Condition
Tennis elbow
Tennis elbow (lateral epicondylopathy) is the most common cause of elbow pain. It is an overuse tendinopathy of the forearm extensor tendons where they attach to the outer side of the elbow. It causes pain when gripping or lifting and is named after the sport because tennis players overload the same tendons, but most patients have never picked up a racquet. The vast majority of cases settle with non-operative treatment.
Anatomy
Where the pain comes from
The wrist extensor muscles run down the back of the forearm and originate from a small bony prominence on the outer side of the elbow called the lateral epicondyle. The tendon most often involved in tennis elbow is the extensor carpi radialis brevis (ECRB), which has a small footprint on the front edge of the lateral epicondyle.
Despite the older name "epicondylitis", the condition is not a true inflammation. It is a degenerative tendinopathy: the collagen fibres in the tendon origin become disorganised and the local blood supply increases in a disordered pattern. This is why anti-inflammatory treatment is only partially effective and why graded loading is the cornerstone of recovery.
Symptoms
How tennis elbow presents
The pain is well-localised to the outer point of the elbow and may radiate down the forearm. It is provoked by gripping, lifting with the palm facing down, shaking hands, opening jars, lifting a kettle or full coffee cup, and racquet sports. Some patients also notice a feeling of weakness in the hand, although true muscle weakness is uncommon. The apparent weakness is from pain inhibition.
On examination, there is well-localised tenderness over the lateral epicondyle and the front edge of it. Resisted wrist extension and resisted middle-finger extension both reproduce the pain. The condition is usually unilateral but can occur on both sides.
Causes
Why it develops
Tennis elbow is an overuse problem. The extensor tendons accumulate microtrauma from repeated gripping or wrist extension that exceeds their tolerance, and the body cannot keep up with repair. Over time, the tendon origin becomes degenerative.
Common triggers include manual trades (plumbing, painting, gardening, dentistry), computer work with a non-ideal mouse and keyboard set-up, weight training with a poor grip, and racquet sports, particularly when grip size, racquet weight, or stroke technique increase load on the extensors. Anything that suddenly increases workload on the wrist extensors can trigger a flare.
Diagnosis
How tennis elbow is diagnosed
Tennis elbow is a clinical diagnosis. The history and examination are usually enough to confirm it. Imaging is reserved for atypical or resistant cases.
- Examination. Tenderness over the lateral epicondyle, pain on resisted wrist extension, and pain on resisted middle-finger extension. Range of motion is usually preserved.
- Ultrasound. Useful when the diagnosis is uncertain or when an injection is being planned. Shows tendon thickening, hypoechoic areas, and any partial tearing.
- MRI. Reserved for resistant cases or to look for an alternative diagnosis such as a radiocapitellar joint problem or a posterior interosseous nerve compression.
Treatment
Treatment options
The natural history of tennis elbow is favourable. The vast majority of cases settle within six to twelve months. Treatment is staged from non-operative measures to surgery, with surgery reserved for resistant cases that have failed a comprehensive programme.
- Activity modification. Identifying and adjusting the activities that overload the tendon. Often the most important single intervention.
- Eccentric loading programme. A structured physiotherapy programme that loads the wrist extensors during the lengthening phase of controlled exercise. The best-supported non-operative treatment.
- Shockwave therapy. Usually given by a physiotherapist over multiple sessions with increasing intensity. It can improve symptoms.
- Counterforce brace. A small strap worn just below the elbow that offloads the tendon origin during gripping activities. Helpful for short-term symptom control.
- Anti-inflammatory medication. Useful for short-term symptom control but does not change the underlying tendon pathology.
- Corticosteroid injection. Provides reliable relief in approximately 70 percent of patients. Used selectively, it allows rehabilitation to progress.
- Platelet-rich plasma (PRP) injection. Some evidence of benefit for resistant cases, although the data is mixed. Considered for selected patients who have failed standard non-operative treatment or cortisone injections. PRP must be delayed for three months after a cortisone injection, as the cortisone will prevent the PRP from working.
- Surgical release and debridement. Reserved for cases that have failed at least six months of comprehensive non-operative treatment. The diseased portion of the ECRB origin is released and debrided. Performed open or arthroscopically.
Recovery
What to expect
With non-operative treatment, expect gradual improvement over months. There are usually flares as activity is reintroduced, and the timeline tends to be longer than patients hope for. Consistency with the rehabilitation programme is the single biggest predictor of a good outcome.
After surgical release, a sling or splint is worn for comfort for one to two weeks. Range of motion exercises start within the first week. Strengthening progresses from around six weeks. Most patients return to office work within a week or two and to full unrestricted activity by three to four months. Some residual ache during heavy gripping can persist for longer.
FAQ
Frequently asked questions
- Do you have to play tennis to get tennis elbow?
- No. The condition is named after the sport because tennis players overload the wrist extensors with repeated backhands, but most patients with tennis elbow have never picked up a racquet. Plumbers, painters, gardeners, mechanics, dentists, and people who do a lot of typing or mouse work are all common groups. Anything that involves repeated gripping, lifting with the palm down, or wrist extension can trigger it.
- How long does tennis elbow take to settle?
- Most cases settle over six to twelve months with non-operative treatment. Some take longer. The natural history is favourable in the majority of patients, which is why surgery is reserved for cases that have failed a comprehensive non-operative programme of at least six months. Early activity modification and a structured eccentric loading programme make a real difference to the timeline.
- Should I get a corticosteroid injection?
- Corticosteroid injections give reliable short-term pain relief, often within days, but must be given in conjunction with a physiotherapy programme to prevent recurrence. Dr Piper uses corticosteroid injections selectively, usually for patients whose pain is preventing them from doing the rehabilitation programme, or causing functional limitation. They are not a stand-alone cure.
- What is an eccentric loading programme?
- It is a structured physiotherapy programme that loads the wrist extensor tendons during the lengthening (eccentric) phase of a controlled exercise. Eccentric loading appears to remodel the tendon and is the best-supported non-operative treatment for tennis elbow. A physiotherapist tailors the programme to your stage and tolerance. Consistency over weeks to months is what produces results.
- When is surgery indicated for tennis elbow?
- Surgery is reserved for patients who have failed at least six months of comprehensive non-operative treatment, including a structured eccentric loading programme, activity modification, and any reasonable adjuncts. The operation is a release and debridement of the diseased portion of the extensor carpi radialis brevis (ECRB) origin. Open and arthroscopic techniques both work; Dr Piper will discuss which is appropriate at consultation.
References
- Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-469.
- Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014;28(1):3-19.
- Vuvan V, et al. The Beneficial Effects of Eccentric Exercise in the Management of Lateral Elbow Tendinopathy: A Systematic Review and Meta-Analysis. J Clin Med. 2021;10(17):3968.
- Smidt N, et al. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol. 2006;33(10):2053-2059.
Outer elbow pain that won't settle?
Book an appointment with Dr Piper
Consultations at Lakeview Private Hospital, Norwest. Bring a referral and any imaging you have.