What Is Tennis Elbow? Symptoms, Causes, And Treatments

Tennis elbow, or lateral epicondylitis, is a prevalent tendinopathy affecting 1-3% of the general population, with a peak incidence among adults aged 35 to 55, particularly women in their fourth and fifth decades [1]. It manifests as pain and tenderness on the outer elbow due to overuse of the extensor carpi radialis brevis (ECRB) tendon, resulting in microtrauma and degeneration [2]. While historically considered an inflammatory condition, recent research highlights angiofibroblastic hyperplasia—a degenerative process with disorganized collagen and increased vascularity—rather than acute inflammation [3]. Symptoms include pain during wrist extension and gripping, impacting daily tasks like lifting or typing. Causes range from repetitive sports movements to occupational strains, and treatments span conservative measures like rest and physical therapy to advanced interventions such as injections or surgery. Most cases resolve within a year with proper management, but chronic cases may require more intensive approaches to restore function [4].

What Is Tennis Elbow?

Tennis elbow is a degenerative condition of the common extensor tendon, primarily the ECRB, at its insertion on the lateral epicondyle [5]. It results from repetitive eccentric loading, causing microtears and tendon weakening [6]. The condition affects middle-aged individuals most frequently, with up to 30% experiencing bilateral symptoms [7]. Pathologically, it involves mucoid degeneration, neovascularization, and fibroblast proliferation, with minimal inflammatory cells, shifting treatment focus to tendon remodeling [8]. Although self-limiting in many cases, persistent symptoms can lead to chronic pain and reduced grip strength, significantly affecting quality of life [9]. Early recognition through clinical evaluation is critical to initiate timely interventions, preventing progression to chronicity and minimizing the need for invasive treatments.

Common Causes Of Tennis Elbow

Tennis elbow causes are rooted in repetitive microtrauma from activities involving wrist extension, gripping, or forearm rotation. In sports, particularly tennis, improper backhand technique, heavy racquets, or high string tension contribute, with up to 50% of tennis players affected [10]. Occupational tasks like plumbing, carpentry, or assembly work, which involve prolonged forearm rotation or high strain, significantly increase risk [11]. The ECRB tendon’s anatomic vulnerability, abutting the capitellum, exacerbates degeneration during repetitive movements [12]. Biomechanical factors, such as weak shoulder stabilizers or scapular dyskinesis, transfer excessive load to the elbow [13]. Age-related tendon changes, smoking, obesity, and comorbidities like rheumatoid arthritis heighten susceptibility [14]. Unlike earlier assumptions, the condition is primarily degenerative, with repetitive overuse leading to failed reparative responses rather than sustained inflammation [15]. Identifying these causes guides targeted interventions, such as ergonomic adjustments and technique correction, to mitigate risk.

Symptoms Of Tennis Elbow

Tennis elbow symptoms typically develop gradually, starting with mild discomfort and progressing to severe pain that hinders daily activities. The hallmark is pain over the lateral epicondyle, often described as burning or aching, exacerbated by wrist extension or gripping tasks like turning doorknobs or shaking hands [16]. Grip weakness is common, making it difficult to hold objects securely, while morning stiffness or rest pain may occur in advanced cases [17]. Some patients report numbness or tingling in the fingers due to radial nerve irritation, particularly in chronic cases [18]. Symptoms can persist for weeks to months if untreated, impacting work productivity and quality of life, underscoring the need for early intervention to manage tennis elbow pain effectively.

Pain And Tenderness On The Outer Elbow

The primary symptom is localized pain and tenderness over the lateral epicondyle, reproducible on palpation or during resisted wrist extension [19]. This pain may radiate distally along the forearm or proximally toward the shoulder, often intensifying with activity and, in chronic cases, becoming constant [20]. The tenderness can disrupt sleep and simple tasks like brushing teeth, highlighting the importance of prompt tennis elbow treatment to alleviate discomfort and restore function.

Diagnosis Of Tennis Elbow

Diagnosis begins with a detailed history of repetitive activities and physical examination, focusing on tests like Cozen’s (resisted wrist extension) and Maudsley’s (resisted middle finger extension), which elicit pain at the lateral epicondyle [21]. Imaging, such as ultrasound, reveals tendon thickening, hypoechoic areas, or tears, while MRI excludes differentials like osteochondral lesions or ligament injuries [22]. Electromyography may be used if nerve involvement is suspected, distinguishing tennis elbow from radial tunnel syndrome or cervical radiculopathy [23]. Accurate diagnosis ensures appropriate treatment selection, optimizing outcomes and preventing unnecessary interventions.

Types Of Tennis Elbow Conditions

Tennis elbow is classified by duration and severity, influencing treatment approaches.

Acute Tennis Elbow

Acute tennis elbow arises suddenly after intense activity or injury, presenting with sharp pain and inflammation lasting up to six weeks [24]. It responds well to rest, ice, and anti-inflammatory measures, with early intervention preventing progression to chronicity [25].

Chronic Tennis Elbow

Chronic tennis elbow, persisting beyond three months, affects up to 20% of cases and involves tendon degeneration with persistent pain and reduced function [26]. It often requires advanced therapies like injections or surgery due to failed conservative management [27].

Treatment Options For Tennis Elbow

Over 90% of tennis elbow cases resolve with non-surgical treatments, following a stepwise approach from conservative to invasive options [28].

Non-Surgical Treatments

Initial management includes rest, activity modification, and non-steroidal anti-inflammatory drugs (NSAIDs) to manage pain [29]. Tennis elbow braces, such as counterforce straps, reduce tendon strain by redistributing load, with studies showing improved grip strength [30]. Physical therapy for tennis elbow, emphasizing eccentric exercises, promotes tendon remodeling and pain reduction [31]. Adjunct therapies like acupuncture or topical nitrates offer short-term relief, enhancing patient comfort during recovery [32].

Minimally Invasive Treatments

For persistent symptoms, corticosteroid injections provide short-term pain relief but risk tendon weakening with repeated use [33]. Platelet-rich plasma (PRP) injections, leveraging growth factors, show superior long-term outcomes in chronic cases, with improved pain scores and function [34]. Extracorporeal shock wave therapy (ESWT) stimulates healing, reducing pain in recalcitrant cases [35]. Botulinum toxin injections temporarily paralyze overactive muscles, aiding recovery [36]. These options balance efficacy and minimal invasiveness, bridging conservative and surgical approaches.

Surgical Treatments (Tendon Repair, Arthroscopy)

Surgery is reserved for 5-10% of cases failing conservative care after 6-12 months [37]. Open procedures, like the modified Nirschl technique, involve debriding degenerated tissue and reattaching healthy tendon, with studies reporting significant pain reduction (VAS from 4.9 to 1.1) and functional improvement (MAYO score from 64 to 90) [38]. Arthroscopic techniques, using small incisions, minimize tissue damage and accelerate recovery, with over 90% success rates [39]. Tennis elbow surgery restores tendon integrity, enabling return to work within 2-3 months for most patients [40].

Exercises And Rehabilitation For Tennis Elbow

Rehabilitation is critical for recovery, focusing on progressive loading to restore tendon strength and flexibility.

Stretching Exercises

Stretching exercises target wrist extensors, with a common technique involving arm extension and downward wrist flexion held for 30 seconds, repeated 3-5 times daily [41]. These stretches reduce stiffness and prepare tendons for strengthening, improving flexibility and reducing pain recurrence [42].

Strengthening Exercises

Eccentric exercises, such as the Tyler twist using a flexible bar, involve slow wrist extension against resistance, performed in sets of 10-15 reps [43]. These exercises significantly reduce pain (SMD -0.63) and improve strength compared to concentric routines [44]. Progressive resistance programs, including TheraBand or plyometric exercises, enhance tendon resilience, with manual therapy augmenting outcomes [45].

Ergonomic Adjustments And Technique Improvement

Ergonomic modifications, like using larger grips or padded handles, minimize tendon strain in sports and work settings [46]. In tennis, refining backhand technique or adopting a two-handed grip reduces stress [47]. Workplace adjustments, such as adjustable desks or frequent breaks, support recovery and prevent flares, ensuring long-term rehabilitation success [48].

Preventing Tennis Elbow

Prevention focuses on reducing risk through education, technique correction, and proactive measures.

Proper Sports Techniques And Equipment

Correct sports techniques, like two-handed backhands or proper grip sizes, and equipment with vibration-dampening features minimize tendon overload [49]. Gradual warm-ups and avoiding sudden intensity increases are critical for athletes [50].

Workplace Ergonomics

Limiting forearm rotation to under 4 hours daily and using ergonomic tools reduce strain indices in occupational settings [51]. Adjustable workstations and task rotation prevent repetitive stress, lowering incidence [52].

Regular Stretching And Strengthening

Daily stretching and eccentric strengthening routines maintain tendon health, particularly in high-risk groups [53]. Prophylactic exercises and early symptom awareness reduce the likelihood of developing tennis elbow, promoting long-term elbow health [54].

Tennis elbow, while challenging, is manageable with a structured approach encompassing early diagnosis, tailored treatments, and preventive strategies. From conservative measures like tennis elbow braces and physical therapy to advanced options like PRP or surgery, effective solutions exist for all stages. Rehabilitation through targeted exercises and ergonomic adjustments ensures recovery and minimizes recurrence. Consult a specialist like Dr. Ömer Bozduman for personalized care to address tennis elbow symptoms and restore full function. 

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