Lateral Epicondylitis (Tennis Elbow)
Summary
Lateral epicondylitis ("tennis elbow") is a common overuse injury affecting the common extensor origin, particularly the extensor carpi radialis brevis (ECRB) tendon. Despite its name, it occurs more often in non-tennis players, typically affecting those with repetitive gripping/twisting occupations. It is a tendinopathy (degenerative) rather than tendinitis (inflammatory). Presentation is lateral elbow pain worse with gripping, wrist extension, and lifting. Most cases (80-90%) resolve within 12-18 months with conservative management including activity modification, physiotherapy (eccentric loading), and counterforce bracing. Steroid injections provide short-term pain relief but may have worse long-term outcomes.
Key Facts
- Prevalence: 1-3% of adults; peak 40-50 years
- Pathology: Tendinopathy (degenerative) of ECRB tendon
- Classic Finding: Tenderness over lateral epicondyle; worse with gripping
- Diagnosis: Clinical (imaging rarely needed)
- Treatment: Conservative (physio, eccentric loading, brace)
- Prognosis: 80-90% resolve by 12-18 months
Clinical Pearls
"Tennis Elbow Without the Tennis": Only 5% of cases occur in tennis players. Repetitive occupational activities (plumbing, carpentry, computer use) are more common causes.
"Degeneration, Not Inflammation": Histology shows angiofibroblastic degeneration, not inflammation. This explains why anti-inflammatories have limited benefit long-term.
"Steroid Injections: Short-Term Gain, Long-Term Pain": Corticosteroid injections provide 6-week relief but may worsen 1-year outcomes compared to wait-and-see.
"Eccentric Loading is Key": Physiotherapy focusing on eccentric strengthening of wrist extensors is the most effective evidence-based treatment.
Incidence & Prevalence
- 1-3% of adults
- 4-7 per 1000 in primary care
- Equal M:F (slight male predominance in some studies)
Demographics
- Peak age: 40-50 years
- Dominant arm affected in 75%
- Bilateral in 20%
Risk Factors
| Factor | Notes |
|---|---|
| Repetitive wrist extension | Occupational or recreational |
| Gripping activities | Screwdrivers, hammers, racquet sports |
| Smoking | Impairs tendon healing |
| Obesity | Associated with tendinopathy |
| Forceful activities | > hour/day of repetitive tasks |
High-Risk Occupations
- Plumbers, electricians, carpenters
- Painters, decorators
- Computer/keyboard workers
- Chefs, butchers
- Assembly line workers
Anatomy
- Common extensor origin attaches to lateral epicondyle
- Comprises: ECRB, ECRL, EDC, ECU, supinator
- ECRB is most commonly affected (deep surface)
Tendinopathy (Not Tendinitis)
- Histology shows:
- Angiofibroblastic degeneration
- Disorganised collagen
- Neovascularisation
- Absence of inflammatory cells
- Term "epicondylitis" is a misnomer
Mechanism
- Repetitive microtrauma to ECRB tendon
- Failed healing response
- Degenerative changes accumulate
- Weakened tendon → Pain with loading
Why ECRB?
- Underside of ECRB rubs against lateral epicondyle and capitellum
- Repetitive friction and compression
- Relatively poor blood supply
Symptoms
| Feature | Description |
|---|---|
| Pain location | Lateral elbow, may radiate to forearm |
| Onset | Gradual, insidious |
| Aggravating factors | Gripping, twisting, lifting, carrying |
| Classic examples | Lifting kettle, turning doorknob, shaking hands |
| Relieving factors | Rest |
Functional Impact
Associations
Inspection
- Usually normal appearance
- Occasionally mild swelling over lateral epicondyle
Palpation
- Maximal tenderness 1cm distal to lateral epicondyle (ECRB origin)
- May have tenderness over radial head
Provocative Tests
| Test | Method | Positive Finding |
|---|---|---|
| Cozen's test | Resisted wrist extension (fist clenched, elbow extended) | Pain at lateral epicondyle |
| Mill's test | Passive wrist flexion with elbow extended | Pain at lateral epicondyle |
| Maudsley's test | Resisted middle finger extension | Pain at lateral epicondyle |
Examination to Exclude Other Causes
| Finding | Suggests |
|---|---|
| Full elbow ROM, no crepitus | Against arthritis |
| Normal radial head | Against fracture |
| No neurological deficit | Against radial nerve entrapment |
| Normal neck examination | Against cervical radiculopathy |
Clinical Diagnosis
- Diagnosis is CLINICAL in most cases
- Imaging rarely needed if typical presentation
Indications for Imaging
| Modality | Indication |
|---|---|
| X-ray | Trauma, suspected arthritis, previous surgery |
| Ultrasound | Consider if symptoms > months, confirms tendinopathy |
| MRI | Atypical presentation, suspected other pathology |
Imaging Findings (When Done)
- Thickened ECRB tendon
- Hypoechoic areas (US)
- Intrasubstance tears
- Increased signal (MRI)
Blood Tests
- Not routinely indicated
- Consider inflammatory markers if systemic features
Conservative Management (First-Line)
┌──────────────────────────────────────────────────────────┐
│ CONSERVATIVE MANAGEMENT OF TENNIS ELBOW │
├──────────────────────────────────────────────────────────┤
│ │
│ 1. EDUCATION & ACTIVITY MODIFICATION │
│ - Explain natural history (self-limiting 12-18 mo) │
│ - Modify aggravating activities │
│ - Ergonomic assessment if occupational │
│ │
│ 2. PHYSIOTHERAPY (MOST EFFECTIVE) │
│ - Eccentric loading exercises │
│ - Progressive strengthening │
│ - 12-week programme │
│ │
│ 3. COUNTERFORCE BRACE │
│ - Forearm strap 5cm below epicondyle │
│ - Reduces load on tendon │
│ │
│ 4. ANALGESIA │
│ - Simple analgesics (paracetamol) │
│ - Topical NSAIDs may provide short-term relief │
│ │
└──────────────────────────────────────────────────────────┘
Eccentric Exercises (Key Intervention)
- Patient holds weight with wrist extended
- Slowly lowers wrist into flexion (eccentric phase)
- Returns to extension with assistance from other hand
- 3 sets of 15 repetitions, twice daily
- Progress load as tolerated
Corticosteroid Injection (Caution)
- Provides short-term (6-week) benefit
- Multiple studies show WORSE long-term outcomes
- Higher recurrence rate
- Consider ONLY for severe short-term pain relief
- Not routinely recommended
Other Injections
- PRP (Platelet-Rich Plasma): Some evidence of benefit; variable results
- Autologous blood: Similar to PRP
- Hyaluronic acid: Limited evidence
- Botulinum toxin: Evidence conflicting
Surgical Management
- Reserved for refractory cases (>12-18 months)
- <5% require surgery
- Options:
- Open ECRB debridement
- Arthroscopic release
- Good outcomes in 80-90%
Of Condition
- Chronic pain
- Loss of grip strength
- Work disability
- Recurrence (common)
Of Treatment
- Steroid injection: Skin atrophy, depigmentation, tendon weakening
- Surgery: Infection, nerve injury, persistent pain
Natural History
- 80-90% resolve within 12-18 months
- Self-limiting condition
- Most improve with or without treatment
Recurrence
- 8.5% recurrence rate
- More likely with:
- Return to aggravating activities
- Manual occupation
- Poor rehabilitation
Factors Affecting Prognosis
| Better | Poorer |
|---|---|
| Early intervention | Delayed treatment |
| Good compliance with physio | Work-related cause |
| Non-manual occupation | Previous episodes |
| Shorter symptom duration | Steroid injections |
Key Guidelines
- NICE CKS: Tennis Elbow (2020)
- BESS Elbow Guidelines
- American Academy of Orthopaedic Surgeons
Key Evidence
Bisset et al (Lancet 2006)
- RCT comparing: Physiotherapy vs Steroid vs Wait-and-see
- At 1 year: Wait-and-see and physio similar, both BETTER than steroid
- Steroid group had highest recurrence
PRP vs Steroid
- Peerbooms et al (2010): PRP superior at 1 year
- Heterogeneous study methods; not universally adopted
Eccentric Exercise
- Multiple studies support eccentric loading
- Superior to concentric exercise
- NNT ~4 for significant improvement
What is Tennis Elbow?
Tennis elbow is pain on the outside of your elbow caused by overuse of the muscles and tendons that straighten your wrist. Despite its name, you don't have to play tennis to get it - any repetitive gripping or twisting movements can cause it.
What Are the Symptoms?
- Pain on the outer part of your elbow
- Pain when gripping things (like a cup or doorknob)
- Difficulty carrying shopping bags
- Weakness in your grip
- Pain that may spread down your forearm
What Causes It?
It's caused by small tears in the tendon that attaches your forearm muscles to your elbow. This usually happens from:
- Repetitive movements at work (typing, using tools)
- Sports that involve gripping (tennis, golf, badminton)
- DIY activities
How is it Treated?
The good news is that tennis elbow usually gets better on its own within 12-18 months. Treatment helps speed this up:
- Rest and modify activities - Avoid what makes it worse
- Physiotherapy exercises - Special strengthening exercises are very effective
- Elbow brace - A strap worn below your elbow can help
- Pain relief - Paracetamol or anti-inflammatory gels
What About Injections?
Steroid injections can help in the short term (a few weeks) but research shows they may actually slow long-term recovery. They're generally not recommended unless you need very quick short-term relief.
When to See a Doctor
See your GP if:
- Pain is severe or not improving after a few weeks
- You have weakness, numbness, or tingling
- There's swelling or redness that won't go away
- The pain is affecting your work or daily life
Primary Guidelines
- NICE Clinical Knowledge Summaries. Tennis Elbow. 2020. cks.nice.org.uk
- BESS. Pathway for Common Elbow Conditions.
Key Studies
- Bisset L, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. PMID: 17012266
- Coombes BK, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia. JAMA. 2013;309(5):461-469. PMID: 23385272