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Magill’s Medical Guide, 9th Edition

Tennis elbow (lateral epicondylitis)

by Jason Pyon, , MD, Marichelle Pita, , OMS-III

Category: Disease/Disorder

CAUSES AND SYMPTOMS

Lateral epicondylitis a condition resulting from chronic inflammation of the muscles that extend the wrist. This condition is most commonly due to excessive pronation/supination and extension motions of the wrist. For example, performing a backhand swinging motion, such as while playing tennis, involves the use of the extensor muscles of the wrist. Chronic overuse of these wrist extensor muscles can cause inflammation and pain. However, although lateral epicondylitis may be observed in individuals who play tennis for more than two hours daily, this condition does not exclusively affect tennis players. Any motion that involves repetitive wrist extension can elicit symptoms of lateral epicondylitis. The risk of developing lateral epicondylitis increases with age. This condition may also be idiopathic or occur without any identifiable cause.

There are three primary muscles involved in wrist extension and originate at the lateral epicondyle of the humerus : the extensor carpi radialis brevis, the extensor digitorum with extensor digiti minimi, and the extensor carpi ulnaris. The pathophysiology of this condition is a result of overuse and repetitive motions. Lateral epicondylitis has been observed in tennis players due to the repetitive rapid and forceful movements as the muscle-tendon unit is lengthened or in eccentric motion. As these muscles are overexerted, microscopic tears form. The healing process of microscopic muscle tears will lead to stronger and larger muscles. However, excessive muscular use results in microtears that do not have time to repair themselves, thus resulting in improper healing. This increased breakdown of the muscle and tendons results in chronic inflammation of these structures. A result of chronic inflammation is neovascularization of the affected area to bring nutrients to the damaged tissues. This process of neovascularization in these extensor muscles causes the pain associated with lateral epicondylitis.

There are some common symptoms when patients present with lateral epicondylitis. The pain in this condition is typically located on the lateral aspect of the elbow about 1.5 cm distal to the lateral epicondyle, and may or may not radiate to the hand. Patients often report an insidious onset to the elbow pain but can relate it to a particular activity twenty-four to seventy-two hours earlier with no associated trauma to the joint. The level of pain reported by patients with lateral epicondylitis is variable depending on how far the condition has progressed. Some patients present with mild pain with occasional aggravation on certain movements while others report a severe pain that limits daily activities like holding objects.

The diagnosis of lateral epicondylitis is typically clinical; the physician relies on history and physical exam findings to make the diagnosis. History of overuse and repetitive wrist movements due to sports or work is common. Pain on palpation of the lateral epicondyle or proximal wrist extensor muscles or pain with resisted wrist extension or flexion while the elbow is in full extension suggests lateral epicondylitis. However, if the clinician is unsure if a patient has elbow pain related to lateral epicondylitis, an MRI or ultrasound can be ordered to see if there is any muscle damage to the area distal to the lateral epicondyle. A three-view X-ray can also be ordered to rule out any osteophytes or an alternative diagnosis.

TREATMENT AND THERAPY

The treatment goals of lateral epicondylitis include pain control, preservation of range of motion and grip strength, prevention of further disease progression, and return to baseline function. Initial treatment for patients with lateral epicondylitis is with conservative measures. These treatments include rest, non-steroidal anti-inflammatory drugs, ice, and activity modification. Counterforce brace placed distal to the lateral epicondyle may also be used during the first six weeks of injury. The brace can help relieve pain by reducing muscle and tendon strain of the forearm extensor muscles. If pain does not improve at six weeks of conservative treatment, the patient is sent to physical therapy as a second-line treatment. Physical therapy focusing on gradual eccentric and isometric muscle strength training helps improve the symptoms associated with this condition.

If there is no improvement of symptoms after six to twelve months, then other more complex treatments are considered. A corticosteroid injection to the elbow can dampen the inflammatory process and provide short-term relief. Since the use of corticosteroid injections does not prevent recurrence of pain from lateral epicondylitis and may cause skin changes at the injection site, this treatment is frequently used as a part of comprehensive therapy rather than as primary treatment. Health care providers can also inject autologous blood or separate the blood into platelet-rich plasma (PRP) for injection to the affected area. Studies have shown that PRP and autologous blood leads to improved healing of the damaged tissue. Other options include acupuncture, injection of botulinum toxin, or prolotherapy, but these treatments are not as well studied as other therapies. Extracorporeal shockwave therapy, which is a treatment that uses acoustic waves, may also be considered. However, this type of therapy may cause some discomfort to the patient and more studies need to be conducted to further investigate its clinical efficacy and benefits. Patients are still encouraged to keep up with physical therapy and other conservative treatment while undergoing second-line interventions.

The majority of lateral epicondylitis cases resolve with either first-line or second-line treatment. However, if the patient continues to have refractory lateral elbow pain after exhausting all other options, then surgical referral to orthopedics may be considered. Patients are referred for surgery consultation if the patient has unimproved symptoms or function despite trial of non-operative treatments for six to twelve months. Surgical referral should be considered for patients with chronic elbow tendinopathy who do not wish to attempt nonsurgical treatments. The role of surgery in these cases is to perform a debridement of the affected arm to remove any offending particles or substances that could be the source of the patient’s pain. Patients should know that surgical intervention is not definitive treatment and they could still have pain after surgery.

For Further Information:

1 

Ahmad, Z., N. Siddiqui, S. S. Malik, et al. “Lateral Epicondylitis: A Review of Pathology and Management.” Bone Joint Journal, vol. 95-B, no. 9, 2013, pp. 1158-64, doi:10.1302/0301-620X.95B9.29285. PMID:23997125.

2 

Bisset L. M., and B. Vicenzino. “Physiotherapy Management of Lateral Epicondylalgia.” Journal of Physiotherapy, vol. 61, no. 4, 2015, pp. 174-81, doi:10.1016/j.jphys.2015.07.015.

3 

Coombes, B. K., L. Bisset, and B. Vicenzino. “Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All.” Journal of Orthopaedic & Sports Physical Therapy, vol. 45, no. 11, 2015, pp. 938-49, doi:10.2519/jospt.2015.5841.

4 

Croisier, J. L., M. Foidart-Dessale, F. Tinant, et al. “An Isokinetic Eccentric Programme for the Management of Chronic Lateral Epicondylar Tendinopathy.” British Journal of Sports Medicine, vol. 41, no. 4, Apr. 2007, pp. 269-75, doi:10.1136/bjsm.2006.033324. Epub 15 Jan. 2007. PMID:17224433; PMCID PMC2658962.

5 

Dingemanse, R., M. Randsdorp, B. W. Koes, and B. M. A. Huisstede. “Evidence for the Effectiveness of Electrophysical Modalities for Treatment of Medial and Lateral Epicondylitis: A Systematic Review.” British Journal of Sports Medicine, vol. 48, no. 12, 2014, pp. 957-65, doi:10.1136/bjsports-2012-091513.

6 

Johnson, Greg W. “Treatment of Lateral Epicondylitis.” American Family Physician, vol. 76, no. 6, 15 Sept. 2007, pp. 843-48.

7 

Landesa-Martínez, L., and R. Leirós-Rodríguez. “Physiotherapy Treatment of Lateral Epicondylitis: A Systematic Review.” Journal of Back and Musculoskeletal Rehabilitation, 4 Aug. 2021, doi:10.3233/BMR-210053. PMID:34397403.

8 

Park, J. Y., H. K. Park, J. H. Choi, et al. “Prospective Evaluation of the Effectiveness of a Home-based Program of Isometric Strengthening Exercises: 12-Month Follow-up.” Clinics in Orthopedic Surgery, vol. 2, no. 3, Sept. 2010, pp. 173-81, doi:10.4055/cios.2010.2.3.173. Epub 2010 Aug. 3. PMID:20808589; PMCID:PMC2915397.

9 

Sims, S. E. G., K. Miller, J. C. Elfar, et al. “Non-surgical Treatment of Lateral Epicondylitis: A Systematic Review of Randomized Controlled Trials.” HAND, vol. 9, no. 4, 2014, pp. 419-46.

10 

Testa, G., A. Vescio, S. Perez, et al. “Extracorporeal Shockwave Therapy Treatment in Upper Limb Diseases: A Systematic Review.” Journal of Clinical Medicine, vol. 9, no. 2, 6 Feb. 2020, doi:10.3390/jcm9020453. PMID: 32041301; PMCID: PMC7074316.

11 

Thanasas, Christos, et al. “Platelet-Rich Plasma Versus Autologous Whole Blood for the Treatment of Chronic Lateral Elbow Epicondylitis: A Randomized Controlled Clinical Trial.” American Journal of Sports Medicine, vol. 39, no. 10, 2011, pp. 2130-34.

12 

Thompson, Jon C. Netter’s Concise Orthopaedic Anatomy. Saunders Elsevier, 2010.

13 

Walrod, Bryant James. “Lateral Epicondylitis.” Medscape, emedicine.medscape.com/article/96969-overview. Accessed 19 Aug. 2017.

14 

Walther M., S. Kirschner, A. Koenig, et al. “Biomechanical Evaluation of Braces Used for the Treatment of Epicondylitis.” Journal of Shoulder and Elbow Surgery, vol. 11, no. 3, May-June 2002, pp. 265-70, doi:10.1067/mse.2002.122623. PMID: 12070500.

15 

Weber C., V. Thai, K. Neuheuser, et al. “Efficacy of Physical Therapy for the Treatment of Lateral Epicondylitis: A Meta-analysis.” BMC Musculoskeletal Disorders, vol. 16, no. 1, 2015, p. 223, doi:10.1186/s12891-015-0665-4.

16 

Yao, G., J. Chen, Y. Duan, and X Chen. “Efficacy of Extracorporeal Shock Wave Therapy for Lateral Epicondylitis: A Systematic Review and Meta-Analysis.” BioMed Research International, 18 Mar. 2020, p. 2064781, doi:10.1155/2020/2064781. PMID: 32309425; PMCID: PMC7106907.

Citation Types

Type
Format
MLA 9th
Pyon, Jason, and Marichelle Pita. "Tennis Elbow (lateral Epicondylitis)." Magill’s Medical Guide, 9th Edition, edited by Anubhav Agarwal,, Salem Press, 2022. Salem Online, online.salempress.com/articleDetails.do?articleName=MMG2022_1339.
APA 7th
Pyon, J., & Pita, M. (2022). Tennis elbow (lateral epicondylitis). In A. Agarwal, (Ed.), Magill’s Medical Guide, 9th Edition. Salem Press. online.salempress.com.
CMOS 17th
Pyon, Jason and Pita, Marichelle. "Tennis Elbow (lateral Epicondylitis)." Edited by Anubhav Agarwal,. Magill’s Medical Guide, 9th Edition. Hackensack: Salem Press, 2022. Accessed October 22, 2025. online.salempress.com.