Tennis Elbow

The elbow joint is formed by the humerus (upper arm bone) with the radius and ulna (forearm bones). On the outer side of the elbow, several tendons attach to a small bony prominence at the end of the humerus called the lateral epicondyle. These tendons anchor the extensor muscles, which extend the wrist and fingers.

With repetitive activity—such as gripping, typing, or lifting objects with the palm facing downward—these tendons can become overloaded. Tiny micro-tears form at the tendon’s attachment site, leading to pain, inflammation, and, eventually, degenerative changes called tendinosis.

Lateral epicondylitis affects approximately 1–3% of adults each year, typically between ages 35 and 55.

Although athletes are susceptible, most cases occur in non-athletes—including carpenters, mechanics, plumbers, musicians, office workers, and healthcare professionals who use their hands repetitively.

Risk factors include:

• Repetitive or forceful wrist extension or gripping
• Poor lifting mechanics or heavy tool use
• Weak shoulder or forearm muscles
• Improper tennis or pickleball technique
• Smoking or metabolic conditions (diabetes, obesity) that slow tendon healing

Common symptoms include:

• Pain or burning on the outer side of the elbow, sometimes radiating into the forearm.
• Tenderness directly over the lateral epicondyle.
• Weak grip strength or pain when shaking hands, turning a doorknob, or lifting objects.
• Stiffness or aching, especially in the morning or after activity.
• Pain with resisted wrist extension (lifting the back of the hand against resistance).

Symptoms typically develop gradually and worsen over weeks or months.

Diagnosis begins with a detailed history and physical examination by Dr. José Vega, Cleveland’s trusted orthopedic sports-medicine specialist.

During your visit, Dr. Vega will evaluate pain location, activity history, and functional limitations.

Physical exam findings often include:

• Point tenderness at the lateral epicondyle.
• Pain with resisted wrist extension or finger extension.
• Normal elbow motion but discomfort with gripping or lifting.

Imaging tests may include:

• X-rays, to rule out arthritis or bone spurs.
• Ultrasound, to visualize tendon thickening or partial tears.
• MRI, if symptoms persist and surgery is being considered or if another diagnosis is suspected.

Most patients recover fully with nonsurgical care, though improvement can take several months.

Nonsurgical Treatment

• Activity modification: Avoid or limit painful gripping, lifting with the palm down, or repetitive wrist extension.
• Bracing: A counterforce strap or forearm band can reduce stress on the tendon during activity, and a supportive wrist brace to be worn at night can help to offload the injured tendon
• Physical therapy:
  • Focuses on stretching the wrist extensors, eccentric strengthening, and improving shoulder and scapular control.
  • Manual therapy and dry needling may help reduce pain and promote healing.
• Anti-inflammatory medications (NSAIDs): Used short-term to relieve pain.
• Ice therapy: Apply 15–20 minutes several times daily after activity.
• Injections:
  • Corticosteroid injections may relieve acute pain but are used sparingly due to evidence that they do not provide long lasting relief.
  • Platelet-rich plasma (PRP) injections are a biologic alternative that promote natural healing through growth factors and have been shown to yield better results than corticosteroid injections.
• Shockwave therapy or ultrasound-guided tenotomy may be recommended for chronic, resistant cases.

With proper rehabilitation, 80–90% of patients experience major improvement within 3–6 months.

Surgical Treatment

Surgery is considered when pain persists for 6–12 months despite comprehensive nonsurgical care.

Surgical goals: remove degenerated tendon tissue, stimulate healing, and reattach healthy tendon to bone.

Procedure Overview

• Performed through a small open or arthroscopic incision.
• Diseased tissue from the extensor carpi radialis brevis (ECRB) is excised.
• The healthy tendon is reattached to the lateral epicondyle.
• Outpatient procedure, typically under regional or general anesthesia.

Recovery

• A soft brace or splint is worn briefly for comfort.
• Gentle range-of-motion begins within days.
• Progressive strengthening at 6–8 weeks.
• Return to full activity and sport in 3–4 months.

Surgical success rates exceed 90%, with most patients achieving complete pain relief and restored function.