Tennis Elbow
Management of persistent pain and tendon problems around the outer elbow
What is tennis elbow?
The muscles that pull the wrist and fingers backwards all originate from a small bony point on the outer side of the elbow, and one of them, the short extensor of the wrist, takes most of the load through a narrow attachment.
Despite the older name, the tissue there is not inflamed. Under the microscope it shows disorganised fibres, poor blood vessel growth and a failed healing response, the pattern of a tendon that has been overloaded and has not recovered. Gripping loads it, and gripping with the elbow straight loads it most.
It is largely an occupational and household condition, and racquet sports account for a small share of cases. It occurs most between the ages of thirty-five and fifty-five, and the natural course is favourable: the majority resolve within a year to eighteen months whatever is done, and treatment is aimed at speeding that up and getting through it.
What you might notice
- Pain on the outer side of the elbow when gripping
- A grip that has weakened
How it is diagnosed
The diagnosis is made by locating the tenderness precisely to the bony point on the outer elbow, then reproducing the pain by asking you to extend the wrist or the middle finger against resistance with the elbow straight.
Your doctor also checks the neck, since a nerve root problem there can send pain to the same area, and examines the joint for the catching that suggests something inside it. Grip strength is measured and compared with the other side, because it drops considerably when this is active.
Imaging is not needed to make the diagnosis. An ultrasound scan or MRI is used where the pain has not behaved as expected, to look at the extent of the degeneration and to check whether the ligament underneath the tendon is involved, which changes the approach.
Recovery
The non-surgical route is slow and works. A brace worn on the forearm below the elbow, a change in gripping and lifting technique, and a programme of controlled loading exercises done daily settle the great majority over six to twelve months. The exercises deliberately load the tendon in a graded way, and being sore during them is expected.
After surgery the elbow is rested in a sling for a few days and then moved freely. The wound is small, on the outer side of the elbow, and settles in two weeks.
Strengthening begins at around three weeks and builds over three months. Full gripping power for heavy manual work comes back at three to six months, and a small ache at the extremes of loading can persist for a year.
If it is left untreated
This is a condition that resolves by itself in most people, so watching it while you modify the load is a legitimate plan and the one most surgeons start with. Between eight and nine in ten are better at a year without any operation.
The reason not to leave it indefinitely is the effect of a year or more of weak grip on work and daily life, and the fact that persistent avoidance of the arm leads to stiffness and wasting. Repeated steroid injections are worth mentioning here: they give quick relief but the evidence suggests they leave people worse at a year than doing nothing, so they are used sparingly.
Questions about tennis elbow
Should I have a steroid injection?
It gives quick relief for six to twelve weeks, and that can be worth having when the pain is stopping you working or sleeping. The evidence is that people who have repeated injections do worse at one year than those who do not, since the steroid does nothing for the underlying degeneration and weakens the tendon tissue. Most surgeons will use one at most, alongside a loading programme and never as a substitute for it.
Do the braces actually help?
A counterforce brace worn on the upper forearm, a few centimetres below the elbow, changes where the load is transmitted and takes some of the tension off the degenerate attachment. Many people find it useful for gripping tasks at work. It is a support to use while the tendon is being rehabilitated, and it does not treat the tendon on its own.
How long before I should think about surgery?
Twelve months of genuine non-surgical treatment is the usual threshold, and genuine means a daily loading programme done consistently and a real change in how the arm is used, not just avoidance. Around eight or nine in ten resolve within that period. Surgery is considered for the remainder whose grip is still limited, and it is followed by three months of rehabilitation of its own.
Other orthopaedics treatments
Replacement of a damaged knee joint to relieve persistent pain and improve mobility when conservative treatment is no longer enough
InpatientAssessment and treatment of ACL injuries, with rehabilitation or reconstruction considered based on activity and instability
InpatientTalk to a care coordinator about tennis elbow
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one