Tennis elbow
Exam Tips
- Classic viva pattern: lateral epicondyle tenderness + pain on resisted wrist extension or Maudsley test, with near-normal passive range of motion.
- Always screen red flags in OSCEs: trauma, hot swollen joint, systemic illness, progressive mass, night pain, or neurological deficit.
- Distinguish from radial tunnel syndrome: tenderness is usually more distal (near radial head), often night pain, and resisted thumb/index extension may provoke symptoms more than standard wrist extension.
- State management hierarchy clearly: education/load modification + topical/simple analgesia first, physiotherapy if not improving, avoid routine steroid injection, specialist referral only after prolonged failed conservative care.
- Mention UK medicines safety point for topical ibuprofen: flammability risk with clothing/dressings exposed to gel.
Definition
Tennis elbow (lateral epicondylitis/lateral elbow tendinopathy) is a painful overuse disorder of the common extensor tendon origin at the lateral epicondyle, most often involving extensor carpi radialis brevis. It is primarily a degenerative tendinosis rather than an acute inflammatory process, presenting with lateral elbow pain provoked by gripping and resisted wrist extension.
Pathophysiology
Repetitive mechanical loading of the forearm extensors causes micro-tearing at the common extensor origin (especially ECRB), with failed tendon healing and loss of normal tendon homeostasis. Over time this leads to angiofibroblastic change (granulation tissue, collagen disorganization, fibrosis, and tendinosis), producing pain and reduced load tolerance; true inflammatory cell infiltrate is usually limited in chronic disease. Pain is often amplified by continued high-force gripping/pronation-supination activity before tendon recovery. See Figure: common extensor tendon origin at the lateral epicondyle (elbow anatomy image).
Risk Factors
- Repetitive wrist extension and forceful gripping (manual trades, assembly-line tasks, keyboard/piano overuse)
- Use of vibrating handheld tools
- Racquet/overhead sports (minority of cases, <10%)
- Age 35-54 years
- Dominant arm use
- High baseline pain or prolonged symptoms before treatment
- Coexisting neck or shoulder pain
- Smoking and heavy alcohol use
- Recurrent episodes and ongoing repetitive manual work
Clinical Features
Symptoms
- Insidious lateral elbow pain, often burning, sometimes radiating down extensor forearm
- Pain worsened by resisted wrist extension, gripping, lifting with elbow extended, and forearm pronation/supination tasks
- Reduced grip strength and difficulty with daily tasks (cup lifting, handshake, carrying bags, shaving)
- Possible sleep disturbance from pain
Signs
- Point tenderness over or just distal to lateral epicondyle/common extensor tendon
- Pain on resisted wrist dorsiflexion (often worse when elbow is extended)
- Pain on resisted middle-finger extension (Maudsley test)
- Reduced grip strength on affected side
- Usually preserved active and passive elbow/wrist range of motion
- Typically normal sensation; negative ulnar Tinel at elbow helps exclude cubital tunnel syndrome
Investigations
Management
Lifestyle Modifications
- Explain natural history and reassure: usually self-limiting; maintain activity but modify load
- Relative rest for about 6 weeks from aggravating high-force gripping, repetitive wrist extension, and vibrating tools
- Use ice or heat for short-term symptom relief
- Consider counterforce forearm strap or wrist/elbow brace (limited evidence; may help selected patients)
- Early physiotherapy if not improving: progressive stretching/strengthening (including eccentric extensor work), manual therapy, functional rehabilitation
- Review psychosocial contributors (sleep disturbance, anxiety/depression, work factors) and support return-to-function plan
Pharmacological Treatment
Simple analgesic
- Paracetamol 500 mg-1 g orally every 4-6 hours when required (maximum 4 g in 24 hours)
First-line for pain relief; check total daily dose from all combination products and use lower maximums in frail/low-body-weight adults per local policy.
Topical NSAID
- Ibuprofen gel 5% applied thinly to painful area up to three times daily (follow product-specific maximum daily amount)
- Diclofenac gel 1.16% typically 2-4 g to affected area 3-4 times daily (maximum 16 g/day to one joint; follow product guidance)
Preferred before oral NSAID because of lower GI risk. Important UK safety advice: topical ibuprofen products are flammable; avoid smoking/naked flames and contaminated dressings/clothing.
Oral NSAID (if persistent pain despite topical/simple analgesia)
- Ibuprofen 200-400 mg orally three times daily with/after food (usual prescription maximum 2.4 g/day)
- Naproxen 250-500 mg orally twice daily
Use lowest effective dose for shortest duration. Check contraindications/interactions: prior GI ulcer/bleed, CKD, heart failure, ischaemic heart/cerebrovascular disease, uncontrolled hypertension, anticoagulants, SSRIs, corticosteroids, pregnancy (especially from 20 weeks; avoid in 3rd trimester). Consider gastroprotection (e. g, omeprazole 20 mg once daily) in higher GI-risk patients.
Corticosteroid injection
- Local corticosteroid injection (e. g, methylprednisolone acetate or triamcinolone preparations)
Not routinely recommended for tennis elbow: can give short-term benefit but worse medium-term outcomes and higher recurrence. Risks include post-injection flare, skin atrophy/hypopigmentation, transient hyperglycaemia, tendon weakening/rupture, and rare infection/nerve injury.
Surgical / Interventional
- Refer to orthopaedics if symptoms persist after 6-12 months of well-delivered conservative care and diagnosis is secure
- Surgical debridement/release of diseased common extensor origin may be considered in selected refractory cases, but evidence does not clearly show superiority over placebo surgery
- Set expectations carefully and continue postoperative rehabilitation
Complications
- Persistent pain and functional limitation affecting work/sport and mental wellbeing
- Recurrence of symptoms (including after injection treatment)
- Post-injection complications: pain flare, skin/fat atrophy, hypopigmentation, transient hyperglycaemia, tendon weakening/rupture, rare infection or nerve injury
- Surgical complications (uncommon): infection, scar discomfort, stiffness/reduced range, reduced grip strength, rare neurovascular injury
Prognosis
Overall prognosis is good: most patients improve substantially with conservative care, and around 80-90% improve within 12-24 months even without invasive treatment. Pain commonly settles over 6-12 months with structured load modification and rehabilitation, but recurrence can occur (reported around 8.5% within 2 years in one cohort). Poorer outcomes are linked to severe baseline pain, long symptom duration, dominant-arm disease, manual repetitive work, coexisting neck/shoulder pain, smoking, and heavy alcohol use.
Sources & References
✅NICE Guidelines(1)
- Tennis elbow[overview]
📖Textbook References(3)
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 724)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 817)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 481, 482)[context]