Lateral epicondylitis, commonly known as tennis elbow, is one of the most prevalent causes of elbow pain in patients who frequently use their wrist and forearm (Fig. 1). Three bones—the humerus, radius, and ulna—come together to form your elbow joint. Tendons (tissues connecting muscle to bone) of the wrist and forearm attach at 2 primary sites, the medial (inside) and lateral (outside) epicondyles, which are bony prominences at the sides of your elbows. Tennis elbow occurs when the tendons that attach to the lateral epicondyle become inflamed due to repetitive forearm and wrist movements, leading to pain over the outside portion of the elbow.
As the name suggests, up to 50% of all tennis players experience this condition at some point during their athletic career.¹ However, it can also occur in other popular sports, like pickleball and golf, where athletes frequently use the muscles of the forearm and wrist. Furthermore, tennis elbow also affects individuals who perform repetitive hand movements, such as swinging a hammer, using a paintbrush, and even cooking.
Causes and risk factors
Tennis elbow results from the overuse of wrist and forearm muscles, leading to irritation of the tendons attached to the lateral epicondyle. The most commonly affected tendon is the extensor carpi radialis brevis, which extends from the lateral epicondyle to the wrist. The tendon helps to extend and stabilize the wrist and elbow, but repetitive motion can cause deterioration and micro tears, resulting in pain.
The condition affects both males and females equally, with most cases arising in people aged 30 to 50, although it can develop at any age. Improper form or inadequate equipment, such as using a tennis racket that is too heavy or that has an incorrect grip size, can lead to overuse of the extensor carpi radialis brevis muscle, and results in tendon irritation. Additionally, individuals who work in jobs requiring vigorous use of their wrist and forearm, such as carpenters who frequently use heavy tools such as hammers, are at a higher risk of developing this condition (Fig. 2). Other contributing factors include engaging in repetitive activities without proper rest or inadequate warm-up, smoking, and obesity.
Symptoms and diagnosis
Because tennis elbow stems from overuse and gradual irritation of the tendons, symptoms typically develop gradually over weeks to months. Patients cannot usually pinpoint a specific injury; instead, the pain begins mildly and worsens as the continuous movement irritates the tendons during everyday activities. Common symptoms can include discomfort while holding a coffee mug, shaking hands, turning a doorknob, or lifting objects. Patients may also experience weakness in grip strength and pain that radiates from the outside of their elbow into the forearm.
An orthopaedist can often diagnosis the condition after taking the patient’s medical history and completing a physical exam of the forearm, wrist, and elbow. Healthcare providers often ask about the onset of symptoms, including whether it developed acutely or gradually, and if there are any relevant physical activities or occupational hazards. During the physical exam, providers will apply pressure to the lateral epicondyle to check for pain and may perform specific tests such as the Cozen’s test (resisted wrist extension) or Mill’s test (passive wrist flexion with elbow extended) to check for pain. They may also test for diminished grip strength.
Imaging tests such as x-rays (Fig. 3), ultrasound, or magnetic resonance imaging (MRI, an image that shows the bones, muscles, tendons, and ligaments) can help rule out other conditions, such as arthritis, and confirm the diagnosis of lateral epicondylitis by showing changes in the tendons.
Treatment
Since tennis elbow is primarily a mechanically induced condition, conservative treatments are often effective. With tennis elbow, there is a wide spectrum of severity ranging from slight tenderness to severe, continuous pain. However, the pain is often exacerbated by resisted extension of the middle finger and extension of the wrist. Tennis elbow typically resolves with conservative treatment in 85% to 95% of cases. Initial approaches include lifestyle modifications such as rest and icing for 15 minutes, 4 times a day. Over-the-counter pain relievers, such as ibuprofen (Advil) or acetaminophen (Tylenol), can provide additional relief. Patients may also use counterforce braces, which wrap around the forearm and help to relieve stress on the affected tendon by distributing the force to other muscles and tendons. Some patients have tried nonconventional modalities such as Botox, lasers, and acupuncture; although they may provide some pain relief, the medical literature does not support them as proven long-term treatments.
Another effective treatment, physical therapy focuses on strengthening the forearm muscles to reduce stress on the affected tendon (Fig. 4). If these treatments are not effective, platelet-rich plasma (PRP) injections, a nonsurgical procedure that uses a patient’s own blood to promote healing, may help reduce inflammation in the affected region.
If conservative treatment fails, surgery may be considered. Surgical options typically involve removing the portion of damaged tendon and reattaching the remaining healthy tendon to the bone. As with any surgery, there are potential risks, including infection, stiffness, nerve damage, and prolonged healing. However, surgery is uncommon since most patients heal without surgical intervention.
Prevention
You can prevent tennis elbow by avoiding overusing your arm and elbow and by paying attention to what your body tells you. If you have pain, it means something has happened or may be happening. If you experience pain, give your arm time to rest and recover. You should stretch and warm-up before playing a sport or after activity. Do sport-specific exercises that help prepare you and keep your muscles in shape for the game. Complete a cool down stretch as well. If you start to experience pain, check out your equipment. Wear the right protective equipment for your sport and work activities. Do not use equipment that is too heavy or does not fit your hands. Make sure your equipment and tools fit you.
Author: Stephen Durkee, BS | Columbus, GA
Reference
- Cutts, S., Shafat Gangoo, Nitin Modi, and Chandra Pasapula. “Tennis Elbow: A Clinical Review Article.” Journal of Orthopaedics 17 (January 1, 2020): 203–7. https://doi.org/10.1016/j.jor.2019.08.005.
Last edited on March 7, 2025