 
Massachusetts General Brigham Sports Medicine  
 
Rehabilitation Protocol for Medial/Lateral Epicondylalgia 
This guideline is intended to assist clinicians and patients through the non-operative course of care for Medial and 
Lateral Epicondylitis/Epicondylalgia. This protocol is time based (dependent upon tissue healing) as well as criterion 
based (dependent upon patient tolerance). Specific intervention should be based on the needs of the individual and 
should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  
 
The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should 
be included and modified based on the progress of the patient and under the discretion of the clinician. 
 
Laterally, this involves tendinopathy of the tendon, sheath, and muscular junction of the extensor carpi radialis brevis 
(ECRB) muscle and other extensor tendons on the lateral epicondyle of the humerus; while medial, this involves 
tendinopathy of the structures of flexor carpi radialis (FCR) muscle and other flexor tendons on the medial epicondyle of 
the humerus.  Typically, repetitive strain is believed to be the mechanism of injury resulting in microscopic and 
macroscopic tears together with potential micro-avulsion fractures. 
 
Diagnosis 
Considerations 
   
• Pain with repetitive wrist flexion/extension, weak grip strength.  Local tenderness. 
• Pain typically described as dull ache immediately after activity and at rest.  Can be sharp and 
radiate down forearm. 
• Common Aggravating Factors: shaking hands, baseball, swimming, golf, tennis, bowling, 
racquetball, football, weightlifting, track and field throwing and repetitive dynamic overload 
activities.  
• Throwing in late cocking and acceleration because of increased valgus stress (medial). 
• Special Tests:  
- Lateral: Resisted isometrics, Cozen’s Test, Chair Test, Mill’s Test, Maudsley Test, Coffee 
Cup Test, Resisted Middle Finger Extension Test, Polk’s Test (Phase 1) 
- Medial: Reverse Cozen’s Test, Polk’s Test (Phase 2) 
• Functional outcome measures: Patient-rated Tennis Elbow Evaluation (PRTEE), Disabilities of 
the Arm, Shoulder, and Hand (DASH) 
Differential 
Diagnosis 
   
• Radial tunnel syndrome 
• Posterior interosseus syndrome 
• Intraarticular abnormalities 
• Lateral collateral elbow instability 
• Cervical pathology (C6) 
• Ulnar nerve entrapment, impingement, or 
neuritis 
• Avulsion of apophysis 
• Ulnar collateral ligament injury 
• Extraarticular olecranon exostosis/bursitis 
• Rotator cuff tendinopathy 
• Thoracic outlet syndrome 
• Biceps/Triceps tendinopathy 
• Loose bodies, chondral involvement 
• Rheumatic disease 
 
PHASE I: IMMEDIATE/ACUTE (0-2 WEEKS) 
Rehabilitation 
Goals 
• Reduce any swelling, minimize pain and immobilization as needed 
• Patient education 
- Minimize aggravating factors as much as possible, activity modification 
- Initial self-symptom management and joint protection 
- Independent with initial home exercise program 
Interventions 
During this early acute phase, numerous manual interventions may be utilized to reduce the 
patient’s pain, restriction to movement, and joint mobility: 
• Soft Tissue Mobilization/Instrument-Assisted Soft Tissue Mobilization 
 
 
• Splinting/Taping 
• Ischemic compression/Bloodflow Restrictive Training 
• Dry Needling 
• Nerve mobilization 
• Joint mobilization/manipulation 
• Strengthening 
• Stretching 
• Modalities 
Criteria to 
Progress 
• Tolerance to full AROM without pain (unloaded) 
• Independent with initial home exercise program 
 
PHASE II: INTERMEDIATE/SUB-ACUTE (2-4 WEEKS) 
Rehabilitation 
Goals 
• Progressive stretching 
• Progressive loading/strengthening of supporting structures 
• Maintain full ROM 
• Independent with progressed home exercise program, all daily activities with appropriate 
activity modification 
• Patient Education 
- Pathomechanics 
- Ergonomics/posture 
- Activity modification 
- Lifting mechanics 
Additional 
Interventions 
*Continue with 
Phase I 
interventions 
Strengthening: Minimal loading 
• Wrist flexor/extensor isometrics 
• Neuromuscular re-education of proximal scapular stabilizing musculature  
Serratus anterior, middle/lower trapezius isometrics  
 
Stretching 
• Wrist flexors (elbow flexed to 90 degrees) 
• Wrist extensors (elbow flexed to 90 degrees) 
Criteria to 
Progress 
• Maintenance of full ROM 
• Full tolerance to stretching at 90 degrees of elbow flexion 
• Tolerance to light/unloaded daily activities without increase in pain 
• 70% strength of contralateral side  
 
PHASE III: LATE/CHRONIC (4-6+ WEEKS) 
Rehabilitation 
Goals 
• Maintain full ROM 
• Promote proper movement patterns 
• Avoid post-exercise pain/swelling 
Additional 
Interventions 
*Continue with 
Phase I-II 
Interventions  
Strengthening 
• Eccentrics/Concentrics (while both motions are beneficial, some patients may tolerate eccentric 
loading prior to concentric loading) 
Wrist flexion/extension 
Forearm pronation/supination 
Mobilization with movement 
• Progression of neuromuscular re-education of proximal scapular stabilizing musculature 
Resisted serratus anterior, lower/middle trapezius strengthening 
 
Stretching 
• Wrist flexors (elbow straight/extended) 
• Wrist extensors (elbow straight/extended) 
 
Correction of movement abnormalities with functional tasks 
 
 
 
Plyometrics Program 
Criteria for 
Progress/ 
Return to Sport 
• Independent self-management of symptoms 
• Achieve all muscle strength goals (90% of contralateral side) 
• Achieve functional goals 
• Demonstrate appropriate understanding of condition and maintenance to prevent risk of 
recurrence 
Revised April 2021 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
 
References: 
Sueki D, Brechter J.  Orthopedic Rehabilitation Clinical Advisor.  1st ed. Maryland Heights, Missouri: Mosby; 2009.  467-472. 
Day JM, Lucado AM, Uhl TL.  A comprehensive rehabilitation program for treating lateral elbow tendinopathy.  The International Journal of Sports Physical 
Therapy.  2019; 14 (5): 818-834 
Wadsworth TG, Elbow Tendonitis. In: Hunter JH, Mackin EJ, Callahan AD, Rehabilitation of the Hand and Upper Extremity. Fifth edition. Mosby.  2002:1263-70.   
 
 
