Tennis Elbow: Symptoms and Treatment
Symptoms
Tennis elbow (lateral epicondylitis) presents with lateral elbow pain during twisting and gripping activities, with tenderness at the lateral epicondyle that worsens with stress testing of the forearm extensors. 1
Key clinical features include:
- Pain localized to the lateral epicondyle that radiates down the forearm 1
- Pain provoked by resisted wrist extension - the primary diagnostic maneuver 2, 1
- Tenderness on palpation at the origin of the extensor muscle mass 1
- Pain with gripping activities such as shaking hands, turning doorknobs, or lifting objects 1
- Decreased grip strength in the affected arm 3
The diagnosis is primarily clinical, based on history and physical examination findings, without requiring advanced imaging in most cases 2, 4.
Initial Diagnostic Approach
Plain radiographs of the elbow are the most appropriate initial imaging study to rule out other causes of elbow pain such as fractures or arthritis 2, 5, 4.
- MRI or ultrasound should be reserved for cases where radiographs are normal but there is clinical suspicion of significant tendon degeneration or tear 2, 4
- Ultrasound and MRI are equivalent alternatives for assessing suspected tendon injury when radiographs are indeterminate 6
Treatment Algorithm
First-Line Conservative Treatment (Months 0-3)
The American Academy of Family Physicians recommends that approximately 80% of patients recover completely within 3-6 months with conservative treatment alone, making this the mandatory first approach 2.
Relative rest and activity modification to reduce repetitive strain on the damaged tendon 2, 4
Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength 2, 4, 3
Cryotherapy (ice application) for 10-minute periods provides acute pain relief 2, 4
NSAIDs can provide short-term pain relief, though they do not affect long-term outcomes 2, 4
Counterforce bracing/orthoses can reduce tension on the tendon origin 2
Stretching exercises for the wrist extensors should be incorporated 2
Deep transverse friction massage can reduce pain 2, 4
Progressive Rehabilitation Protocol
Intermediate phase (2-6 weeks): Progressive eccentric strengthening exercises of wrist extensors 5
Advanced phase (6+ weeks): Progressive loading to promote tendon healing and collagen fiber alignment 5
Second-Line Options (If Conservative Treatment Fails After 3-6 Months)
Corticosteroid injections provide short-term pain relief and are more effective than NSAIDs in the acute phase, but they do not change long-term outcomes and may inhibit healing 4. Use cautiously as they can reduce tendon strength long-term 5.
Manual joint mobilization combined with exercise therapy is more effective than exercise therapy alone 2
Adjunctive modalities such as ultrasound therapy, heat application (paraffin, warm compresses), and laser therapy may provide additional benefit 2, 3
Critical Considerations About Surgery
Surgery should not be first-line treatment despite good clinical outcomes, because many patients respond well to conservative treatment and surgery carries potential complications 2.
New evidence challenges traditional surgical indications: There is a 50% probability of recovery every 3-4 months regardless of symptom duration, and no evidence supports surgery's superiority over continued nonoperative care 7. The duration of symptoms alone should not be used as an indication for surgery 7.
Common Pitfalls to Avoid
Do not misdiagnose this as primarily inflammatory - tennis elbow is a degenerative tendinopathy, not an inflammatory condition, which affects treatment selection 5
Avoid over-reliance on corticosteroid injections - while they provide short-term relief, they can inhibit healing and reduce tendon strength long-term 5
Address biomechanical factors such as improper technique or equipment issues that contributed to the initial injury to prevent recurrence 5
Do not rush to surgery - the condition is self-limiting in most patients, and prognosis is not influenced by symptom duration 7