Forehand and backhand with tennis elbow

This post was again prompted by a patient who came to see me with this problem.

Pain on the outer side of the elbow that gets worse when you pick up a cup, shake hands or lift a bag is a common reason to see a doctor. Most often it is “tennis elbow”, or lateral epicondylitis. Let us look at what it is, how to recognise it, what really helps and why you should not rush into injections.

1. What tennis elbow is

The tendons of the muscles that extend the wrist attach to the bony bump on the outer side of the elbow (the lateral epicondyle). With overload, tiny injuries appear where they attach and do not have time to heal. The tendon tissue degenerates — which is why this condition is now considered a tendinopathy rather than classic inflammation, although inflammatory substances do take part in the healing process.

There is also a “mirror” condition — golfer’s elbow, or medial epicondylitis: the tendons of the muscles that flex the wrist are affected at the inner epicondyle.

• Lateral epicondylitis develops in 1–3% of adults each year; medial epicondylitis is much rarer.
• It is most common at the age of 40–59, equally in men and women.
• Despite the name, tennis causes only about 5% of cases. The risk is raised by heavy manual work, work involving forearm rotation for more than 4 hours a day, smoking and excess weight.
• Golfer’s elbow is linked with golf, throwing sports and weightlifting.

2. What it feels like

Tennis elbow: pain and tenderness when pressing on the outer bump of the elbow. The pain gets worse when you extend the wrist against resistance, grip objects or lift something with the palm facing down. The grip may weaken.

Golfer’s elbow: pain at the inner bump of the elbow that gets worse when you flex the wrist and turn the palm down against resistance.

The two conditions can occur at the same time — they share a cause, overload.

3. How it is diagnosed

The diagnosis is mostly made on examination: the doctor finds the tender spot and checks whether movement against resistance causes pain. Scans are usually not needed.

• An X-ray is done if a fracture or osteoarthritis of the elbow is suspected.
• Ultrasound or MRI is needed if the diagnosis is unclear, the pain lasts a long time, or a torn tendon or ligament is suspected. Tendon changes on scans are also found in people without pain, so they are judged together with the examination.

Other conditions can cause similar pain, and the doctor rules them out:

• nerve compression in the upper forearm (radial tunnel syndrome) — the pain is lower, on the forearm; it can occur together with epicondylitis;
• problems in the neck — pain spreads from the neck into the arm;
• osteoarthritis of the elbow — the joint itself hurts and movement is limited;
• with pain on the inner side — irritation of the ulnar nerve (numbness of the ring and little fingers) and damage to the inner ligament of the elbow.

4. Does it go away on its own?

Yes, in most cases. Tennis elbow usually settles without treatment within 6–12 months: according to a review of studies, symptoms disappear in about 90% of patients after a year. Sometimes the pain lasts up to 2 years.

Importantly, there is no evidence that using the arm despite the pain is harmful. So complete rest is not needed.

5. What helps

No treatment has yet convincingly beaten natural recovery. But some measures ease the symptoms:

• Changing the load. Cut down on movements that cause pain, but keep using the arm.
• A forearm strap (worn just below the elbow) may reduce pain during activity.
• Therapeutic exercise — gradual strengthening of the forearm muscles (eccentric and isometric exercises). This is the basis of rehabilitation, although the quality of the studies varies.
• Non-steroidal anti-inflammatory drugs may help in the first weeks but hardly affect the long-term result. Take them as agreed with your doctor.
• Shockwave therapy may give a moderate effect, best as an addition to exercise.
• Platelet-rich plasma (PRP) — for cases where the pain does not settle for a long time. In a study with 2 years of follow-up, PRP improved arm function more than physiotherapy and shockwave therapy, but the effect appeared only later.

6. Steroid injections: use with caution

A glucocorticoid injection around the elbow relieves pain quickly — but only for a while. According to studies, a few months later patients who had an injection do worse than after other treatments or even no treatment, and the pain comes back more often. In addition, an injection can cause thinning and lightening of the skin and damage the tendon.

That is why steroid injections for epicondylitis are used with caution and are not the first step.

7. When surgery is needed

Surgery is discussed only if the pain persists for more than a year despite treatment — and it is rarely needed. For tennis elbow, surgery in studies did no better than non-surgical treatment or even a sham operation. For persistent golfer’s elbow, surgery is successful in 63–100% of cases.

8. Work and sport

Because the condition usually goes away on its own and activity does no harm, you can return to work and sport as the pain allows — without waiting for the symptoms to disappear completely. Increase the load gradually.

Disclaimer: This article is for information only and does not replace an examination by a doctor.

Sources

1. Wolf JM. Lateral Epicondylitis. New England Journal of Medicine, 2023.
2. Karjalainen TV et al. Glucocorticoid injections for lateral elbow pain. Cochrane Database of Systematic Reviews, 2022.
3. Wallis JA et al. Manual therapy and exercise for lateral elbow pain. Cochrane Database of Systematic Reviews, 2024.
4. Lian J et al. Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Extensor Carpi Radialis Brevis: A Meta-analysis of Randomized Placebo-Controlled Trials. American Journal of Sports Medicine, 2019.
5. Lhee SH, Lee KR, Lee DY. Comparing Physiotherapy, Shockwave Therapy, Prolotherapy, and Platelet-Rich Plasma for Chronic Lateral Epicondylosis: A Randomized Controlled Trial With 2-Year Follow-up. American Journal of Sports Medicine, 2025.
6. Arevalo A et al. Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review. American Journal of Sports Medicine, 2023.
7. Millar NL, Murrell GA, McInnes IB. Inflammatory mechanisms in tendinopathy — towards translation. Nature Reviews Rheumatology, 2017.