Summary

Lateral epicondylitis ("tennis elbow") is a common cause of lateral elbow pain, affecting the common extensor origin at the lateral epicondyle. Despite its name, only 5% of cases occur in tennis players — it more commonly results from repetitive occupational activities. The condition is a degenerative tendinopathy rather than an inflammatory condition. Most cases resolve spontaneously within 1-2 years, but symptoms can be significantly debilitating during this period.

Key Facts

• Definition: Degenerative tendinopathy of the common extensor origin (primarily ECRB)
• Prevalence: 1-3% of population; peak age 35-55 years
• Muscle Affected: Extensor carpi radialis brevis (ECRB) — origin at lateral epicondyle
• Classic Test: Pain on resisted wrist extension with elbow extended (Cozen's test)
• Prognosis: 80-90% resolve within 12-24 months
• Steroid Caution: Short-term benefit but WORSE long-term outcomes

Clinical Pearls

Not Really Inflammation: This is "tendinopathy" not "tendinitis" — histology shows angiofibroblastic degeneration, not inflammatory cells. Treatment should focus on rehabilitation, not just anti-inflammatories.

Steroids Make It Worse Long-Term: Despite short-term relief, corticosteroid injections are associated with poorer outcomes at 1 year compared to physiotherapy or even watchful waiting. Use with caution.

Think Radial Tunnel: If symptoms extend distally to forearm or there's night pain, consider radial tunnel syndrome (posterior interosseous nerve compression) which can coexist.

Why This Matters Clinically

Tennis elbow is extremely common and can significantly impact work and daily activities. Understanding that this is a self-limiting condition and that "less is often more" (avoiding aggressive early intervention) leads to better long-term outcomes for patients.

Structured Approach

General:

• Observe for swelling, deformity
• Compare to opposite elbow
• Assess neck and shoulder (referred pain)

Specific Examination:

• Palpate lateral epicondyle and ECRB origin
• Test active and passive ROM
• Provocative tests for lateral epicondylitis
• Neurological examination (radial nerve)

Special Tests

Natural History

Tennis elbow is self-limiting in the majority of cases, with 80-90% resolving within 12-24 months regardless of treatment. Early aggressive intervention (especially steroids) may paradoxically prolong recovery compared to physiotherapy or watchful waiting.

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Shorter symptom duration at presentation
• Compliance with physiotherapy
• Ability to modify aggravating activities
• No previous episodes

Poor Prognosis:

• Chronic symptoms (>12 months)
• Bilateral involvement
• Unable to modify work activities
• Multiple steroid injections
• Workers' compensation claims

Key Guidelines

1. NICE Clinical Knowledge Summary (2021) — Recommends conservative management first; advises against routine steroid injection due to worse long-term outcomes.

2. BESS / BOA Guidelines — Support physiotherapy as mainstay; surgery reserved for refractory cases.

Landmark Trials

Bisset et al. (2006) — RCT comparing physiotherapy, corticosteroid, wait-and-see

• 198 patients randomised
• Key finding: Steroid better at 6 weeks, but physiotherapy and wait-and-see superior at 52 weeks; steroid had highest recurrence
• Clinical Impact: Changed practice away from routine steroid injection

Coombes et al. (2013) — Systematic review

• Meta-analysis of corticosteroid injections
• Key finding: Worse outcomes in steroid group at intermediate and long-term follow-up
• Clinical Impact: Reinforced caution with steroid injections

Evidence Strength

What is Tennis Elbow?

Tennis elbow is a common condition that causes pain on the outer part of your elbow. It happens when the tendons that attach your forearm muscles to your elbow bone become irritated and wear out (degenerate). Despite its name, most people with tennis elbow don't play tennis — it's more common from work activities that involve repetitive gripping or wrist movements.

Why does it matter?

Tennis elbow can make everyday activities difficult — gripping, carrying bags, opening jars, shaking hands. The good news is that it almost always gets better on its own, usually within 1-2 years. The challenge is managing symptoms during this time.

How is it treated?

1. Activity changes: Identify what's causing it (work activity, sport) and try to reduce or modify it.

2. Elbow strap: A special band worn just below your elbow can reduce strain on the tendon.

3. Physiotherapy exercises: Specific strengthening exercises (eccentric exercises) are the most effective treatment.

4. Painkillers: Anti-inflammatory gels or tablets can help with pain — not for long-term use.

5. Steroid injection: Can give quick relief, but studies show it actually makes recovery take longer in the long run. Best avoided if possible.

6. Surgery: Very rarely needed — only if nothing else has worked after many months.

What to expect

• Most cases get better within 12-24 months
• Early on, expect some ups and downs
• Exercises take time to work (6-12 weeks to see improvement)
• Steroid injections may seem helpful at first but can delay overall recovery

When to seek help

See a doctor if:

• Pain is getting worse despite rest
• You have numbness or tingling in your hand
• You can't straighten your elbow
• Pain is keeping you awake at night
• You're unable to work or do normal activities