Best Practice & Research Clinical Rheumatology 25 (2011) 43–57

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Rheumatology
journal homepage: www.elsevierhealth.com/berh

Lateral and medial epicondylitis: Role of occupational

factors
Rahman Shiri, MD, MPH, PhD, Senior Researcher *,
Eira Viikari-Juntura, MD, PhD, Research Professor
Centre of Expertise for Health and Work Ability, Finnish Institute of Occupational Health, Topeliuksenkatu 41 a A,
Helsinki 00250, Finland

Keywords:
Epicondylitis is a common upper-extremity musculoskeletal
Cumulative trauma disorders disorder. It is most common at the age of 40–60 years. Epicondylitis
Incidence seems to affect women more frequently than men. Diagnosis of
Posture epicondylitis is clinical and based on symptoms and findings of
Prevalence physical examination. The prevalence of lateral epicondylitis in the
Prognosis general populations is approximately 1.0–1.3% in men and 1.1–4.0%
Risk factors in women and that of medial epicondylitis is nearly 0.3–0.6% in
Tennis elbow
men and 0.3–1.1% in women. The incidence rate of medical
consultations has been estimated at 0.3–1.1 for lateral and 0.1 for
medial epicondylitis per year per 100 subjects of general practice
populations. Of occupational risk factors, forceful activities, high
force combined with high repetition or awkward posture and
awkward postures are associated with epicondylitis. The number of
studies is limited to work-related psychosocial factors and the
effects are not as consistent as those of physical load factors. Topical
non-steroidal anti-inflammatory drugs, corticosteroid injections
and acupuncture provide short-term beneficial effects. Workload
modification should be considered, especially in manually stren-
uous jobs. According to clinical case series, surgical treatment has
shown fair to good results; however, the efficacy of surgical treat-
ment has not been evaluated in randomised controlled trials.
Poorer prognosis of epicondylitis has been reported for individuals
with high level of physical strain at work, non-neutral wrist
postures during work activity and for those with the condition on
the dominant elbow. Modification of physical factors could reduce
the risk or improve the prognosis of epicondylitis.
Ó 2011 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ358 30 4742993; fax: þ358 30 4742006.

E-mail address: rahman.shiri@ttl.fi (R. Shiri).

1521-6942/$ – see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.berh.2011.01.013
44 R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57

Epicondylitis is one of commonly diagnosed upper-extremity musculoskeletal disorders. It is also

called epicondylalgia, elbow tendinosis and elbow tendinopathy [1–3]. Lateral epicondylitis or tennis
elbow is a painful disorder of the tendinous origin of the wrist extensor muscles [4–6] and medial
epicondylitis or golfer’s elbow is a painful condition of the tendinous origin of the wrist flexor muscles
[5]. Lateral epicondylitis is more common than medial epicondylitis [7–9]. In epicondylitis, pain is
localised to the lateral or medial epicondyle of the humerus. It may spread up and down the upper
extremity [10], and is aggravated with wrist and hand movements. Moreover, hand grip is impaired
because of the pain [10–12].
Individuals with epicondylitis are typically 40 years or older [10,13], and epicondylitis is most
common in individuals aged 40–60 years [14,15]. The condition seems to affect women more often
than men [16–21]. The duration of epicondylitis symptoms usually ranges from few weeks to few
months. It may sometimes be a rather long-lasting condition [22].

Diagnosis

Diagnosis of epicondylitis is clinical and based on symptoms and findings of physical examination
[4]. Pain in the lateral or medial aspect of the elbow is the main symptom. Pain is typically related to
activity. There is tenderness at the lateral or medial humeral epicondyle on clinical examination.
Clinical tests, consisting of active and resisted movements of the extensor or flexor muscles of the
forearm, provoke epicondylar pain [23].
In most cases, imaging is not necessary for diagnosis of epicondylitis [24–26]. Imaging can be used
to evaluate the extent of tissue damage and to exclude other causes of elbow pain [26]. Plain X-ray is
useful in making differential diagnosis, such as osteoarthritis of elbow, osteochondrosis dissecans or
other pathological processes of the bone. Ultrasonography and magnetic resonance imaging (MRI) may
help to detect epicondylitis [24,27]. On sonography, epicondylitis appears as thickening or thinning of
the tendon, poor definition of the tendon and decreased echogenicity of the tendon [27]. On MRI,
epicondylitis appears as areas of thickening and high signal intensity of the tendon [27,28]. Ultraso-
nography is more cost-effective, but is not as sensitive as MRI [24,27]. MRI is the gold-standard imaging
procedure for the diagnosis of epicondylitis [9]. Both ultrasound and MRI have low specificity [9,29].
Few diagnostic criteria have been proposed for case definitions of lateral and medial epicondylitis
[23,30,31]. In 1997, a workshop of experts was organised by the UK Health and Safety Executive (HSE)
and the University of Birmingham to develop consensus criteria for common work-related upper-
extremity musculoskeletal disorders [23,32]. The Birmingham workshop proposed diagnostic criteria
for use in epidemiological research. The Birmingham workshop criteria for lateral and medial epi-
condylitis were local pain and two clinical signs (Table 1).
Relaxing the Birmingham workshop criteria to epicondylar pain and requiring only one of the two
clinical signs (either epicondylar tenderness or pain on resisted extension (or flexion) of the wrist)
increases the sensitivity and reduces the specificity only little [33].
Literature/consensus clinical criteria proposed by Sluiter et al. [31]. were at least intermittent,
activity-dependent pain localised around the lateral (or medial) epicondyle for more than 4 of the past
7 days and local pain on resisted wrist extension (or flexion).

Table 1
Diagnostic criteria for lateral and medial epicondylitis.

Reference Lateral epicondylitis Medial epicondylitis

Harrington 1) Epicondylar pain and 1) Epicondylar pain and
et al., 1998 2) Epicondylar tenderness and 2) Epicondylar tenderness and
[23] 3) Pain on resisted extension of the wrist with the 3) Pain on resisted flexion of the wrist with the
elbow extended elbow extended

Sluiter et al., 1) At least intermittent, activity-dependent pain 1) At least intermittent, activity-dependent pain
2001 [31] localised around the lateral epicondyle for localised around the medial epicondyle for
more than 4 of the past 7 days and more than 4 of the past 7 days and
2) Local pain on resisted wrist extension 2) Local pain on resisted wrist flexion
 R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57 45

In the general population, between-observers repeatability has been good for tenderness over the
lateral and medial epicondyle, lateral elbow pain on resisted wrist extension and medial elbow pain on
resisted wrist flexion [34]. The diagnostic accuracy of physical examination signs has been even better
in clinical populations than in the general population [33]. Physical examination signs have a high
specificity for both lateral and medial epicondylitis [33]. They seem to have an acceptable sensitivity for
lateral epicondylitis [33].

Prevalence

The prevalence of lateral or medial epicondylitis ranges between 1% and 3% in the general pop-
ulations [7,13,35], and between 0.8% and 29.3% in different working populations [11,36–43] (Table 1).
Epicondylitis is more prevalent in certain occupations, for instance, food processing and forest workers,
with prevalence up to several times the overall prevalence (Table 2).
The prevalence of lateral epicondylitis ranges from 1% to 1.3% in men and from 1.1% to 4.0% in
women in the general populations [7,13,44]. It varies between 0.3% and 13.5% in working populations
[11,17,20,37,39,40,45–51]. Lateral epicondylitis is most common in manually intensive occupations
(Table 2).
The prevalence of medial epicondylitis is nearly 0.3–0.6% in men and 0.3–1.1% in women in the
general populations [7,44]. It ranges between 0.2% and 3.8% in working populations [11,15,20,37,39,40].
Medial epicondylitis frequently co-occurs with lateral epicondylitis [39,44].
The prevalence of epicondylitis increases with age [14,15,17,35,46,52], and is the highest in indi-
viduals aged 40–60 years [14,15,35,44,46]. Individuals with epicondylitis are typically older than 40
years [37,46]. Epicondylitis is more common in the right [7,8,11,15,16,20,46] or dominant [7,8,37,48,51]

Table 2
Prevalence of lateral and medial epicondylitis.

Population Lateral Medial Lateral or medial

% Reference % Reference % Reference

General populations 0.7–4.0 [7,13,44,104] 0.3–1.1 [7,44] 1.0–3.0 [7,13,35]

Working populations 0.3–12.2 [11,17,20,37,39, 0.2–3.8 [11,15,20, 0.8–29.3 [11,36–43]

40,45,46,48–51] 39,40]

Construction foremen 1.4 [14]

Textile workers 2.0 [36]
Aeroengineering factory workers 2.0 [51]
Shop assistants 2.3 [40] 0 [40] 2.3 [40]
Plastic surgeons 13.5 [47]
Nursery school cooks 10.5 [11] 1.4 [11] 11.5 [11]
Nursery school workers other than cooks 2.5 [11] 0 [11] 2.5 [11]
Kindergarten teachers and traffic 0.3 [45]
policemen
Automobile manufacturing workers 3.3 [39] 2.2 [39] 5.5 [39]
Meat cutters 8.9 [14]
Fish-processing factories workers 14.5 [38]
Shoe factory workers 2.0 [50] 0 [50]
Supermarket cashiers 4.8 [17]
Clothing and shoe industry workers 4.8 [17]
Food industry workers 7.0 [17]
Engineering industry workers 7.4 [51]
Auto assembly workers 16.0 [41]
Assembly line packers in a food 2.6 [40] 3.3 [40] 5.9 [40]
production factory
Assembly line workers of the manufacture 20.0 [17]
of small electrical appliances, motor vehicle
accessories, or ski accessories
Vibration-exposed forestry workers 29.3 [43]
Sewing machine operators 4.9 [42] 0 [42] 4.9 [42]
46 R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57

Table 3
Incidence of lateral and medial epicondylitis.

Population Lateral Medial Lateral or medial

% Reference % Reference % Reference

General practice populations, consultation rate 0.3–1.1 [8,13,18,21] 0.1 [8,21] 0.4 [8,21]
Working populations, consultation rate 0.6–3.7 [16,53]
Working populations, incidence rate 2.0–4.0 [17,50] 1.5 [15,50]

Supermarket cashiers 0.8 [17]

Shoe factory workers 2.1 [50] 0 [50]
Clothing and shoe industry workers 2.8 [17]
Food industry workers 3.8 [17]
Assembly line workers of the manufacture of 5.8 [17]
small electrical appliances, motor vehicle
accessories, or ski accessories

than in the left or non-dominant elbow. A slightly higher prevalence of epicondylitis has been reported
in women than in men in many studies [13,17,19,20,46,48], but not all [38,44].

Incidence

Of all visits to general practices, nearly 0.4% are due to lateral or medial epicondylitis [8,21] (Table 3).
Incidence rates for consultations for epicondylitis range between 0.6 and 3.7 per year per 100 workers
[16,53].
In general practices, the incidence rate of medical consultations has been estimated at 0.3–1.1% for
lateral [8,13,18,21] and 0.1% for medial [8,21] epicondylitis. The incidence rate in working populations is
nearly 2–4% for lateral [17,50] and 1.5% for medial [15,50] epicondylitis. One study [35] attempted to
estimate the incidence of lateral epicondylitis; however, the true incidence rate of lateral or medial
epicondylitis in the general population is not known.
A higher incidence of epicondylitis has been reported in women than in men [16,18,21,35], although
some studies have reported a similar incidence in both genders [8,17].

Morbidity

Epicondylitis causes functional disability and high costs due to productivity loss and health-care use
[44,49,54,55]. Productivity loss has been reported by a considerable proportion of inflicted workers
already at an early stage of the disorder [56]. The length of sick leave due to epicondylitis is nearly 2
weeks [16,53]. Approximately 10–30% of individuals with epicondylitis have prolonged duration of sick
leave up to 11–12 weeks [16,57,58], and, in rare cases, work disability extends up to 1 year or over [59].
Epicondylitis can cause job changing in strenuous jobs [16,53]. Moreover, it may restrict leisure time
activities [44,60].

Geographical variation

There is no evidence to support geographical variations in the occurrence of epicondylitis. The

findings of studies on epicondylitis cannot be compared directly due to differences in the inclusion and
diagnostic criteria. Studies have differed in their choice of age range, gender distribution, source
population, prevalence period, follow-up period and case definition [32]. Disagreement exists about
case definition of lateral and medial epicondylitis [61]. Some studies have included tests of hand grip
strength [14,20,62], or excluded tenderness on epicondyle [13,19]. Some studies included either epi-
condylar pain or epicondylar tenderness, in addition to pain on resisted wrist extension or flexion
[15,17]. Even though most studies used similar diagnostic criteria, their findings cannot be compared
because of differences in the technique of examination (e.g., site and pressure of palpation), age range
and occupational background of the studied populations.
 R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57 47

Occupational risk factors

Physical load factors associated with upper-extremity disorders include high force demands,
repetitive movements, hand–arm vibration and awkward postures. Epicondylitis is more common in
the right [7,8,11,15,16,20,46] or dominant [7,8,37,48,51] elbow than in the left or non-dominant elbow,
indicating that exposure to physical load factors plays a role in epicondylitis.

Job title

Using job title as an indicator of exposure to workload factors, there is little evidence to support the
role of occupation in epicondylitis [63]. Previous studies have reported inconsistent findings (Table 4).
Some studies have shown associations of occupations with strenuous and manually intensive work
tasks with epicondylitis [11,14,16,40,43]. They have shown evidence for increased risk of epicondylitis,
for instance, in meat cutters and sausage makers [63]. On the other hand, some other studies did not
support associations of physically stressful jobs with epicondylitis [36,37,42,51,64,65]. Most of these
studies, however, were conducted among small and selected populations. Some studies have suffered
from selection bias due to high non-response rate. Most of the studies did not control the observed
associations for potential confounders.

Physical load factors

Lateral and medial epicondylitis is more common in individuals with higher exposure to ergonomic
stressors [11,20,52,66–68] (Table 5). Forceful activities [15,19,48,69], high force combined with high
repetition [19,38] or awkward posture [48] are associated with epicondylitis (Table 5). Few studies
reported a link between awkward posture and epicondylitis [17,69]. Studies reported inconsistent
findings on the role of repetitive work in epicondylitis [15,19,69,70], some having found an association
between repetitive work and epicondylitis [19,69], and others not [15,70].

Psychosocial factors

The number of studies on work-related psychosocial factors is limited, and the effects are not as
consistent as those of physical load factors. Few epidemiological studies showed that psychosocial
workplace factors, such as low social support at work [48,69] and low job control [69], are associated
with lateral epicondylitis. Low social support at work had a stronger role in women than in men [69].
Moreover, individuals with lateral epicondylitis have reported less job satisfaction [48] and more
depressive symptoms [17] than individuals without epicondylitis. An increased risk of lateral epi-
condylitis in women with high physical strain and low social support at work has been reported [69].

Exposure assessment

Job title has often been used as an indicator of exposure to physical and psychosocial workload
factors [71]. Group-level exposure assessment misclassifies individual exposure to physical workloads.
There is individual variation in exposure to physical loads when the same task is performed by different
individuals [72].
Most of the studies have used self-reported exposure assessment. Self-assessments of work-related
physical exposures are less accurate than direct measurement or observational video analysis [73];
they may overestimate work constraints [73]. Symptomatic individuals may rate their exposure to
physical loads higher than asymptomatic individuals [74].
There are few longitudinal studies on the aetiology of epicondylitis. Most of our knowledge about
risk factors of epicondylitis comes from cross-sectional studies. The association between physical load
factors and epicondylitis, based on cross-sectional studies, does not indicate a causal relationship.
However, reverse causality between physical workload factors and epicondylitis is unlikely. Individ-
uals, who develop epicondylitis, are unlikely to seek physically loading tasks, and they are more likely
to transfer to less ergonomically stressful jobs or to leave the workplace [71]. This leads to an
 48
Table 4
Association between job title and epicondylitis.

First author and Country Exposed group Reference group Age range Gender Epicondylitis Results Adjustment for other
year (years) covariates
Cross sectional

R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57
Luopajärvi et al., Finland 152 assembly line 133 shop assistants 21–58 (mean Women Lateral, Medial epicondylitis was more Unadjusted. Age and
1979 [40] packers in a food 39) for packers medial common in packers than shop length of employment
production factory and 18–60 assistants (3.3% vs. 0%) but not lateral were not associated
(mean 39) for epicondylitis (2.6% vs. 2.3%). with upper extremity
shop musculoskeletal
assistants. disorders.
Roto and Kivi, Finland 90 meat cutters 72 construction foremen Mean age 39. 2 Men Lateral or OR ¼ 6.4 (95% CI 0.99–40.9) Unadjusted
1984 [14] for meat medial
cutters and
38.4 for
construction
foremen
Dimberg, Sweden 340 blue-collar 200 white collar 89% aged 20– Both Lateral No significant association. Prevalence Unadjusted
1987 [51] workers workers 59 and 11% (489 was 5.3% in blue collar and 11% in
below 20 or men, 51 white collar workers.
above 59. women)
McCormack et al., USA Textile workers Non-office workers Mean age Both Lateral No association. Compared with non- Age, gender and years of
1990 [36] involved in boarding (468) (maintenance, 33.0–38.1 office workers, OR ¼ 0.5 (CI 0.1–2.1) for employment
(296), knitting (352), transport, cleaning and boarding, OR ¼ 1.1 (CI 0.4–2.9) for
packaging/folding sweeping) sewing, OR ¼ 1.1 (CI 0.4–3.2) for
(369) and sewing packaging and OR ¼ 1.2 (CI 0.5–3.4) for
(562) knitting.
Bovenzi et al., Italy 65 vibration-exposed 31 mixed blue-collar Mean age 44.0 Lateral or OR ¼ 4.9 (1.3–56.0) Age and ponderal index
1991 [43] forestry workers workers in controls and medial
44.7 in forestry
workers
Viikari-Juntura Finland 91 male meat cutters, 288 matched subjects 17–64 Both Lateral, No association with clinical Unadjusted. referents
et al., 1991 [37] 95 female sausage from non-strenuous jobs medial epicondylitis were selected from
makers and 97 (office, maintenance, structurally similar with
female packers supervisors) regard to sex, age, and
duration of
employment.
Andersen and Denmark 82 sewing machine 25 auxiliary nurses and Mean age Women Lateral, Lateral epicondylitis: 4.9% in exposed Frequency matching for
Gaardboe, 1993 operators home helpers 38–40 medial versus 0% in controls, P ¼ 0.26. Medial age
[42] epicondylitis: no case in both groups.
Bystrom et al., Sweden 199 automobile 186 randomly selected 18–65 Both Lateral No significant association with tender Analysis stratified by
1995 [65] assembly line subjects from the lateral epicondyle and epicondylitis. age and gender.
workers general population Lateral epicondylitis 0% (exposed
group) vs. 1% (referent group).
Ono et al., Japan 209 female nursery 366 female controls 40–59 Women Lateral or OR 5.4 (95% CI 2.4–11.9) Age, body length and
1998 [11] school cooks belonging to the same medial body mass index
social welfare labour

R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57
union (nurses, health-
care workers,
handywomen)
Wang et al., China 20 betel pepper leaf 47 non-cullers 40–64 Women Lateral No association (15% vs. 11%, P ¼ 0.44) Unadjusted. Age did not
2005 [64] cullers differ between two
groups.

Cohort
Kurppa et al., Finland 377 meat cutters, 338 manual jobs (office, 17–64 Both Lateral or Incidence rate (IR) was higher in Unadjusted
1991 [16] sausage makers and maintenance, medial workers of strenuous than in non-
packers followed-up supervisors) strenuous jobs (IR ¼ 6.7, 95% CI 3.3–
for 31 months 13.9)

49
Table 5

50
Associations between physical load factors and epicondylitis.

Author and Country Study Age Gender Sample Physical load factors Epicondylitis Results Adjustment for other
year population range size (in covariates
(years) analysis)
Cross sectional
Chiang et al., China 146 workers in fish Mean age Both 207 High force (average hand Lateral or OR ¼ 6.75 (CI 1.6–32.7) in Gender-specific

R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57
1993 [38] processing on 34.6–36.7 force of more than 3 kg), medial men and OR ¼ 1.44 (CI 0.3– unadjusted
a production line 61 repetitive (a cycle time <30 s 5.6) in women for high force
managers, office staff and or >50% of the cycle time and high repetition
craftsmen involved the same compared with low force and
fundamental cycle. low repetition.
Moore and USA Pork processing plant Not Both 230 Force, wrist posture, high Lateral, OR ¼ 5.5 (95% CI 1.5–62) for Unadjusted
Garg, 1994 workers reported. speed work, vibration, and medial workers in “hazardous” jobs
[68] repetition. Jobs were compared with those in
classified as “hazardous” or “safe” jobs [67].
“safe” based on data and Repetitiveness was not
authors judgements. a significant factor between
hazardous and safe jobs.
Ritz, 1995 Germany Public gas- and 18–64, Men 290 Biomechanical strain to the Lateral or A dose–response relation Age, and cervical spine
[52] waterworks employees mean age elbow was grouped into medial between duration of symptoms
46.2 three categories; no, employment in stressful jobs
moderate, high work-related and epicondylitis. OR for 10
exposure. years of high exposure to
elbow straining work was 1.7
(95% CI 1.04–2.681) for
currently held jobs and 2.16
(95% CI 1.08–4.32) for
formerly held jobs.
Ono et al., Japan 209 nursery school cooks, 40–59 Women 575 Mechanic workload, Lateral or OR ¼ 1.7 (95% CI 1.2–2.6) for Age, body length, body
1998 [11] 366 controls (nursing psychosocial stressors medial mechanic workload and 1.2 mass index, and each
assistants, nurses for the (95% CI 1.0–1.4) for other
aged, home care service psychosocial stressors.
workers, nursery workers
for the handicapped, and
handywomen)
Hansson et al., Sweden 87 laminate industry 19–63 Women 155 Repetitive work vs. no Lateral No association Age
2000 [70] workers performing repetitive work
repetitive work, 68
workers in same company
with mobile and varied
works tasks and office
workers
Descatha France Occupational Not Both 1757 Holding in position, turning Lateral or OR of medial epicondylitis for Gender, age, Number of
et al., 2003 reported and screwing, forceful work, medial forceful work was 1.91 (CI years on the job,
[15] using tools forcefully, and 1.03–3.55). OR of lateral repetitive pressing with
holding a tool in position epicondylitis for pressing a hand, forceful work,
with the hand was OR 1.55 psychosomatic or
(CI 1.12–2.15). No association depressive symptoms
with repetitive work and satisfaction at work

R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57
Shiri et al., Finland General population 30–64 Both 4783 Manual handling of loads, Lateral, Forceful activities and Age, gender, smoking,
2006 [19] hand grip forces, repetitive medial repetitive movements of the waist-to-hip ratio and
movements of the hand or hands or wrists were using vibrating tools
wrist, using vibrating tools, associated with medial
and keying epicondylitis and
a combination of forceful
activities and repetitive
movements with lateral
epicondylitis. Longer
duration of exposures to
forceful activities and
repetitive movements were
associated with lateral and
medial epicondylitis.
Fan et al., USA Workers in 12 different 18–65 Both 733 Forceful exertions, power Lateral Frequency of forceful Age, gender and BMI,
2009 [48] sites in manufacturing and (mean grip, pinch grip, manual exertion (OR 5.2, 95% CI 1.7– smoking, and social
health-care sectors 39.5) handling, posture, and using 15.0 for 5 vs.<1, and OR 4.5, support at work
vibrating tools 95% CI 1.5–13.7 for 1 to <5
vs.<1 times/min) and
a combination of forearm
supination at 45 for 5% of
the time and high lifting force
(OR ¼ 3.0, 95% CI 1.1–7.6)
Nordander Sweden 2677 workers in the 43 Mean age Both 915 men Repetitive (a cycle time <30 s Lateral, Prevalence ratio of lateral Gender-specific
et al., 2009 different occupational 37–43 and or >50% of the cycle time medial epicondylitis was 1.0 (CI 0.3– unadjusted
[20] groups 1762 involved the same 2.8) in men and 1.9 (1.0–3.8)
women fundamental cycle)/ in women for repetitive/
constrained (>50% of constrained vs. varied/mobile
working time involved work. PR of medial
prolonged awkward epicondylitis was 4.0 (CI 1.1–
postures) vs. varied/mobile 15) in men and 3.5 (CI 1.0–
work. 12) in women.

(continued on next page)

51
 52
Table 5 (continued).

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Author and Country Study Age Gender Sample Physical load factors Epicondylitis Results Adjustment for other
year population range size (in covariates
(years) analysis)

Case control
Haahr and Denmark Persons enrolled in the 18–66 Both 209 Force, repetitive movements, Lateral Manual job tasks (OR 3.1, 95 Age, body mass index,
Andersen, practices of general cases working posture, precision, CI 1.9–5.1), posture and and psychosocial
2003 [69] practitioners and 274 and vibration forceful work were factors: demands, low
controls associated with lateral control, and low social
epicondylitis. Repeated support at work
movements of the arms (OR
3.7, CI 1.7–8.3) in women and
work with precision
demanding movements (OR
5.2, CI 1.5–17.9) in men.

Cohort
Leclerc et al., France Employees of occupations Not Both 525 Turn and screw, tighten with Lateral OR ¼ 2.1 (95% CI 1.1–3.7) for Age, gender, depression,
2001 [17] requiring repetitive work, reported. force, work with force (other repetitive turning and number of upper limb
3-year follow-up 71% aged than tighten), press with the screwing diagnoses
30–49 hand or elbow, hit, pull, push,
hold in position.
Descatha France Occupations requiring Not Both 598 Holding in position, turning Medial No association Unadjusted
et al., 2003 repetitive work, 3-year reported and screwing, forceful work, epicondylitis
[15] follow-up using tools forcefully, and
holding a tool in position
 R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57 53

underestimate of the relationship between workload factors and epicondylitis. Moreover, available
longitudinal studies [16,17] have confirmed the conclusions drawn from cross-sectional studies.

Management

Epicondylitis may be a self-limiting disorder [10]. Only half of the patients with epicondylitis
probably seek medical treatment [4,13]. The treatments for epicondylitis include general advice,
medication (non-steroidal anti-inflammatory drugs and steroids), a variety of physical treatments, the
use of different appliances or bandages and a number of surgical procedures [4,9,10] (Table 6).
Over 80% of patients with epicondylitis report improvement in the condition within a year, with
a wait-and-see policy [75]. Workload modification should be considered, especially in manually
strenuous jobs [56]. Topical non-steroidal anti-inflammatory drugs provide beneficial short-term (3–4
weeks) pain relief [76–80]. Oral non-steroidal anti-inflammatory drugs do not provide more long-term
effects [76–80], and show more gastrointestinal adverse effects [78].
Local corticosteroid injections have beneficial short-term (6 weeks) effects [58,76,77,79,81,82].
They have no intermediate (6 weeks–6 months) or long-term (6 months) beneficial effects [58,79,82].
Corticosteroid injections are much more effective than physiotherapy in the short term [13,75,83,84];
however, due to shrinking of soft tissue, their use is limited to maximally three injections per year.
Acupuncture may alleviate symptoms of epicondytis [77,79,85–88]; however, the effect seems to be
very short term [88].
Wrist orthoses are used to limit wrist extension. An orthotic device is in the form of a brace, splint,
cast, band or strap [89]. Orthotic devices are commonly used as treatment strategy for epicondylitis.
Despite common use, there is no clear evidence base for application [76,79,89]. According to reviews,
there is no clear effect of exercises or strength training on epicondylitis [76,77,79,87,90]; however,
a recent study reported beneficial short effects of physiotherapy combining elbow self-manipulation and
exercise [84]. The effectiveness of ultrasonography [76,77,87,90], iontophoresis with non-steroidal anti-
inflammatory drugs [77,87,91], phonophoresis [87,92], electromagnetic field therapy [77,87], mobi-
lisation techniques [76,77,79,87,90], botulinum toxin [9,77] and topical nitrates [77] in the treatment of
epicondylitis is not well known. Extracorporeal shockwave therapy [76,77,79,91,93,94], laser therapy
[77,87,90,93] and autologous blood injections [9,77] are not beneficial in the treatment of epicondylitis.
According to clinical case series, surgical treatment has shown fair to good results [4,13,76]. However,
the efficacy of surgical management has not been evaluated in randomised controlled trials [77,95].

Table 6
Management of epicondylitis.

Treatment Reference
Probably beneficial
Topical non-steroidal anti-inflammatory drugs (short term) [76–80]
Oral non-steroidal anti-inflammatory drugs (short term) [76,78–80]
Local corticosteroid injection (up to 6 weeks) [58,76,77,79,81,82]
Acupuncture (very short term) [77,79,85–88]

Unknown effectiveness
Exercise [76,77,79,87,90]
Mobilisation [76,77,79,87,90]
Orthoses [76,79,89]
Ultrasound [76,77,87,90]
Botulinum toxin injection [9,77]
Iontophoresis [77,87,91]
Phonophoresis [87,92]
Electromagnetic field therapy [77,87]
Topical nitrates [77]
Surgery [4,13,76]

Unlikely to be beneficial
Autologous blood injection [9,77]
Extracorporeal shock wave therapy [76,77,79,91,93,94]
Laser therapy [77,87,90,93]
54 R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57

Neither have indications for surgical treatment been clearly defined. Open, percutaneous and arthro-
scopic techniques [77,96] are available, which include open release or lengthening of the extensor origin,
percutaneous release of the extensor origin, debridement of the extensor origin, arthroscopic release or
radiofrequency microtenotomy [9,96]. No surgical technique seems to be superior [97].

Prognosis

Epicondylitis is usually a self-limiting condition [10]. Over 80% of patients report improvement in
the condition within a year [9,39,75,98,99]. However, a small number of patients may have a painful
long-lasting disease [5,10]; some will have prolonged minor discomfort for a few years [5,100]. A
considerable proportion of individuals with epicondylitis have reoccurrence of the disease [10,101].
Prognostic factors influence improvement, recurrence or duration of epicondylitis [100]. Both
ergonomic and psychosocial factors may influence the prognosis of epicondylitis. Manual workers are
most susceptible to recurrence [10,102]. Manual work may hinder recovery or increase the risk of
relapse after treatment [102]. Individuals working in manual jobs and those with a high level of
physical strain at work [41,98,102] or non-neutral wrist postures during work activity [41] have
reported poor prognosis during follow-up for lateral epicondylitis. Moreover, poorer prognosis has
been reported for lateral epicondylitis on dominant than non-dominant elbow [98], and in individuals
with prior occurrence of the disorder [100]. Older individuals compared with younger [41,98], and
subjects with a high level of pain at baseline [98,100,102] have reported poorer prognosis.
Of psychosocial factors, individuals with lower perceived decision authority have reported poor
prognosis of epicondylitis [41], while poor social support at work has had no effect on the prognosis of
epicondylitis [98].

Prevention

Modification of physical factors could reduce the risk or improve the prognosis of epicondylitis
[56,71]. Designing of workplaces and ergonomic modifications should focus on minimising work tasks
requiring deviated wrist postures, forceful exertions, highly repetitive movements and providing
adequate rest and recovery periods [6,76,103]. An effort to modify workplaces, especially those that
have very high physical loads and combinations of physical risk factors, remains one of the most
important issues in the prevention of epicondylitis.

Practice points

 Epicondylitis is most common at the age of 40–60 years and affects women more frequently
than men.
 Epicondylitis is usually a self-limiting condition.
 Workload factors increase the risk and influence the prognosis of epicondylitis.
 Workload modification could reduce the risk and improve the prognosis of epicondylitis. It
should be considered in the management of epicondylitis, especially in manually strenuous
jobs.
 Topical non-steroidal anti-inflammatory drugs, corticosteroid injections and acupuncture
provide short-term beneficial effects.

Research agenda

 Future studies should investigate potential prognostic factors.

 Investigating the effects of improved workplace designs and ergonomic modifications on
epicondylitis.
 R. Shiri, E. Viikari-Juntura / Best Practice & Research Clinical Rheumatology 25 (2011) 43–57 55

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