How to diagnose an Epicondylitis or Lateral Elbow Tendinopathy with 6 simple tests
Commonly known as Lateral Epicondylitis, Epicondylalgia or Tennis Elbow Tendinopathy, is one of the most prevalent conditions affecting the upper limb. This Epicondylitis is associated with pain and functional disability. Among the many causes that can trigger it, tendon disorder is one of them, which we will discuss in this blog post.
Lateral Elbow Tendinopathy, or Tennis Elbow, is characterised by the presence of pain and functional disability associated with tendon dysfunction of the lateral epicondyle musculature. Its prevalence rates are similar between both genders, and it is estimated that between 1-3% of the population between 35 and 50 years of age will present Lateral Elbow Tendinopathy (Karanasios S et al 2021). Being a smoker, working in manual labour or being a tennis player increases the risk of developing it (Coombes BK et al 2015).
Although its frequency is important, its management is complex given the large number of clinical presentations, pathophysiology and differential diagnoses that can cause similar clinical presentation. This is why evidence-based diagnostic and assessment guidelines are required to allow the clinician to make a proper therapeutic decision.
For this reason, we present in this new Blog post 6 Simple Tests and Diagnostic Tests that can help us to Diagnose Lateral Elbow Tendinopathy.
1. Cozen Test
This test consists of evaluating the isometric resistance of the wrist extensor muscles.
To perform this test, the patient is placed with the shoulder in neutral position, the elbow flexed at 90º, the forearm in pronation and the wrist in neutral flexion-extension. In this position, the patient is asked to perform a combined contraction against resistance in extension and radial deviation.
The test will be positive if sudden pain appears associated with the contraction in the epicondyle area.
It is the test with the highest sensitivity among all those available for the diagnosis of Lateral Elbow Tendinopathy of Epicondylitis. Specifically, it has a sensitivity of 91% (95% CI 81-96%).
2. Mill Test
The Mill test consists of a manoeuvre that seeks to passively stretch the epicondylar extensor muscles of the wrist.
To perform the test, the patient’s upper limb is placed with the shoulder in neutral position, the elbow flexed to 90º, forearm pronated and the wrist in maximum flexion. In this position, the patient will gradually extend the elbow passively until reaching 0º towards extension, while maintaining the previous forearm pronation and wrist flexion.
The test will be positive if the patient complains for pain in the epicondyle region.
This test is the second most sensitive test for diagnosing lateral epicondylitis, with a mean of 76% (95% CI 63-85%).
3. Maudsley Test
The Maudsley Test consists of the execution of an isometric contraction against resistance of third extensor digitorum muscle.
For this test, the patient will be placed with the shoulder in neutral position, the elbow at 90º, the forearm in pronation and the wrist in neutral flexion-extension (the same as during the Cozen Test). On this occasion, we will ask for a extension of the middle finger against resistance, contractin its respective extensor digitorum.
The test will be positive if pain appears in the epicondyle region.
This test is the third with the best sensitivity rates reported in the literature. Specifically, a mean of 70% (50% CI 57-80%) have been reported.
4. Thomsen Test
The Thomsen manoeuvre is a test very similar to the Cozen Test, where the extensor musculature is tested by means of a resisted isometric contraction of the wrist extensor musculature. In this case, the position varies slightly from the Cozen test.
The literature describes it in a position of 60° of shoulder flexion, elbow in extension, forearm in pronation and wrist extended to 30° of extension. In this position, pressure is applied to the dorsal aspect of the patient’s hand, and a contraction towards extension is requested to the patient against the applied resistance.
The appearance of pain will be a sign of a possible diagnosis of lateral epicondylitis associated with extensor tendon disorder.
5. Maximum Grip Strength Pain-free
The pain-free maximal grip strength test is a reliable, valid and sensitive measure of physical impairment in lateral epicondylalgia.
A dynamometer is used to measure the grip strength applied prior to the onset of pain. Most protocols recommend performing the test with the elbow in relaxed extension and the forearm in pronation, repeating the test 3 times at 1 minute intervals and comparing the mean of these 3 measurements between the affected and unaffected side.
An interesting paper by Dorf et al 2007 observed how maximal hand grip strength progressively decreased when changing position from elbow flexion to extension in patients with epicondylitis or lateral epicondylalgia tendinopathy.
Specifically, they found that an 8% change in grip strength between flexion and extension is 80% sensitive and 85% specific for the diagnosis of epicondylitis. If this change increased to 10%, the test figures increased to 78% sensitivity and 90% specificity.
6. Patient Rated tennis Elbow Evaluation Questionnaire | PRTEE
Clinical Practice Guidelines and clinical trials recommend the use of the PTREE Questionnaire to assess patient outcomes. The PRTEE is a reliable and valid questionnaire for the assessment of pain and disability associated with epicondylitis or lateral tendon epicondylalgia.
It consists of 15 questions, 5 related to pain and 10 to functional limitations during activities of daily living, work and sports. Both subscales contribute equally to the final score, with a range between 0 (no pain or disability) and 100 (worst pain and disability).
Some studies propose that scores above 54 points are considered a range associated with severe pain and disability, while scores below 33 points represent a mild level of pain and disability. A change of 11 points or 37% improvement from baseline has also been proposed as the minimum clinically relevant difference.
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Regarding the psychometric characteristics of the questionnaire, a good internal consistency was observed (cronbach’s alpha 0.94). Furthermore, it has an excellent correlation with pain and NRS during resisted wrist extension (r2=0.84) and with the DASH questionnaire (r2=0.75). The reliability of the questionnaire is excellent, with its total score with r2=0.87. Sensitivity to change pre-post treatment is related to the Thomsen Test (r2=84) and DASH (r2=0.66).
Lateral Elbow Tendinopathy management with Telerehabilitation
Once a thorough assessment of the upper limb has been performed, we can select the treatment that best suits the patient’s condition. One of the most evidence-based interventions is Exercise Therapy. Its use in an individualised manner and with a gradual progression of intensity allows for optimal functional recovery.
Do you want to prescribe an Exercise Program for Lateral Elbow Epicondylalgia or Epicondylitis? Check out our publication 🔴”23 Exercises for Lateral Elbow Tendinopathy“🔴
The ReHand telerehabilitation system allows you to prescribe, treat and monitor your patients with Lateral Epicondylalgia through a Tablet. Here is an example of an intervention with exercise focused on the wrist extensor muscles using the app:
This approach with Tailored Exercise Programmes through a touch-screen Tablet allows a direct effect on the sensorimotor cortex itself, which promotes an early improvement in pain and optimal functional recovery.
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Dorf ER, Chhabra AB, Golish SR, McGinty JL, Pannunzio ME. Effect of Elbow Position on Grip Strength in the Evaluation of Lateral Epicondylitis. J Hand Surg Am. 2007;32(6):882–6.
Karanasios S, Korakakis V, Moutzouri M, Drakonaki E, Koci K, Pantazopoulou V, et al. Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) – A systematic review. J Hand Ther. 2021;(xxxx):1–10.
Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: One size does not fit all. J Orthop Sports Phys Ther. 2015;45(11):938–49.
Rompe JD, Overend TJ, MacDermid JC. Validation of the Patient-rated Tennis Elbow Evaluation Questionnaire. J Hand Ther. 2007;20(1):3–11.
Dones VC, Grimmer K, Thoirs K, Suarez CG, Luker J. The diagnostic validity of musculoskeletal ultrasound in lateral epicondylalgia: a systematic review. BMC Med Imaging [Internet]. 2014;14(1):10. Available from: BMC Medical Imaging
Pablo Rodríguez Sánchez-Laulhé
MSc Physical therapist and PhD Candidate in the University of Seville
Hand Therapy and Digital Health researcher