Tennis Elbow: Symptoms, Causes & Treatment Guide

What Is Tennis Elbow?

Tennis elbow (lateral epicondylitis) is a condition causing pain on the outer side of the elbow, where the forearm extensor muscles attach to the lateral epicondyle bone. It results from overuse and repetitive strain leading to small tears and degeneration in the tendon, causing pain with gripping and wrist movements.

Tennis elbow is one of the most common causes of elbow pain, affecting approximately 1-3% of the general population. The condition occurs when the tendons that attach the forearm muscles to the bony bump on the outside of the elbow become damaged through repetitive stress. Despite its name, the condition is far more commonly caused by everyday activities and occupational tasks than by playing tennis. In fact, less than 5% of tennis elbow cases are actually related to the sport.

The medical term for tennis elbow is lateral epicondylitis, though modern research suggests that the term "epicondylopathy" or "lateral elbow tendinopathy" may be more accurate. This is because studies have shown that the condition involves degeneration of the tendon (tendinosis) rather than active inflammation (tendinitis). Understanding this distinction is important because it affects treatment approaches - anti-inflammatory medications may be less effective than previously thought.

The lateral epicondyle is the bony prominence on the outside of the elbow where several forearm muscles that extend the wrist and fingers originate. The main tendon affected is the extensor carpi radialis brevis (ECRB), which is crucial for stabilizing the wrist during gripping activities. When this tendon is repeatedly stressed beyond its capacity to heal, microscopic tears develop, leading to the characteristic pain and weakness of tennis elbow.

Who Gets Tennis Elbow?

Tennis elbow can affect anyone, but certain factors increase the risk. The condition most commonly occurs in people between 35 and 54 years of age, with equal prevalence in men and women. The dominant arm is more frequently affected, and the condition is particularly common in certain occupations and activities.

Risk factors for developing tennis elbow include occupations requiring repetitive arm movements such as plumbing, painting, carpentry, butchering, and computer work. Hobbies like gardening, knitting, and playing musical instruments can also contribute. Smoking has been associated with increased risk and delayed healing, likely due to reduced blood flow to the tendons.

What Are the Symptoms of Tennis Elbow?

The main symptoms of tennis elbow include pain on the outer side of the elbow that may radiate down the forearm, weakness in grip strength, and pain when gripping objects, twisting the forearm, or extending the wrist. Symptoms typically develop gradually and worsen over weeks to months.

Tennis elbow symptoms usually develop gradually rather than suddenly. The pain begins as a mild discomfort on the outer elbow and progressively worsens over weeks to months. Many people continue their normal activities initially, which can allow the condition to become more established before they seek treatment.

The hallmark symptom is pain localized to the lateral epicondyle - the bony bump on the outside of the elbow. This pain often radiates down the outer forearm toward the wrist. The pain is typically described as a burning or aching sensation that becomes sharp with certain movements. Many people notice their symptoms are worse in the morning, with stiffness that improves as they start moving.

Specific activities that typically aggravate tennis elbow symptoms include gripping objects (especially with force), turning doorknobs, shaking hands, using tools, typing, and lifting objects with the palm facing down. Even simple tasks like holding a coffee cup or turning a key can become painful as the condition progresses.

Common Symptoms Include

• Pain on the outer elbow: Tender spot over the lateral epicondyle that is painful to touch
• Weak grip strength: Difficulty holding objects or performing activities requiring grip
• Pain with gripping: Increased pain when grasping objects or making a fist
• Pain when extending the wrist: Discomfort when bending the wrist backward against resistance
• Pain radiating down forearm: Aching sensation that travels from the elbow toward the wrist
• Morning stiffness: Elbow feels stiff and painful upon waking, improving with movement
• Pain with twisting motions: Discomfort when turning doorknobs or using screwdrivers

Symptoms That Are NOT Tennis Elbow

Certain symptoms suggest a different diagnosis and should prompt medical evaluation. If you experience numbness or tingling in your fingers, this may indicate nerve involvement such as radial tunnel syndrome. Pain on the inner side of the elbow (medial epicondylitis or "golfer's elbow") is a different condition. Swelling, redness, or warmth around the elbow could indicate infection or inflammatory arthritis. Sudden onset of severe pain after an injury may indicate a tendon tear or fracture.

What Causes Tennis Elbow?

Tennis elbow is caused by repetitive stress and overuse of the forearm extensor muscles, leading to microscopic tears and degeneration of the tendon attaching to the lateral epicondyle. Common causes include repetitive gripping, wrist extension, and twisting movements from work activities, sports, or hobbies.

The fundamental cause of tennis elbow is repetitive microtrauma to the common extensor tendon, particularly the extensor carpi radialis brevis (ECRB). When the forearm muscles are repeatedly contracted - especially during gripping and wrist extension - the tendon experiences cumulative stress. If the rate of damage exceeds the body's ability to repair the tissue, degenerative changes occur in the tendon.

Modern research has changed our understanding of what happens in tennis elbow. Rather than acute inflammation (which the term "tendinitis" implies), studies show that chronic tennis elbow involves tendon degeneration called "angiofibroblastic tendinosis." This means the tendon tissue breaks down and attempts to heal with disorganized collagen fibers and abnormal blood vessel growth. Understanding this pathophysiology explains why anti-inflammatory treatments may have limited effectiveness in chronic cases.

The forces through the ECRB tendon during wrist extension and gripping can be substantial. Studies have shown that simple activities like gripping a coffee cup generate significant loads on this tendon. When these loads are repeated thousands of times daily in certain occupations, the cumulative stress can exceed the tendon's healing capacity.

Occupational Causes

Work-related activities are the most common cause of tennis elbow. Jobs requiring repetitive forearm movements, forceful gripping, or vibrating tools significantly increase risk. Occupations with elevated rates of tennis elbow include:

• Manual laborers: Plumbers, carpenters, painters, electricians, and mechanics
• Food industry workers: Butchers, chefs, and food processing workers
• Office workers: Extended computer mouse use and typing
• Healthcare workers: Dentists, surgeons, and physiotherapists
• Musicians: Especially string instrument players

Sports and Recreational Causes

While tennis contributes to less than 5% of cases overall, the condition affects up to 50% of recreational tennis players at some point. Improper technique, inappropriate grip size, and string tension all contribute to risk. Other racket sports like badminton and squash carry similar risks. Weightlifting with improper form, golf, bowling, and fencing can also cause tennis elbow.

Biomechanical Factors

Several biomechanical factors can predispose someone to developing tennis elbow. Poor ergonomics at workstations can increase forearm muscle strain. Inadequate warm-up before physical activities increases injury risk. Using tools or equipment that are too heavy or improperly sized adds unnecessary stress. Poor technique in sports, particularly the backhand stroke in tennis, is a well-documented risk factor.

How Is Tennis Elbow Diagnosed?

Tennis elbow is typically diagnosed through physical examination without the need for imaging tests. The doctor will assess tenderness over the lateral epicondyle and perform provocative tests like resisted wrist extension (Cozen's test) and passive wrist flexion (Mill's test). Imaging may be used to rule out other conditions.

The diagnosis of tennis elbow is primarily clinical, meaning it is based on the patient's history and physical examination rather than imaging or laboratory tests. A careful history will reveal the characteristic pattern of pain with gripping activities, the gradual onset of symptoms, and potential contributing factors like occupational or recreational activities.

During the physical examination, the healthcare provider will examine your elbow for tenderness over the lateral epicondyle - the bony bump on the outside of the elbow. This tenderness is typically very localized, often described as a "point tenderness" that the patient can identify with one finger. The provider will also assess grip strength, range of motion, and perform several provocative tests.

Clinical Tests for Tennis Elbow

Several specific tests help confirm the diagnosis of tennis elbow. These tests reproduce the characteristic pain by stressing the affected tendons:

• Cozen's test: The examiner stabilizes the elbow while the patient makes a fist and extends the wrist against resistance. Pain at the lateral epicondyle indicates a positive test.
• Mill's test: With the elbow extended and forearm pronated (palm down), the examiner passively flexes the wrist. Pain at the lateral epicondyle is a positive finding.
• Maudsley's test: The patient extends the middle finger against resistance while the elbow is straight. Pain at the lateral epicondyle suggests tennis elbow.
• Chair lift test: The patient attempts to lift a chair with the arm extended and palm facing down. Inability or pain performing this indicates tennis elbow.

When Is Imaging Needed?

Imaging studies are not routinely required to diagnose tennis elbow but may be helpful in certain situations. X-rays can identify bone abnormalities, calcifications, or arthritis that might contribute to symptoms. Ultrasound can visualize tendon thickening, tears, and abnormal blood flow within the tendon. MRI provides detailed images of soft tissues and is useful when surgery is being considered or when the diagnosis is uncertain.

Imaging becomes particularly important when symptoms don't respond to treatment as expected, when there's concern about a complete tendon tear, or when other conditions need to be ruled out. These might include radial tunnel syndrome, cervical radiculopathy, or elbow joint pathology.

What Is the Best Treatment for Tennis Elbow?

The most effective treatment for tennis elbow combines rest from aggravating activities, physical therapy with eccentric exercises, and pain management. Research shows that 80-90% of patients recover with conservative treatment within 1-2 years. Key treatments include activity modification, specific strengthening exercises, bracing, and anti-inflammatory medications as needed.

Treatment of tennis elbow follows a stepped approach, starting with conservative measures that are effective for most patients. The goals of treatment are to reduce pain, promote tendon healing, restore function, and prevent recurrence. Understanding that tennis elbow is a degenerative condition rather than an inflammatory one has shifted treatment emphasis toward rehabilitation and loading programs rather than anti-inflammatory approaches alone.

The cornerstone of tennis elbow treatment is activity modification rather than complete rest. Research has shown that complete immobilization can actually delay healing and lead to muscle weakness. Instead, the goal is to modify activities to reduce strain on the affected tendon while maintaining movement and strength. This might mean changing how you grip objects, adjusting workstation ergonomics, or temporarily avoiding specific aggravating activities.

First-Line Treatments

Rest and activity modification involves identifying and reducing activities that aggravate symptoms. This doesn't mean stopping all activity - continued gentle use is important for maintaining strength and promoting healing. Ergonomic modifications at work, such as using a mouse pad with wrist support or adjusting keyboard height, can make a significant difference.

Ice application can help manage pain, especially after activities. Apply ice wrapped in a towel for 15-20 minutes several times daily. While ice doesn't address the underlying tendon degeneration, it provides symptomatic relief and may reduce any associated inflammation.

Over-the-counter pain relievers such as NSAIDs (ibuprofen, naproxen) or acetaminophen can help manage pain. However, given the limited inflammatory component in chronic tennis elbow, these should be used primarily for pain relief rather than as a primary treatment strategy.

Eccentric Exercises - The Key Treatment

Research consistently shows that eccentric strengthening exercises are the most effective conservative treatment for tennis elbow. Eccentric exercises involve lengthening the muscle while it's under tension - essentially the "lowering" phase of an exercise. These exercises stimulate tendon remodeling and strengthen the tendon structure.

The standard eccentric exercise protocol involves:

1. Rest your forearm on a table with your wrist hanging over the edge, palm facing down
2. Use your other hand to lift your wrist into extension (bent upward)
3. Slowly lower your wrist down over 3-5 seconds, controlling the movement
4. Return to the starting position using your other hand (not the affected arm)
5. Perform 3 sets of 15 repetitions, twice daily
6. Progress by adding light weights (starting with 0.5-1 kg) as tolerated

It's normal to experience some discomfort during these exercises, but sharp or severe pain indicates you should reduce the load. Consistency is crucial - improvements typically begin after 4-6 weeks of regular exercise but may take 3-6 months for full benefit.

Tennis Elbow Braces and Supports

Counterforce braces (tennis elbow straps) are worn around the forearm just below the elbow. They work by changing the point of stress on the tendon, reducing strain at the damaged area. While research on their effectiveness is mixed, many patients find them helpful for performing activities that would otherwise be painful.

Wrist splints that hold the wrist in slight extension can also reduce tendon loading by preventing full wrist flexion. These are sometimes used at night or during aggravating activities. The key is using supports to enable function while the tendon heals, not as a substitute for rehabilitation exercises.

Physical Therapy

A physical therapist can provide a comprehensive treatment program including manual therapy techniques, specific exercise prescription, ergonomic advice, and activity modification guidance. They may also use modalities such as ultrasound, electrical stimulation, or dry needling, though evidence for these additional treatments is limited.

Corticosteroid Injections

Corticosteroid injections can provide rapid pain relief and are still commonly used. However, important research has changed how we view this treatment. Studies show that while steroid injections provide superior short-term relief (up to 6 weeks), patients who receive injections actually have worse outcomes at 6-12 months compared to those who don't. This is likely because steroids may interfere with the natural healing process and can weaken tendon tissue.

Current recommendations suggest limiting steroid injections to patients with severe symptoms who need short-term relief to participate in rehabilitation, or those who haven't responded to other treatments. Multiple injections should be avoided due to the risk of tendon weakening and rupture.

Other Treatments

Platelet-rich plasma (PRP) injections involve injecting concentrated platelets from your own blood into the affected tendon. Some studies show benefit, particularly in chronic cases that haven't responded to other treatments, but evidence is still evolving.

Extracorporeal shockwave therapy (ESWT) uses acoustic waves to stimulate healing. It may be helpful for chronic cases, though results vary and multiple sessions are typically needed.

Acupuncture may provide short-term pain relief for some patients, though high-quality evidence is limited.

When Is Surgery Needed for Tennis Elbow?

Surgery for tennis elbow is only considered after 6-12 months of failed conservative treatment, affecting only 4-11% of patients. Surgical options include open or arthroscopic release of the damaged tendon. Success rates are approximately 80-90%, though recovery takes 3-6 months and return to full activity may take up to a year.

Most patients with tennis elbow recover with conservative treatment, and surgery is reserved for the minority who don't improve. Generally, surgery is considered when symptoms have persisted for at least 6-12 months despite adequate conservative treatment including physical therapy, bracing, and possibly injection therapy.

The decision to proceed with surgery should be made carefully, considering the impact of symptoms on quality of life and function, patient expectations, and the potential risks of surgery. A thorough evaluation before surgery helps ensure the diagnosis is correct and that there are no other contributing factors that might affect surgical outcomes.

Surgical Procedures

The most common surgical approach involves releasing or debriding the damaged portion of the ECRB tendon at its attachment to the lateral epicondyle. This can be performed through:

• Open surgery: A small incision is made over the lateral epicondyle, allowing direct visualization and treatment of the damaged tendon. This traditional approach has well-established outcomes.
• Arthroscopic surgery: Using small incisions and a camera, the surgeon can visualize the joint and tendon attachment from inside the elbow. This may allow faster recovery but requires specialized equipment and expertise.
• Percutaneous release: A minimally invasive technique using a small blade through a tiny incision, guided by ultrasound. This newer technique shows promising early results.

Surgical Outcomes and Recovery

Surgical success rates are approximately 80-90%, with most patients experiencing significant pain relief and improved function. However, recovery takes time. Most patients can return to light activities within 4-6 weeks, but full recovery and return to demanding work or sports may take 3-6 months or longer.

Complications are uncommon but can include infection, nerve injury, persistent pain, or recurrence of symptoms. Some patients may have residual weakness or stiffness. Setting realistic expectations before surgery is important - while most patients improve significantly, complete elimination of all symptoms is not guaranteed.

How Can You Prevent Tennis Elbow?

Preventing tennis elbow involves proper technique in sports and work activities, ergonomic workplace setup, regular strengthening exercises for forearm muscles, taking breaks during repetitive tasks, and using appropriate equipment. Warm-up before activities and gradual progression of intensity are also important preventive measures.

Prevention is particularly important for those who have recovered from tennis elbow, as recurrence is common. Understanding the factors that contributed to the initial episode helps guide preventive strategies. For many people, this means addressing workplace ergonomics, modifying sports technique, or changing how they perform daily activities.

Workplace Prevention

For those whose work involves repetitive arm movements, ergonomic modifications can significantly reduce risk. This includes:

• Proper workstation setup: Computer monitors at eye level, keyboards at elbow height, and mouse positioned close to the body
• Ergonomic tools: Tools with larger, cushioned handles reduce grip force required
• Regular breaks: Taking short breaks every 20-30 minutes to rest the forearm muscles
• Task rotation: Alternating between different activities to avoid prolonged repetitive motions
• Proper lifting technique: Lifting with palms facing up reduces stress on the lateral elbow

Sports Prevention

For tennis players and other racket sport enthusiasts, proper technique is crucial. Working with a coach to ensure correct backhand technique can significantly reduce tennis elbow risk. Equipment considerations include using a racket with appropriate grip size (too small or too large increases risk), string tension (lower tension reduces shock transmission), and racket weight (lighter rackets may increase vibration).

Adequate warm-up before playing, progressive training intensity, and regular strengthening exercises for the forearm muscles all contribute to prevention. Avoiding playing through pain is also important - early symptoms should prompt modification of activity rather than continued play.

General Prevention Strategies

• Maintain forearm strength: Regular exercises strengthen the muscles and tendons, making them more resistant to injury
• Stretch regularly: Gentle wrist and forearm stretches before and after activities maintain flexibility
• Use proper technique: Whether lifting, typing, or playing sports, good form reduces unnecessary strain
• Avoid smoking: Smoking impairs blood flow to tendons and delays healing
• Progress gradually: When starting new activities, increase intensity slowly to allow tissues to adapt

What Is the Long-Term Outlook for Tennis Elbow?

The prognosis for tennis elbow is generally good, with 80-90% of patients recovering within 1-2 years with conservative treatment. The condition is self-limiting in most cases, meaning it will eventually resolve even without treatment. However, active rehabilitation typically speeds recovery and reduces the risk of recurrence.

Tennis elbow follows a variable course, with some patients recovering within weeks while others have symptoms lasting years. On average, most patients can expect significant improvement within 6-12 months with appropriate treatment, though complete resolution may take up to 2 years. Studies following patients long-term show that the vast majority eventually achieve good outcomes.

Factors associated with slower recovery include longer duration of symptoms before treatment, higher initial pain levels, manual occupations, concurrent neck pain, and certain psychological factors like fear of movement or catastrophizing. Identifying and addressing these factors can help optimize outcomes.

Recurrence is common, particularly in those who return to the activities that caused the initial episode without modification. This emphasizes the importance of addressing underlying causes and maintaining a preventive exercise program even after symptoms resolve. Those who continue regular forearm strengthening exercises have lower rates of recurrence.

When Should You See a Doctor for Tennis Elbow?

See a doctor if elbow pain persists for more than 2-4 weeks despite rest and self-care, if pain is severe or worsening, if you have significant weakness or numbness, or if you cannot perform daily activities. Seek immediate attention for fever, redness, or swelling around the elbow, which may indicate infection.

While many cases of tennis elbow can be initially managed with self-care, certain situations warrant medical evaluation. Early diagnosis and appropriate treatment can help prevent the condition from becoming chronic and difficult to treat.

See a Healthcare Provider If:

• Pain persists beyond 2-4 weeks despite rest and activity modification
• Pain is severe enough to interfere with sleep or daily activities
• You notice significant weakness or difficulty gripping objects
• You experience numbness or tingling in your hand or fingers
• The elbow appears swollen, red, or warm to touch
• You have fever along with elbow symptoms
• Symptoms developed suddenly after an injury
• You've had tennis elbow before and want to prevent recurrence