cervical/thoracic/wrist) as adjuncts when impairments are identified.
Soft tissue interventions: may be used as adjuncts within a multimodal plan (particularly when paired with exercise).
Adjuncts for short-term symptom relief: taping, TENS/cryotherapy/laser where appropriate, recognizing that benefits may be short-term.
Dry needling: may be considered for pain/function as part of a broader plan (evidence varies by technique and comparator).

Medial epicondylitis (ME)

Exercise: progressive loading of the wrist flexor–pronator group.
Screen and account for ulnar nerve involvement: ulnar neuritis can co-occur and should inform treatment and referral/co-management decisions.

Adjuncts: consider bracing/supports and other modalities selectively based on symptom response and functional demands (not as stand-alone care).

10. Risk and Prognosis for Epicondylitis

Common Risk Factors (Lucado et al., 2022):

Repetitive or sustained wrist bending/twisting and forearm rotation (e.g., screwing, tool use).
High perceived physical exertion combined with elbow flexion/extension and wrist bending, particularly when performed for more than 2 hours per day.
Repetitive hand or wrist movements for at least 2 hours per day, especially among individuals with long-term exposure (e.g., ≥9 years).
Occupational tasks involving handling loads greater than 20 kg at least 10 times per day over prolonged periods (e.g., >20 years).
Individual factors including female sex, dominant-side involvement, previous smoking history, and co-existing upper-limb conditions (e.g., rotator cuff disorders, De Quervain’s disease, carpal tunnel syndrome).
Low job control and low social support.

Prognosis (Lucado et al., 2022):

The clinical course is influenced by the degree to which ongoing activity demands continue to exceed tissue load tolerance.
Some individuals experience full and timely symptom resolution with conservative, non-surgical care.
However, more than half of individuals seeking general medical care continue to report symptoms at one year.
Approximately 20% of individuals report persistent pain lasting 3–5 years following care.

11. Ongoing Follow-up

Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.

12. Criteria for Discharge

Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

Epicondylitis