What is the condition? 
Tennis elbow is pain on the outside of the elbow caused by overload of the tendon origin of 
the wrist and finger extensor muscles. The most commonly involved tendon is the extensor 
carpi radialis brevis. Despite the term 'epicondylitis', this is usually not a true inflammatory 
condition. It is a tendon overuse problem where the tendon fibres become painful and 
disorganised over time. 

It is common in people who do repetitive gripping, lifting, twisting, or tool use, and it is also 
seen in racquet sports. The tendon is particularly stressed when you grip with the wrist 
held slightly extended. Symptoms often build gradually and then persist because the tendon 
struggles to recover if the provoking load continues. 

Why does it happen? 
The tendon at the lateral epicondyle has a relatively limited blood supply. Repeated small 
overload events can exceed the tendon’s ability to repair itself. This leads to microscopic 
tendon fibre disruption, tendon thickening, and pain sensitivity. The pain is often out of 
proportion to what is seen on imaging, because tendon pain is strongly influenced by load 
and sensitivity of local nerve endings. 

Tennis elbow can also coexist with other problems that feel similar, such as radial tunnel 
syndrome (nerve irritation) or neck-related pain. A careful assessment is important to avoid 
treating the wrong problem. 

What are the symptoms? 
Most patients have localised tenderness over the bony prominence on the outer side of the 
elbow. The pain can spread down the forearm, particularly with heavier or prolonged 
activity. 

Pain is usually worse with gripping, lifting a kettle, turning a door handle, using a 
screwdriver, shaking hands, or lifting with the palm facing down. Many people notice 
reduced grip strength because pain inhibits normal muscle activation. 

Night pain can occur, particularly after a heavy day of use, but constant severe night pain is 
not typical and should be reviewed. 

How is it diagnosed? 
The diagnosis is usually clinical. Your examination focuses on tenderness at the lateral 
epicondyle and pain provocation with resisted wrist extension and gripping. 
Ultrasound or magnetic resonance imaging may be used when symptoms are atypical, 
persistent, or if there is concern about alternative diagnoses. Imaging can show tendon 
thickening or small tears, but the scan does not always correlate with pain severity. 

Non-surgical treatment 
Most people improve without surgery, but it often takes time. Treatment focuses on 
reducing painful overload while progressively rebuilding tendon capacity. This usually 
includes activity modification, short-term pain relief measures, and a structured 
physiotherapy programme. 

A counterforce strap worn just below the elbow can reduce load through the tendon during 
activity. A wrist brace may help in more irritable cases by reducing extensor demand. Ice 
massage after aggravating activity can help symptoms. 

Physiotherapy is the mainstay of treatment. It typically includes stretching and a 
progressive loading programme, often using eccentric strengthening. The goal is not to 
avoid load forever, but to reintroduce it in a controlled, graduated way so the tendon 
adapts. 

Injections may be considered in selected cases. Steroid injections can provide short-term 
relief, but the effect may not last and recurrence is common. Other injection options, 
including platelet-rich plasma, are sometimes used for chronic tendinopathy, typically 
alongside rehabilitation. 

When is surgery considered? 
Surgery is considered when symptoms remain functionally limiting despite a well performed rehabilitation programme over several months. The decision is based on 
persistence of pain, impact on work and daily function, and response to non-operative care. 
Surgical options include arthroscopic or open debridement and release of the diseased 
portion of the tendon. Arthroscopy also allows inspection of the elbow joint for associated 
pathology, such as synovitis or loose bodies. 

Recovery and rehabilitation 
After surgery, early elbow movement is encouraged to reduce stiffness. A sling is usually for 
comfort only. Most patients return to light daily activity within the first couple of weeks, but 
rebuilding strength takes longer. 

A staged strengthening programme is important. Return to heavier manual work, racquet 
sport, or weight training is usually progressed over 6 to 12 weeks, depending on pain, 
strength, and the demands of the activity. Tendon recovery can continue over several 
months. 

Expected outcomes 
Most people improve with non-surgical treatment. When surgery is required, many patients 
experience meaningful pain relief and improved function, but recovery is gradual and 
depends on adherence to rehabilitation and load management. 

Risks and complications 
Non-surgical treatment risks are low. Injection risks include skin depigmentation, fat 
atrophy, tendon weakening, and infection, which is rare. 

Surgical risks include infection, stiffness, persistent pain, recurrence, and nerve irritation. 
Nerves run close to the arthroscopy portals, so careful technique is required. 

When should I seek urgent review? 
Seek urgent medical review if you develop increasing redness, heat, rapidly worsening 
swelling, fever, increasing pain that does not settle with rest, or new weakness or numbness 
in the hand. If you have had a recent injury and the elbow looks deformed, feels unstable, or 
you cannot move it, this also requires urgent assessment.

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What does the rehabilitation/recovery involve?

To find out more about rehabilitation and recovery after elbow surgery please see our Rehabilitation Protocols here.

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