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Degenerative Condition

Tennis Elbow

Lateral Epicondylitis

Expert information on diagnosis, treatment, and recovery from lateral epicondylitis

Understanding Tennis Elbow

Tennis elbow is one of the most common causes of elbow pain, affecting 1-3% of the general population, with peak incidence between ages 35-50. Despite its name, only about 5% of cases are related to tennis.

Epidemiology

  • • Prevalence: 1-3% of general population
  • • Peak age: 35-50 years
  • • Equal gender distribution (slight male predominance)
  • • Dominant arm affected in 75% of cases
  • • Bilateral involvement in 5-10% of cases

The condition results from angiofibroblastic degeneration (not inflammation) of the extensor carpi radialis brevis (ECRB) tendon origin at the lateral epicondyle. This is caused by repetitive microtrauma that exceeds the tissue's ability to heal.

Nirschl Classification

Stage 1: Inflammatory
Acute inflammatory changes without pathological alterations. Reversible with rest.
Stage 2: Angiofibroblastic
Pathological changes in tendon (most common presentation). Gray, friable tissue.
Stage 3: Structural Failure
Partial or complete tendon rupture with angiofibroblastic changes.
Stage 4: Fibrosis/Calcification
End-stage with fibrosis, soft calcium deposits, and hard calcific deposits.

Symptoms & Diagnosis

Common Symptoms

Pain over lateral epicondyle (outer elbow)
Pain worsens with gripping activities
Weakness in grip strength
Pain when lifting objects palm-down
Tenderness 1-2 cm distal to lateral epicondyle
Pain with resisted wrist/finger extension

Clinical Tests

Cozen's Test

Resisted wrist extension with elbow extended

Mill's Test

Pain with passive wrist flexion and forearm pronation

Maudsley's Test

Resisted middle finger extension

Treatment Options

90% of tennis elbow cases resolve with conservative treatment

Conservative Treatment (First Line)

Activity Modification

Avoid aggravating activities, ergonomic adjustments, proper lifting technique

Counterforce Bracing

Tennis elbow strap worn 2-3 cm distal to lateral epicondyle reduces strain on ECRB origin

Eccentric Exercises (Tyler Twist)

Gold standard rehabilitation - progressive eccentric wrist extension strengthening using FlexBar

Physical Therapy

Deep friction massage, stretching, ultrasound, and manual therapy

Injection Therapies

Corticosteroid Injections

Short-term relief but poorer long-term outcomes vs physiotherapy. Use sparingly.

PRP (Platelet-Rich Plasma)

Emerging evidence shows benefit in chronic cases. May promote tendon healing.

Autologous Blood Injection

Similar concept to PRP, introduces growth factors to promote healing.

Surgical Treatment

Reserved for cases failing 6-12 months of conservative treatment (10% of patients)

Nirschl Debridement (Open)

Excision of angiofibroblastic tissue from ECRB origin. 85-90% success rate.

Arthroscopic Release

Minimally invasive debridement and release. Faster recovery, similar outcomes.

TENEX/Percutaneous Tenotomy

Ultrasound-guided minimally invasive debridement using specialized device.

Evidence & References

• Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. JBJS 1979

• Coonrad RW, Hooper WR. Tennis elbow: its course, natural history, conservative and surgical management. JBJS 1973

• Bisset L, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow. BMJ 2006

• Tyler TF, et al. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis. JOSPT 2010

Last Updated: January 2025 | Content reviewed by Dr. Deepthi Nandan Reddy, FRCS (Ortho)

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