Lateral Epicondylitis (Tennis Elbow)

Lateral epicondylitis, commonly known as tennis elbow, is a painful condition that occurs when tendons in the elbow are overloaded, usually by repetitive motions of the wrist and arm.

Overview

Lateral epicondylitis is one of the most common overuse injuries affecting the elbow. Despite its nickname "tennis elbow," this condition affects not just tennis players but anyone who performs repetitive arm, elbow, and wrist movements. The condition involves inflammation and microtears in the tendons that attach the forearm muscles to the lateral epicondyle, the bony bump on the outer part of the elbow.

The primary tendon affected is the extensor carpi radialis brevis (ECRB), which helps stabilize the wrist when the elbow is straight. When this tendon is weakened from overuse, microscopic tears form and lead to inflammation and pain. The condition typically develops gradually over weeks or months rather than from a single injury.

Tennis elbow affects approximately 1-3% of the population, with the highest incidence occurring in people aged 30-50 years. While the condition can be quite painful and limiting, most people recover with conservative treatment, though recovery can take several months to a year in some cases.

Symptoms

The symptoms of lateral epicondylitis typically develop gradually and worsen over time without proper treatment. The dominant arm is usually affected, though both arms can develop the condition.

Primary Symptoms

  • Elbow pain on the outer side, which may radiate down the forearm
  • Pain or burning sensation on the lateral epicondyle
  • Weak grip strength
  • Pain that worsens with forearm activity
  • Morning stiffness in the elbow

Associated Symptoms

Activities That Trigger Symptoms

  • Shaking hands or gripping objects
  • Turning a doorknob or wrench
  • Holding a coffee cup or lifting a plate
  • Using tools like screwdrivers or hammers
  • Playing racquet sports
  • Computer mouse use
  • Lifting objects with palm facing down

Causes

Lateral epicondylitis is caused by overuse and muscle strain from repetitive motions. The condition results from small tears in the tendons that attach forearm muscles to the bone at the elbow.

Primary Causes

  • Repetitive stress: Continuous contractions of forearm muscles used to straighten and raise the hand and wrist
  • Overuse: Excessive use without adequate rest periods
  • Poor technique: Improper form during sports or work activities
  • Direct trauma: A direct blow to the elbow, though less common
  • Age-related degeneration: Natural wear and tear of tendons

Common Activities Leading to Tennis Elbow

Sports-related:

  • Tennis (especially backhand stroke)
  • Squash and racquetball
  • Fencing
  • Weight lifting
  • Baseball and softball pitching

Occupation-related:

  • Plumbing and pipe fitting
  • Painting and decorating
  • Carpentry
  • Butchering and meat cutting
  • Computer work (extensive mouse use)
  • Assembly line work
  • Cooking and food preparation
  • Auto mechanics

Risk Factors

Several factors can increase the likelihood of developing lateral epicondylitis:

  • Age: Most common between ages 30-50, though it can occur at any age
  • Occupation: Jobs requiring repetitive arm and wrist motions
  • Sports participation: Racquet sports with poor technique or equipment
  • Duration of activity: Performing repetitive activities for more than 2 hours daily
  • Smoking: May affect tendon health and healing
  • Obesity: Increased body weight may stress arm tendons
  • Previous elbow injury: History of elbow problems
  • Poor conditioning: Weak forearm muscles
  • Improper equipment: Using tools or sports equipment that don't fit properly

Diagnosis

Diagnosis of lateral epicondylitis is primarily clinical, based on history and physical examination. Imaging tests are usually not necessary but may be ordered to rule out other conditions.

Medical History

Your doctor will ask about:

  • Onset and duration of symptoms
  • Activities that trigger or worsen pain
  • Occupation and recreational activities
  • Previous elbow injuries
  • Treatment attempts and their effectiveness

Physical Examination

Common diagnostic tests include:

  • Cozen's test: Resisted wrist extension with elbow extended
  • Mill's test: Passive wrist flexion with elbow extended
  • Maudsley's test: Resisted middle finger extension
  • Palpation: Direct pressure over lateral epicondyle
  • Grip strength testing: Comparing affected and unaffected sides

Imaging Studies

  • X-rays: To rule out arthritis or fracture
  • MRI: Shows soft tissue damage in unclear cases
  • Ultrasound: Can visualize tendon thickening and tears
  • EMG: If nerve compression is suspected

Treatment Options

Treatment for lateral epicondylitis focuses on relieving pain, promoting healing, and preventing recurrence. Most cases (80-95%) improve with conservative treatment.

Conservative Treatment

  • Rest and activity modification: Avoid activities that worsen symptoms
  • Ice therapy: Apply ice for 15-20 minutes, 3-4 times daily
  • NSAIDs: Ibuprofen or naproxen for pain and inflammation
  • Bracing: Counterforce brace or wrist splint to reduce tendon stress

Physical Therapy

  • Stretching exercises: Wrist extensor stretches
  • Strengthening: Eccentric exercises for forearm muscles
  • Manual therapy: Soft tissue mobilization
  • Modalities: Ultrasound, electrical stimulation, or laser therapy
  • Ergonomic assessment: Workplace or sports technique evaluation

Medical Interventions

  • Corticosteroid injections: Short-term pain relief, but may delay healing
  • Platelet-rich plasma (PRP): May promote healing in chronic cases
  • Botulinum toxin: Can reduce muscle tension
  • Prolotherapy: Injection of irritant solution to stimulate healing
  • Dry needling: To break up scar tissue

Surgical Treatment

Surgery is considered only after 6-12 months of failed conservative treatment:

  • Open surgery: Removal of damaged tendon tissue
  • Arthroscopic surgery: Minimally invasive tendon debridement
  • Percutaneous tenotomy: Ultrasound-guided needle procedure

Recovery Timeline

  • Mild cases: 6-8 weeks with conservative treatment
  • Moderate cases: 3-6 months
  • Severe/chronic cases: 6-12 months or longer
  • Post-surgery: 4-6 months for full recovery

Prevention

Preventing lateral epicondylitis involves reducing strain on the elbow tendons and maintaining good muscle conditioning:

General Prevention Strategies

  • Proper technique: Learn correct form for sports and work activities
  • Equipment optimization: Use properly sized tools and sports equipment
  • Regular breaks: Rest arms during repetitive activities
  • Strengthening exercises: Build forearm and grip strength
  • Stretching: Regular wrist and forearm stretches
  • Gradual progression: Slowly increase activity intensity

Workplace Ergonomics

  • Adjust workstation height and chair position
  • Use ergonomic keyboard and mouse
  • Keep wrists neutral during typing
  • Use tools with larger grips
  • Alternate tasks to avoid repetition

Sports-Specific Prevention

  • Use proper racquet size and string tension
  • Learn proper stroke mechanics
  • Warm up before playing
  • Use two-handed backhand in tennis
  • Strengthen shoulder and core muscles

When to See a Doctor

Consult a healthcare provider if you experience:

  • Elbow pain that persists despite rest and home treatment
  • Inability to carry objects or use your arm normally
  • Pain that interferes with sleep or daily activities
  • Swelling, redness, or warmth around the elbow
  • Signs of nerve involvement (numbness, tingling)
  • Fever accompanying elbow pain
  • Deformity or inability to move the elbow
  • Pain that radiates to the neck or shoulder

Early treatment typically leads to better outcomes and may prevent the condition from becoming chronic. Don't wait for severe symptoms before seeking help.

Frequently Asked Questions

Do I need to play tennis to get tennis elbow?

No, only about 5% of people with tennis elbow actually play tennis. The condition can result from any repetitive arm and wrist movements.

Can tennis elbow heal on its own?

Mild cases may improve with rest alone, but most benefit from active treatment including stretching, strengthening, and activity modification.

How long should I rest my elbow?

Complete rest isn't usually recommended. Instead, modify activities to avoid pain while maintaining gentle movement and prescribed exercises.

Are steroid injections recommended?

Steroid injections can provide short-term relief but may actually delay healing and weaken tendons. They're typically reserved for severe cases.

When can I return to sports or work?

Return depends on symptom resolution and can range from a few weeks to several months. Gradual return with proper technique is essential.

References

  1. Bisset L, Coombes B, Vicenzino B. Tennis elbow. BMJ Clinical Evidence. 2023.
  2. Johns N, Shridhar V. Lateral epicondylitis: Current concepts. Australian Journal of General Practice. 2020.
  3. Ma KL, Wang HQ. Management of Lateral Epicondylitis: A Narrative Literature Review. Pain Research and Management. 2020.
  4. Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Reviews. 2023.
  5. American Academy of Orthopaedic Surgeons. Tennis Elbow (Lateral Epicondylitis). OrthoInfo. 2024.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of any medical condition.