Tennis Elbow
What Is Tennis Elbow?
Tennis elbow, medically known as lateral epicondylitis, is an overuse injury that causes pain on the outside of the elbow. This condition develops when the tendons and muscles that connect the forearm to the outer part of the elbow become inflamed or develop small tears from repetitive stress. Despite its common name, tennis elbow is not limited to tennis players—it affects more than 200,000 people in the United States each year across all demographics and occupations. The condition results from repetitive contraction of the forearm muscles used to straighten the hand and wrist or to lift with the palm facing down, movements that generate significant stress where the extensor tendons attach to the lateral epicondyle (the bony prominence on the outside of the elbow).
The name "tennis elbow" arose because the injury is common in racquet sports, particularly among players who use improper backhand technique. When executing a backhand stroke in tennis, the wrist extensors and forearm muscles must work forcefully to stabilize and control the wrist against the impact of the ball. Repeated backhands, especially with poor technique or using a racquet that's too heavy or has improper grip size, places enormous stress on the extensor tendons. However, tennis players represent only a small fraction of people who develop this condition. Any repetitive activity that involves twisting of the wrist, gripping, or lifting can cause tennis elbow.
Common occupational causes include extensive computer mouse use, where repetitive wrist extension stresses the extensor tendons. Carpenters, plumbers, painters, and other tradespeople who frequently use hand tools are at increased risk. Assembly line workers performing repetitive motions develop the condition frequently. Chefs and butchers who repeatedly use knives and other kitchen tools may be affected. Gardeners who engage in repetitive pruning or raking can develop symptoms. Even musicians, particularly violinists and pianists, can develop tennis elbow from the repetitive motions required to play their instruments. The key factor is not the specific activity but rather the repetitive nature of wrist and forearm movements, particularly those involving gripping combined with wrist extension.
Women and men are equally affected by tennis elbow, though the condition is most common in people aged 30 to 50 years. This age range corresponds to peak working years when people are most likely to be performing repetitive occupational tasks. The dominant arm is typically affected, though bilateral symptoms can occur in people whose activities involve both arms equally. A similar condition called golfer's elbow (medial epicondylitis) affects the inside of the elbow and results from repetitive wrist flexion motions. While related, these are distinct conditions affecting different muscle groups and tendon attachment sites.
The pain of tennis elbow typically develops gradually over time rather than appearing suddenly. Initially, patients may notice mild discomfort on the outside of the elbow after intense activity. As the condition progresses, pain becomes more persistent and may occur even during routine daily activities. The pain is localized to the lateral epicondyle and surrounding area, and patients can often pinpoint the exact site of maximum tenderness. The discomfort characteristically increases with activities that involve gripping, lifting, or wrist extension. Simple tasks that were previously effortless become painful—opening jars, turning doorknobs, shaking hands, or lifting a coffee cup can all provoke sharp pain. Weakness in grip strength develops, causing people to drop objects unexpectedly. Some patients experience pain radiating down the forearm toward the wrist. If the condition has become severe, pain may extend throughout the forearm and can even be present at rest or at night, interfering with sleep.
Nonsurgical Treatments
The vast majority of tennis elbow cases—approximately 80 to 95 percent—resolve with conservative treatment. Our doctors offer comprehensive nonsurgical approaches to promote healing and restore function.
Lifestyle Modifications
The foundation of tennis elbow treatment is modifying or temporarily stopping the activity causing the pain. This allows the damaged tendons to heal. Complete rest from aggravating activities is ideal, though this may not always be practical for occupational injuries. When work modifications are possible, alternating tasks, taking frequent breaks, and using ergonomic tools can reduce tendon stress while allowing continued work. For recreational athletes, taking several weeks off from tennis or other racquet sports gives tendons time to recover. When returning to activity, proper technique is essential. Tennis players should work with a coach to ensure proper backhand form, use an appropriately sized and weighted racquet, and avoid playing with wet or heavy balls. Learning proper body mechanics for occupational tasks—keeping wrists in neutral positions, avoiding repetitive twisting motions, and using larger muscle groups rather than just wrist and forearm muscles—helps prevent recurrence.
Medications & Injections
Initial treatment should include the RICE protocol—rest, ice, compression, and elevation of the elbow. Ice application for 15 to 20 minutes several times daily helps reduce inflammation and pain. Over-the-counter medications such as ibuprofen or naproxen can relieve pain and reduce inflammation. However, it's important to consult with a pharmacist or doctor before using anti-inflammatories, as these medications may be contraindicated or may interact with other medications and medical conditions. Topical anti-inflammatory gels applied directly to the painful area can provide relief with fewer systemic side effects than oral medications. In severe or long-lasting cases, an injection of corticosteroid medication directly into the affected area may provide significant relief. Corticosteroid injections can dramatically reduce pain and inflammation, though benefits are typically temporary. Multiple injections should be avoided as they can potentially weaken tendon tissue and increase rupture risk. Platelet-rich plasma (PRP) injections, which use the patient's own concentrated blood platelets to stimulate healing, are sometimes used for chronic cases, though evidence for effectiveness is mixed.
Physical & Occupational Therapy
After a few weeks of initial rest and pain control, exercise and stretching to strengthen the muscles and improve flexibility are essential to prevent tennis elbow symptoms from returning. Physical therapy is a cornerstone of treatment. A therapist designs a progressive exercise program starting with gentle stretching of the wrist extensors and forearm muscles to improve flexibility. As inflammation subsides, strengthening exercises gradually rebuild tendon and muscle strength. Eccentric strengthening exercises—where the muscle lengthens under load—have been shown to be particularly effective for tendon healing. These exercises might involve slowly lowering a weight held in the hand with the wrist extended. Strengthening exercises progress from isometric (no movement) to concentric (muscle shortening) to eccentric (muscle lengthening) phases. Manual therapy techniques including soft-tissue mobilization, deep friction massage, and joint mobilization can improve tissue quality and reduce pain. A therapist also educates patients on proper techniques for activities and provides exercises that can be continued at home for long-term management.
Supportive & Assistive Devices
Wearing a counterforce brace or strap on the forearm just below the elbow can significantly reduce pain during activities. These braces work by distributing the forces across a broader area rather than concentrating stress at the tendon attachment point. The brace should be worn during activities that typically provoke symptoms. A wrist splint worn at night maintains the wrist in a neutral position, preventing the unconscious wrist positions during sleep that can aggravate symptoms. Some patients benefit from ergonomic modifications to work tools—padded handles, tools with larger grips that require less gripping force, and power tools that reduce manual force requirements can all help. Proper tennis equipment including an appropriately sized racquet with proper string tension and grip size is essential for tennis players returning to sport.
Surgical Treatments
Surgery for tennis elbow is rarely necessary and is only considered after 6 to 12 months of diligent conservative treatment has failed to provide adequate relief. Surgical success rates are high when patients are properly selected.
Lateral Epicondylitis Release (Debridement & Repair)
The surgical procedure for tennis elbow involves removing the diseased portion of the extensor tendon and repairing the remaining healthy tendon. The surgery can be performed through an open incision or arthroscopically using small incisions and a camera. During open surgery, the surgeon makes an incision over the lateral epicondyle, identifies the affected extensor carpi radialis brevis tendon (the tendon most commonly involved in tennis elbow), and removes the damaged, degenerative tissue. The diseased tendon appears grayish and friable rather than healthy white and firm. After debriding the damaged tissue, the remaining healthy tendon is repaired and reattached to the bone. Small holes may be drilled in the bone to encourage healing and blood flow. The surgeon also examines other tendons and removes any bone spurs if present.
Arthroscopic Tennis Elbow Release
Some surgeons perform tennis elbow surgery arthroscopically using small incisions and a miniature camera. This approach potentially offers less tissue trauma, smaller scars, and faster recovery. The camera allows visualization of the joint and lateral epicondyle region. Using small instruments, the surgeon can debride damaged tendon tissue and stimulate healing. However, not all cases are suitable for arthroscopic treatment, and the open technique remains the gold standard.
Recovery from tennis elbow surgery requires patience and dedicated rehabilitation. The arm is typically immobilized in a splint for one to two weeks. Gentle range of motion exercises begin early to prevent stiffness. Strengthening exercises begin after about six weeks once healing is progressing. Most patients can return to light activities by three months and full activities including sports by four to six months post-surgery. Physical therapy is essential during recovery to restore strength, flexibility, and proper movement patterns. Success rates for tennis elbow surgery are generally good, with 75 to 90 percent of patients reporting significant improvement. However, there is still a risk of recurrence if patients return to the same activities that caused the original injury without making appropriate modifications.
Prevention of tennis elbow recurrence is crucial once symptoms have resolved. This involves maintaining the strength and flexibility gains achieved during rehabilitation through continued home exercises. Using proper technique during sports and occupational activities reduces tendon stress. Taking regular breaks during repetitive activities allows tendons to recover. Using appropriate equipment, whether sports gear or work tools, minimizes unnecessary stress. Gradually increasing the intensity and duration of new activities rather than making sudden changes helps prevent overuse injuries. Paying attention to early warning signs of pain and addressing them promptly can prevent minor irritation from progressing to chronic tendinopathy.