Tennis Elbow

(Lateral Epicondylitis)

Tennis elbow is one of the most common causes of elbow pain, affecting around 1-3% of the population. Despite the name, most cases have nothing to do with tennis, it is caused by overload of the extensor tendons at the outer elbow, particularly the extensor carpi radialis brevis (ECRB).

What is happening in the Tendon?

The extensor tendons attach to the lateral epicondyle, the bony prominence on the outer side of the elbow. Repeated gripping and wrist extension place high tensile loads on this attachment, causing microscopic tears and a failed healing response. This process, now called tendinopathy, involves disorganised, degenerated tendon tissue rather than simple inflammation.

Who gets Tennis Elbow?

Desk workers

Prolonged mouse use and keyboard work with repetitive wrist extension. A very common occupational cause.

Manual workers

Plumbers, painters, carpenters, and chefs are frequently affected by repetitive gripping and tool use.

Age 35-55

Peak incidence in this age group, when tendons are less resilient but activity levels remain high.

Racket sport players

Improper backhand technique or a racket that is too heavy or strung too tightly increases risk.

Symptoms

  • Pain and burning over the lateral epicondyle, often radiating down the outer forearm

  • Weak grip - shaking hands, lifting a kettle, or turning a door handle provokes pain

  • Pain with wrist extension: bending the wrist back against resistance reproduces pain

  • Morning stiffness and tenderness, easing after warming up

⚠ Not all lateral elbow pain is tennis elbow. Your surgeon will exclude radial tunnel syndrome (posterior interosseous nerve entrapment), referred cervical spine pain, and elbow joint pathology, all of which can closely mimic tennis elbow.

Treatment - Stepwise Approach

Activity modification and relative rest

Identify and reduce the aggravating activity. Complete rest is not recommended, tendons need load to heal. The goal is activity at a level that does not provoke significant pain.

1

Physiotherapy - eccentric exercise

A structured programme of eccentric (lengthening under load) and heavy slow resistance exercises is the most effective long-term treatment. Results take 6-12 weeks of consistent effort.

2

Counterforce brace (tennis elbow strap)

A strap worn just below the elbow reduces tensile load on the tendon origin during activities. Useful for short-term symptom control during rehabilitation, not a cure on its own.

3

Corticosteroid injection

Provides reliable short-term (6-8 week) pain relief. Outcomes at 12 months are no better, and may be worse, than physiotherapy alone. Best used to enable engagement with rehabilitation, not as a standalone treatment.

4

Platelet-rich plasma (PRP) injection

Growth factors from the patient's own blood injected into the degenerated tendon to stimulate healing. Evidence potentially shows better long-term outcomes than steroid at 6-12 months. Increasingly used for chronic cases.

5

Surgery

Reserved for the ~5-10% failing 6-12 months of conservative treatment. Arthroscopic or open debridement of the ECRB origin. Around 85% of patients achieve good or excellent outcomes.

6

RECOVERY AFTER SURGERY

  • Wrist extensor stretch: arm extended, palm down, gently bend wrist downward. Hold 30 sec, 3 reps, 2-3x daily.

  • Isometric wrist extension: press back of hand upward against resistance, no movement. Hold 30-45 sec, 5 reps. Pain 3-4/10 is acceptable.

  • Eccentric wrist extension with weight: raise wrist with good hand, then lower slowly over 3-5 seconds. 3 x 15 reps daily. The slow lowering phase is therapeutic.

  • Heavy slow resistance, wrist extensions and reverse curls at 3 sec up / 3 sec down tempo. 3 sets, 3x per week. Progress load by 10% when 15 reps become easy.

Tennis elbow is self-limiting, around 80-90% of patients recover fully within 1-2 years with conservative treatment. The key is patience and consistent rehabilitation. Rushing back to aggravating activities is the most common cause of relapse.

FREQUENTLY ASKED QUESTIONS

  • Neither complete rest nor pushing through severe pain is correct. The goal is to exercise at a level that produces mild discomfort (3-4 out of 10) but no flare-up lasting more than 24 hours. Tendons respond to graduated loading.

  • A steroid injection provides excellent short-term pain relief but does not address the underlying tendon degeneration. Patients who receive injections without physiotherapy have higher relapse rates at 6-12 months. The injection is best used as a window to allow engagement with exercise.

  • Continue strengthening exercises for at least 3 months after symptoms resolve. Review your technique for sport or work. Gradually increase training loads. Ensure your racket, tools, or workstation are set up to reduce forearm strain.

This guide is intended for patient education purposes and does not replace a formal surgical consultation. Treatment decisions are always individualised based on your specific history, examination findings, and imaging. Please discuss your symptoms and management plan directly with your orthopaedic surgeon.