Epicondylitis

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
  Sociodemographic information: age, sex, gender identity, language, hand dominance, occupation, work or study demands, caregiving responsibilities, sport and recreation, and access or communication needs.

Primary concerns

• Context and onset: side, dominant arm, gradual or sudden onset, recent change in work, sport, tools or training, direct blow or other trauma, previous episodes, and change over time.
• Location and pattern: lateral or medial elbow, focal or diffuse pain, proximal or distal spread, duration, variability, severity, irritability, rest or night symptoms, and pain-free periods.
• Aggravating and relieving factors: gripping, lifting, carrying, wrist or forearm movement, racquet or throwing activity, force, repetition, posture, vibration, task duration, rest, pacing, bracing, medication and previous self-management.
• Associated symptoms: swelling, redness, warmth, bruising, deformity, locking, catching, stiffness, instability, numbness, tingling, objective weakness, neck or shoulder symptoms, fever, constitutional symptoms and symptoms in other joints.
• Function and participation: grip and hand use, self-care, household tasks, sleep, work, school, caregiving, driving, exercise, sport and other patient-prioritized activities.
• Body systems review: neurological, vascular, integumentary, constitutional, inflammatory or rheumatologic and other musculoskeletal symptoms, including the cervical spine and the rest of the upper limb when relevant.
• Health, lifestyle and history: inflammatory or metabolic conditions, diabetes, cancer, infection risk, osteoporosis or fragility risk, relevant neck or upper-limb injury or surgery, medication and supplements, sleep, smoking, physical activity and recovery demands.
• Work and exposure context: forceful or repeated hand use, forearm rotation, sustained or awkward wrist posture, tool or vibration exposure, recovery time, control over tasks and available accommodations. Occupational exposure is an association and does not establish an individual’s cause (Curti et al., 2021).
• Social determinants of health: work, education, caregiving, income, housing, food security, discrimination, safety, social support and access when these may shape health, care or participation (Public Health Agency of Canada, 2026).
• Previous care and responses: advice, activity or equipment changes, exercise, hands-on care, taping or orthosis, medication, injection or surgery; what helped or did not help; adverse effects; and reasons care was difficult to use or continue.
• Patient perspective: understanding of the problem, priorities, preferences, cultural context, concerns, expectations and previous experiences of care.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

​​Outcomes measures

• Use a small, repeatable set that reflects the person’s priorities and the pathway goals. Record baseline values and reassess often enough to guide decisions.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF, or another validated measure suitable for the person and setting.
• Lateral elbow symptoms and disability: the Patient-Rated Tennis Elbow Evaluation (PRTEE) can track pain and functional difficulty for lateral elbow tendinopathy (Bateman et al., 2022; Singh et al., 2023).
• Broader upper-limb disability: the QuickDASH can be used when limitations extend beyond a focal elbow presentation.
• Physical capacity and individual goals: use a consistent pain-free grip or task-specific load-tolerance measure when it is relevant and reliable, and agree on patient-defined goals and how progress will be recognized (Lucado et al., 2022; Bateman et al., 2022).

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to the patient’s presentation, comfort, consent and abilities.

• Consent and comfort: explain what you propose, provide choices about positioning, pace and support, and confirm ongoing consent.
• Condition-specific safety: defer or modify testing when major trauma, marked swelling, heat or redness, deformity, severe rest pain, impaired circulation or progressive neurological loss requires medical assessment.
• Observation: swelling, redness, bruising, deformity, muscle bulk, protective behaviour, arm use and any orthosis, tape or equipment.
• Movement and range of motion: active and passive elbow flexion and extension, forearm pronation and supination, and wrist movement; include the shoulder and cervical spine when the history indicates. Note restriction, movement quality and symptom response.
• Palpation: lateral epicondyle and common extensor origin, medial epicondyle and flexor-pronator origin, joint line, radial head, olecranon, bony landmarks and nearby soft tissues as indicated. Tenderness supports but does not establish the diagnosis.
• Resisted loading and grip: wrist extension, middle-finger extension or grip may reproduce lateral symptoms; wrist flexion or forearm pronation may reproduce medial symptoms. A pain-free or maximum grip measure can be repeated when it is relevant and reliable. Interpret findings with the history rather than as stand-alone diagnostic tests (Lucado et al., 2022; Singh et al., 2023).
• Neurological and regional examination when indicated: motor, sensation, reflexes, neural provocation and cervical or upper-limb assessment guided by the symptom pattern, including radial or posterior interosseous and ulnar nerve involvement.
• Joint and ligament assessment when indicated: valgus or varus stability, joint-line findings, locking, catching and other tests selected to examine a plausible alternative or coexisting condition.
• Functional assessment: observe a patient-prioritized task such as gripping, lifting, carrying, tool use, racquet activity or throwing, and record load, technique and symptom response.
• Imaging: not routine for a typical atraumatic presentation. Plain radiographs can be useful after acute trauma or when fracture, arthritis, a loose body or another diagnosis is suspected. Ultrasound or MRI can be used selectively when diagnostic uncertainty, suspected substantial tendon injury or another finding would change care or referral (American College of Radiology, 2024; Singh et al., 2023).
• Repeat and adapt: repeat focused findings when needed to review progress, revisit the working diagnosis or decide whether further assessment or referral is appropriate.

Working clinical presentations

• Lateral elbow tendinopathy: gradual or load-related pain and tenderness at the lateral epicondyle or common extensor origin, often reproduced by gripping, lifting or resisted wrist or finger extension, without red flags or a better alternative explanation (Lucado et al., 2022; Singh et al., 2023).
• Medial elbow tendinopathy: load-related pain and tenderness at the medial epicondyle or flexor-pronator origin, often reproduced by gripping, throwing, resisted wrist flexion or pronation. Examine for ulnar nerve or ligament involvement (See et al., 2026).
• Recent traumatic presentation: symptoms beginning with a direct blow, fall, forceful event or sudden load. Injury severity, bony tenderness, swelling, loss of movement, instability, neurological findings and function determine whether the presentation follows acute-injury assessment rather than routine tendinopathy care.
• Persistent or recurrent load-sensitive presentation: ongoing or recurrent symptoms with substantial effects on work, sport or daily tasks, prompting review of diagnosis, load, recovery, previous care, coexisting neck or nerve symptoms and participation barriers.
• Alternative, overlapping or uncertain presentation: features of cervical referral, radial tunnel or posterior interosseous nerve involvement, ulnar neuropathy, ligament injury, intra-articular disorder, arthritis or another condition. Document the working impression and revisit it as new information or response to care becomes available.

Base care on the presentation, safety, goals, context and response. Use adaptable principles and options rather than a ranked sequence, and repeat meaningful outcomes to guide change.

Education, self-management and participation

• Explain the working presentation: discuss the load-related nature of symptoms, the variable course, uncertainty where present and the signs that need earlier reassessment. Make clear that pain with use does not automatically mean new tissue damage (Lucado et al., 2022; Singh et al., 2023).
• Support participation: agree on feasible ways to maintain or gradually resume valued work, caregiving, daily and recreational activity, using changes that are acceptable in the person’s actual environment.

Protection and load management

• Lateral elbow tendinopathy – load management: temporary changes to force, repetition, grip intensity, forearm rotation, vibration, task duration, technique, equipment or recovery time, followed by progressive rebuilding of tolerance (Curti et al., 2021; Lucado et al., 2022).
• Lateral elbow tendinopathy – optional support: taping, a counterforce support or a wrist orthosis for a specific activity or short-term symptom change; review fit, skin, benefit, burden and continued need (Lucado et al., 2022).

Physical activity and exercise

• Lateral elbow tendinopathy – progressive loading: isometric, concentric and/or eccentric wrist extensor loading, with type, dose, range and progression matched to goals, capacity, irritability and response (Lucado et al., 2022; Wallis et al., 2024).
• Medial elbow tendinopathy – progressive loading: flexor-pronator strengthening, including eccentric loading, matched to the clinical presentation and functional demands (See et al., 2026).
• Lateral elbow tendinopathy – task practice: progressive gripping, lifting and other patient-prioritized work, daily or sport tasks within load tolerance (Lucado et al., 2022; Wallis et al., 2024).
• Lateral elbow tendinopathy – linked capacity: shoulder, scapular, cervical, forearm, grip, endurance and coordination exercise when an identified impairment or activity demand makes it relevant (Lucado et al., 2022).

Hands-on and symptom-relieving care

• Lateral elbow tendinopathy – hands-on care: local elbow mobilization with movement, regional joint mobilization or manipulation, and soft-tissue approaches as time-limited adjuncts to active care for short-term symptom or pain-free grip goals (Lucado et al., 2022; Wallis et al., 2024).
• Simple symptom relief: heat, cold or another low-risk strategy can be used if safe and helpful, while avoiding skin injury or prolonged compression.
• Culturally grounded approaches: traditional or community-based approaches identified by the patient can be incorporated when they are safe, acceptable and consistent with the presentation and goals.

Psychological, social and interdisciplinary support

• Address barriers to participation: use psychologically informed communication and collaborative problem solving when fear, distress, sleep disruption, uncertainty, work demands, caregiving, cost or access affects activity or recovery.
• Coordinate supports when useful: occupational, ergonomic, vocational, medical, pharmacy, sport, pain, mental health or community support can be included when needs extend beyond one clinician’s role.

Medication and injection

• Medication: review current topical or oral analgesic and anti-inflammatory use, perceived benefit, adverse effects, health conditions and interactions within scope. Questions or changes belong with a pharmacist or authorized prescriber.
• Lateral elbow tendinopathy – injections and percutaneous procedures: requests for corticosteroid, platelet-rich plasma, autologous blood, dextrose prolotherapy, botulinum toxin, dry needling or another procedure require an appropriately qualified clinician and discussion of the expected time course, uncertainty, potential harms and the option of no procedure (Lapner et al., 2022; Xu et al., 2026).

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review symptoms, relevant neurological findings, functioning, participation, benefits, harms, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the clinical presentation, differential diagnosis, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: in placebo or no-treatment groups from randomized trials, 89% of participants with lateral elbow tendinopathy reported marked improvement or recovery at one year. Symptoms can persist or recur. Direct prognostic evidence for medial elbow tendinopathy remains limited, so no universal timeline applies (Ikonen et al., 2022; See et al., 2026).
• Factors associated with a less favourable course: greater baseline pain or disability, ongoing high manual load and coexisting neck, nerve or other upper-limb symptoms may be associated with slower recovery in lateral elbow tendinopathy. Symptom duration before trial entry did not predict the subsequent course in placebo or no-treatment groups. These group-level findings do not determine an individual’s outcome (Ikonen et al., 2022; Lucado et al., 2022).
• Potential supports for recovery: a credible explanation, feasible protection and load changes, gradual capacity building, meaningful activity goals, supportive work or caregiving adaptations and timely access to coordinated care may support progress without guaranteeing it.
• Discussing prognosis: acknowledge uncertainty, avoid fixed promises, connect prognosis to the person’s goals and context, and update it using repeated outcomes, new information and response over time.