Tennis Elbow

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Tennis Elbow

Tennis Elbow
Mark Clough MD
  • Lateral epicondylitis (tennis elbow) is a tendinopathy of the origin of the ECRB tendon.
  • The lateral epicondyle is the origin of the common wrist extensor tendon, including:
    • ECRL
    • ECRB
    • Extensor digitorum communis
    • Extensor carpi ulnaris
  • The ECRB lies beneath the ECRL.
  • These extensors stabilize the wrist and are used in sports (such as tennis) during a backhand stroke.
  • Lateral epicondylitis typically occurs from overuse in the nonathlete’s dominant arm during the 4th and 5th decades.
General Prevention
Use of good form while playing tennis (i.e., proper grip size, backhand technique)
Occurs equally in males and females
The peak incidence is in the 5th decade (1).
Risk Factors
  • Patients are susceptible with activities
    of repetitive supination and pronation of the forearm in which the
    elbow is near full extension (such as in tennis).
  • Although tennis elbow is its common name,
    lateral epicondylitis can be seen in other racket sports, fencing, and
    certain occupations with repetitive actions (e.g., plumbing, painting,
    knitting, and dentistry).
  • Associations have been made to poor stroke mechanics, improper racket grip size, racket weight, and racket stringing.
  • Harder playing surfaces produce more
    force on the ball and therefore create greater transmitted forces to
    the lateral epicondyle.
  • Initiated as a microtear within the origin of ECRB.
  • The ECRL and extensor digitorum communis also are susceptible.
  • Insufficient healing response leaves the ECRB origin vulnerable to secondary injury.
Signs and Symptoms
  • Patients usually have a history of repetitive activity.
  • Pain is present at the lateral epicondyle with resisted wrist extension that is made worse when the elbow is extended.
  • Symptoms are exacerbated with activity and improve with rest.
  • Patients report pain with grasping objects.
  • Elbow ROM usually is not compromised.
Physical Exam
  • Tenderness over the origin of the common wrist extensor tendons at the lateral epicondyle
  • Tenderness may extend distally.
  • Reproduction of pain with passive flexion of the wrist with the elbow extended
  • The clinician should check for radial
    tunnel syndrome, in which pain is reproduced with active middle finger
    extension against resistance.
  • A cervical spine examination is warranted for all patients, especially if symptoms are bilateral.
  • Radiographs:
    • AP and lateral radiographs of the elbow are obtained to rule out fractures or other lesions in the elbow.
    • AP and lateral plain radiographs usually are negative, but 23% of patients may show calcifications in the local soft tissue (2).
    • Consider cervical spine radiographs if symptoms possibly originate from the neck.
  • CT may be warranted for detailed evaluation of the joint in cases of a loose body or arthritis.
  • MRI usually is not necessary, but it may show tendon thickening with increased T1 and T2 signals.
Diagnostic Procedures/Surgery
Electromyography may be helpful in distinguishing radial tunnel syndrome from lateral epicondylitis (see “Differential Diagnosis”).
Pathological Findings
  • Microscopic tears within the substance of the ECRB
  • Histology shows replacement of tendon
    collagen fibers with vascular granulation-like tissue and fibroblasts,
    termed “angioblastic proliferation.”
Differential Diagnosis
  • Differential diagnosis includes cervical spine disease with radiculopathy.
  • Radial tunnel syndrome (5% coexistence
    reported, compression of posterior interosseous nerve as it enters the
    supinator muscle) (3)
  • Olecranon bursitis
  • Medial epicondylitis
  • UCL strain/sprain
  • Intra-articular disease, such as arthritis, osteochondritis dissecans of the capitellum, or loose body
General Measures
  • Nonoperative treatment includes rest,
    counterforce straps, wrist splint, activity modification, cryotherapy,
    NSAIDs, and physical therapy initially.
  • Athletes should improve technique and mechanics and modify equipment as detailed above.
  • If results are poor with initial therapy, then consider corticosteroid injection.
    • Caution should be used, because multiple injections or incorrectly given injections increase the risk of tendon rupture.
  • Nonoperative treatment is successful in 95% of patients (1).
  • Newer treatments, including low-level
    laser and extracorporeal shock wave, have not shown substantial benefit
    when compared with placebo treatment in a recent meta-analysis (4).
Patients should be instructed to rest the affected
extremity and that activity can be resumed in a graduated fashion as
symptoms improve.
Special Therapy
Physical Therapy
  • If pain continues, physical therapy
    (including ultrasound, iontophoresis, friction massage, and
    counterforce bracing [tennis elbow strap]) may be helpful.
  • Once symptoms have diminished, a
    stretching and strengthening program directed at forearm extensors may
    help to prevent recurrence.


  • If nonoperative therapy fails over a 6-month period, operative treatment may be warranted.
  • Traditional surgery consists of resection of the degenerated ECRB origin.
  • The 5% coexistent radial tunnel syndrome also should be released (3).
  • Arthroscopic débridement of the ECRB origin represents a promising surgical procedure with quicker return to activity (5).
  • The splint is removed in 1 week, and ROM exercises are initiated.
  • Once the wound is well healed,
    strengthening exercises are added to the therapy program and
    pain-limited activity can be started.
  • Full activity usually is possible in ~3 months.
  • Lateral epicondylitis has the potential to be a chronic problem with periods of exacerbation and relief.
  • Patients usually (95%) have success with nonoperative treatment (1).
  • Few complications occur with nonoperative therapy.
  • Potential surgical complications include tendon rupture (retear), infection, decreased ROM, and stiffness.
Patient Monitoring
Repeat radiographs in 3 months if the pain persists.
1. Coonrad RW. Tennis elbow. Instr Course Lect 1986;35:94–101.
2. Nirschl
RP. Muscle and tendon trauma: Tennis elbow. In: Morrey BF, ed. The
Elbow and Its Disorders. Philadelphia: WB Saunders, 1985:481–496.
3. Werner CO. Lateral elbow pain and posterior interosseous nerve entrapment. Acta Orthop Scand Suppl 1979;174:1–62.
4. Speed
CA, Nichols D, Richards C, et al. Extracorporeal shock wave therapy for
lateral epicondylitis—a double blind randomised controlled trial. J Orthop Res 2002;20:895–898.
5. Baker
CL, Jr, Murphy KP, Gottlob CA, et al. Arthroscopic classification and
treatment of lateral epicondylitis: Two-year clinical results. J Shoulder Elbow Surg 2000;9:475–482.
Additional Reading
Azar FM. Shoulder and elbow injuries. In: Canale ST, ed. Campbell’s Operative Orthopaedics, 10th ed. St. Louis: Mosby, 2003:2339–2375.
L, Paungmali A, Vicenzino B, et al. A systematic review and
meta-analysis of clinical trials on physical interventions for lateral
epicondylalgia. Br J Sports Med 2005;39:411–422.
Brashear HR, Jr, Raney RB, Sr. Affectations of the elbow, wrist, and hand. In: Brashear HR, Jr, Raney RB, Sr, eds. Handbook of Orthopaedic Surgery, 10th ed. St. Louis: CV Mosby, 1986:476–497.
Ilfeld FW. Can stroke modification relieve tennis elbow? Clin Orthop Relat Res 1992;276:182–186.
Jobe FW, Ciccotti MG. Lateral and medial epicondylitis of the elbow. J Am Acad Orthop Surg 1994;2:1–8.
Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg 1979;61A:832–839.
Porretta CA, Janes JM. Epicondylitis of the humerus. Mayo Clin Proc 1958;33:303–306.
Tearse DS. Sports injuries. In: Clark CR, Bonfiglio M, eds. Orthopaedics: Essentials of Diagnosis and Treatment. New York: Churchill Livingstone, 1994:237–247.
726.32 Tennis elbow (lateral epicondylitis)
Patient Teaching
Lateral epicondylitis is typically a result of chronic overload of the wrist extensors.
Activity modification is an important element of treatment.
  • Proper technique and grip size for playing tennis
  • 2-hand backhand eliminates strain on the ECRB.
Q: What devices can one wear to relieve lateral epicondylitis?
Patients with lateral epicondylitis typically respond to counterforce
strapping (placing a strap around the proximal forearm) and wrist
splinting (immobilizing the wrist puts the wrist extensors at rest).
Q: When would injecting lateral epicondylitis with cortisone be considered?
A: If symptoms persist after activity modification, physical therapy, and bracing.

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