- Also known as
- Lateral epicondylitis, ECRB tendinopathy
- Most common in
- Adults 35–55
- Natural course
- Self-limiting, often 12–18 months
- First-line
- Load management, eccentric loading physio
- Surgery rate
- Less than 10% of cases
What tennis elbow is.
Tennis elbow — properly called lateral epicondylitis, or more accurately lateral elbow tendinopathy — is a degenerative condition of the common extensor tendon origin at the outside of the elbow. The tendon most often affected is the extensor carpi radialis brevis (ECRB), which runs from the lateral epicondyle of the humerus down into the wrist. Histologically, the condition is one of tendon failure and disorganised repair rather than true inflammation.
Only a small minority of patients with tennis elbow are tennis players. The condition is much more common in manual workers — carpenters, plumbers, painters, electricians, dental hygienists — and in office workers with a long history of mouse-driven wrist extension.
Natural history.
This is the single most important piece of information to give patients. Tennis elbow is genuinely self-limiting in the great majority of people, with symptoms resolving over 12–18 months from onset.1 The treatment goal is therefore to manage symptoms during that window, not to "cure" the condition itself.
How the diagnosis is made.
The diagnosis is clinical. Tenderness is reproducibly localised directly over the lateral epicondyle, and pain is reproduced on resisted wrist extension with the elbow straight. Mill's and Cozen's tests are positive. Imaging is usually not needed; ultrasound or MRI is reserved for atypical cases or pre-operative planning.
Non-operative treatment.
- Education and load management — the most important intervention. Reducing the provoking activity allows the tendon to settle.
- Eccentric loading physiotherapy — has the best evidence base. A structured 8–12 week programme.
- Counterforce brace — a forearm strap; modest evidence, often helpful in manual work.
- Anti-inflammatories — short course only.
- Corticosteroid injection — provides short-term relief but is associated with worse long-term outcomes when used early; reserved for the disabling acute flare only.2
- PRP (platelet-rich plasma) — modest and inconsistent evidence; used selectively.
When surgery is considered.
Less than 10% of patients require surgery. The threshold is 6–12 months of well-conducted non-operative care without satisfactory improvement. The operation involves debridement of the diseased ECRB tendon origin, either open or arthroscopically. Recovery takes 2–3 months, with most patients reporting improvement at 6–12 months.
Frequently asked questions.
How long will my tennis elbow last?
On average 12–18 months from first symptom to resolution. Some patients are better sooner; a minority take longer. Surgery is reserved for the small group who do not settle with time and well-conducted physiotherapy.
Should I get a cortisone injection?
Cortisone injection provides short-term relief but is associated with worse long-term outcomes when used early. It is reserved for disabling acute flares, not as first-line treatment.
Will physiotherapy fix it?
Eccentric loading physiotherapy is the best-evidenced non-operative treatment. Combined with load management, it improves outcomes through the natural recovery period.
When is surgery the right answer?
After 6–12 months of well-conducted non-operative treatment without satisfactory improvement. Less than 10% of patients reach this point.
References.
- Smidt N, et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis. Lancet. 2002;359(9307):657–662.
- Coombes BK, et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461–469.