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Elbow · treated under Musculoskeletal Physiotherapy

Tennis Elbow

Also called Lateral epicondylitis, Lateral elbow tendinopathy, Lateral epicondylalgia.

Pain on the outside of the elbow that bites when you grip or lift. A tendon that has been overloaded, not inflamed, and it recovers with graded loading rather than rest or injections.

Written by , BPT, MPT · MIAP License No. 69386

Updated · Awaiting clinical review

A physiotherapist guiding a patient through a light dumbbell exercise in a clinic

What it is

Tennis elbow is pain at the bony point on the outside of the elbow, where the muscles that lift the wrist and straighten the fingers attach through one shared tendon. Every grip loads that tendon, whether or not the wrist moves, which is why a kettle, a door handle or a handshake can hurt as much as a backhand. Most people who get it have never held a racquet. It affects around 1 to 3% of the general population and 15% of workers in at-risk industries [1]; a Finnish population study of 30 to 64 year olds found it in 1.3% of adults, men and women alike [5].

The old name, lateral epicondylitis, suggests inflammation, and that is the wrong picture. When the tendon has been examined under the microscope it shows disorganised, degenerated collagen rather than inflammatory cells, a state called tendinosis [6]. It is a tendon that has been asked for more than it could tolerate and has repaired badly. That single fact explains the treatment: anti-inflammatory approaches disappoint, rest weakens it further, and the thing that changes the tissue is load applied in the right dose over months.

How it presents

  • Pain over the bony point on the outside of the elbow, sometimes spreading down the forearm
  • Worst with gripping, especially with the elbow straight: a kettle, a jar, a shopping bag, a handshake
  • Tender to press directly on or just in front of the bony point
  • Stiffness in the forearm first thing in the morning that eases after a few minutes
  • Grip strength noticeably down on that side, and sometimes dropping things
  • Pain when the wrist is lifted against resistance, or when the middle finger is lifted against resistance with the elbow straight
  • Usually one arm, most often the dominant one

Pain-free grip, the force you can squeeze before it hurts, is the measure we track through treatment, because it responds to the right loading and it was a main outcome in the trials this page relies on [1][11]. If the pain is on the inside of the elbow it is golfer's elbow, the same problem on the other side. If it sits further down the forearm and aches rather than bites, or comes with neck pain or tingling in the hand, it may not be the tendon at all.

Who gets it and why

Tendons cope with the load they are used to. Trouble starts when the load changes faster than the tendon can adapt: a weekend of painting or moving house, a new job with heavy hand tools, a change of racquet, mouse or keyboard, a return to the gym or the garden after months away. The tendon is loaded a little beyond what it can repair, day after day, and the repair becomes disorganised [6]. Age matters too, because a tendon adapts more slowly in middle age; the Finnish study found it most common between 45 and 54 [5].

Work is a bigger factor than sport. In that population study the combination of repetitive arm movements and forceful gripping carried about five and a half times the odds of neither, and smokers had roughly three times the odds of never-smokers [5]. Racquet sports do provoke it, especially a backhand hit late or with a grip that is the wrong size, but they account for a small share of the people who walk in with it.

Risk factors

  • Age 45 to 54, when prevalence peaks; men and women are affected equally [5]
  • Repetitive arm movements combined with forceful gripping at work, about five and a half times the odds of neither [5]
  • Smoking, current or former, at roughly three times the odds [5]
  • A sudden rise in hand and forearm load: DIY, a new job, a new sport or gym programme, a change of tools or equipment
  • Racquet sports played with a late backhand, a grip that is the wrong size or a heavy, tightly strung racquet
  • Neck involvement. Irritation of the C6 or C7 nerve roots can refer pain to the outer elbow and lower the tendon's tolerance

How it is diagnosed

Tennis elbow is diagnosed in the room. The story of grip-provoked pain at the outer elbow, tenderness at or just in front of the bony point, and pain reproduced when the wrist or middle finger is lifted against resistance are enough. We measure pain-free grip on both sides, because the difference is the number that tracks recovery [1], and we check how far the elbow bends and straightens, since a stiff or clicking joint points to the joint itself rather than the tendon.

The rest of the assessment rules out the look-alikes. The neck can refer pain to the outer elbow from the sixth or seventh cervical nerve root, so we examine the neck and the nerves in everyone. Radial tunnel syndrome, a nerve trapped a little below the epicondyle, causes a deeper forearm ache that is tender lower down and does not fit the grip pattern. The elbow joint itself, and the rare inflammatory arthritis, are the others. Getting this right at the start matters, because the exercises that fix a tendon do nothing for a nerve.

When imaging earns its place

Imaging is rarely needed. Ultrasound can show a thickened tendon and increased blood flow, and MRI shows the same, but neither changes the first three months of treatment. A scan earns its place when the picture is atypical, when there has been an injury, when the joint is locking or swollen, or when a proper course of loading has not worked and an injection or a surgical opinion is being weighed.

What the evidence says

Treatment by treatment, with the studies behind each verdict numbered to the sources at the end of the page.

  • Progressive loading exercise

    Core treatment

    The centre of treatment. Across 30 trials and 2123 people, exercise beat passive treatments on pain and function, and beat corticosteroid injection on every outcome at every time point except pain in the first weeks [11]. The gains over waiting alone are small and the programmes varied widely [11], which is why the dose matters more than the label: slow, heavy wrist and grip work, progressed over weeks, with some discomfort during the exercise but no flare the next morning.

  • Advice and activity modification

    Core treatment

    Reduce the aggravating loads, do not remove them: carry with the palm up, lift with two hands, change the grip on tools and the mouse, and trim the week's hand-heavy work to what the tendon tolerates. In the two large wait-and-see trials this advice, with time, took 83% and 90% of people to a good outcome by one year [1][4]. It is the floor that everything else is built on.

  • Manual therapy alongside exercise

    Helps alongside

    Mobilisation with movement, a hands-on technique done while you grip, combined with exercise in the Brisbane trial gave 65% of people a good outcome at six weeks against 27% of those who waited, and 94% at one year [1]. In a later trial, physiotherapy improved the four-week result but made no difference at one year [2]. That is how we use it: to make the early weeks tolerable while the loading takes hold, not as the treatment itself.

  • Bracing and taping

    Helps alongside

    A counterforce strap below the elbow reduces pain with gripping for many people, and taping is used the same way for a day or two at a time. The Cochrane review of five small trials could not reach a conclusion either way [12]. A cheap strap worn for the hand-heavy parts of the day is a reasonable aid while the loading does the work; it is not a treatment on its own.

  • Topical anti-inflammatory gels

    Helps alongside

    Low-quality evidence from placebo-controlled trials that a topical NSAID gel reduces pain for up to four weeks, by about 1.6 points on a ten-point scale [10]. Oral anti-inflammatories have conflicting evidence and more stomach side effects [10]. Reasonable for comfort in the early weeks; they do not change the tendon, so they are not the plan.

  • Corticosteroid injection

    Use with caution

    The clearest finding on this page. Injection wins at six weeks, with 78% and 92% success against 27% and 32% for waiting [1][4], then loses: by one year 68% and 69% of the injected were well against 90% and 83% of those who waited [1][4], and 54% relapsed within the year against 12% after a placebo injection [2]. A pooled analysis of 41 tendon trials found the same reversal, and the case against repeating an injection follows from it [3].

  • Platelet-rich plasma and autologous blood

    Avoid

    In the best trial, 60 people were given PRP, corticosteroid or saline without knowing which; at three months there was no difference between any of them [7]. The Cochrane review of 32 trials and 2337 people found the same: probably no clinically important benefit over a placebo injection, with 65% success on placebo and 67% on PRP or blood [14]. Costly, uncomfortable, and not better than salt water.

  • Shockwave therapy

    Avoid

    Nine placebo-controlled trials with 1006 participants: little or no benefit for pain or function, with 11 of 13 pooled analyses showing no advantage over sham [9]. Whatever its place elsewhere, the evidence at the elbow is against it, and we do not suggest it for this condition.

  • Surgery

    Second line

    In the only placebo-controlled trial, 26 people with pain for more than six months had either the degenerate tendon removed or a skin incision alone; both groups improved, and there was no difference at six months or two and a half years [8]. In a population cohort, about one in ten of those still symptomatic at six months went on to surgery [13]. It is a last resort after a year of properly delivered loading, not an alternative to it.

  • Rest until it settles

    Avoid

    Rest reduces the pain and the tendon's capacity together. Six weeks off the kettle usually feels better and leaves a weaker tendon for the day you pick it up again, which is why rested elbows come back. Reduce the load; do not remove it.

Read together, the trials say something unusual for a painful condition: doing less can beat doing more. Most people are well within a year with advice alone [1][4]; the injections that feel best early leave people worse at a year [1][2][4]; PRP, shockwave and surgery have each failed to beat their placebo [7][8][9][14]. What physiotherapy adds is speed and a stronger tendon at the end: a good outcome for two in three by six weeks rather than one in four [1], and the grip strength to go back to what caused it [11]. Our reading is that the early weeks are for comfort and the months are for load, and the people who stay stuck are the ones who had the pain settled for them and never rebuilt the tendon.

How we treat it

At The Rym Space, Bagalur

  1. 1

    Assessment

    The story, then the tests that provoke the tendon, pain-free grip measured on both sides, and the elbow joint, neck and radial nerve checked so the look-alikes are ruled out. You leave knowing it is the tendon, how irritable it is, and what your baseline grip is.

  2. 2

    A plan you start that day

    How to carry, lift and grip without feeding it, changes to your tools, mouse or racquet, and the first isometric holds: a lifted wrist held against light resistance, which often eases the pain for an hour or two. Straight talk about injections and why we hold them back.

  3. 3

    Week 1: settle the elbow

    3 to 5 sessions close together. Mobilisation with movement and soft-tissue work to take the bite out of gripping, a strap fitted if you need one, the isometric holds made a habit, and the week's hand-heavy work trimmed to what the tendon tolerates.

  4. 4

    Week 2 onwards: load the tendon

    Slow, heavy wrist extension with a dumbbell or band, then grip and forearm rotation work, progressed by load rather than by how it feels that morning. Hands-on treatment continues while the programme takes hold, and sessions space out as the home programme carries the work.

  5. 5

    Back to the racquet, the tools or the gym

    Heavier and faster loading, then the specific task that brought you in: the backhand, the screwdriver, the pull-up, rebuilt on a graded plan. Technique and equipment are adjusted so the load that caused it lands differently, and the neck is treated if it is part of the picture.

  6. 6

    Discharge, or the next tier

    Done when everyday gripping is pain free, grip is close to the other side and you are back to what you came in for. Not on track by three months: we say so and talk through the next tier, usually more time and load rather than an injection.

What to expect, and when

Ranges, not promises. Where a figure comes from a study, the study is numbered.

First 6 weeks
The most irritable stretch. With hands-on treatment and exercise, 65% of people rated themselves much improved or recovered by six weeks, against 27% of those who were given advice and waited [1]. Pain-free grip is the number that should be moving.
By 3 months
In the same trial, 76% of the physiotherapy group and 59% of the wait-and-see group were much improved or recovered at twelve weeks, while the injected group had slipped back to 45% [1]. The tendon is now being loaded properly, and the mornings are easier.
By 6 months
86% with physiotherapy and 83% with waiting [1]. After a placebo injection, 85% were much improved or recovered at 26 weeks, against 55% after a corticosteroid injection [2]. Improved is not finished: grip usually still lags the other side.
By 12 months
94% with physiotherapy and 90% with waiting in the Brisbane trial [1]; 91% and 83% in the Dutch one [4]. The injected did worst in both, at 68% and 69% [1][4]. Most tennis elbow is self-limiting within a year; the question is how the year is spent.
Recurrence
In a population cohort, 8.5% of cases recurred within two years [13]. People whose symptoms had not settled by six months had a longer course, and about one in ten of them went on to surgery [13].

The two trials count slightly different things, and both recruited people who had already had the pain for at least six weeks, so their figures describe established tennis elbow rather than a sore elbow that started last week. The one-year numbers are the reason we do not rush to an injection; the six-week numbers are the reason we do not simply wait.

When to be seen sooner

Signs that this is something else, or that it needs looking at now rather than after a few weeks of self-care.

  • Pain after a fall or a direct blow to the elbow, until a fracture is excluded
  • An elbow that locks, catches or will not fully straighten, which points to the joint rather than the tendon
  • Numbness, tingling or weakness in the hand or fingers, which suggests a nerve, in the neck or the forearm, rather than the tendon
  • A hot, swollen or red elbow, or elbow pain with fever or feeling unwell
  • Pain in both elbows, or in several joints, especially with prolonged morning stiffness, which raises the question of inflammatory arthritis
  • Elbow pain in a child or teenager, which is usually a growth plate problem and is assessed differently
  • No change at all after three months of properly dosed loading, which changes the plan rather than the urgency

Common questions

Should I have an injection?
Not as a first step. It will very likely feel better within a few weeks; 78% to 92% of people report success at six weeks [1][4]. But by a year the injected groups did worse than people who simply waited, and 54% relapsed within the year against 12% after a placebo injection [2]. We keep it for the rare case where pain is stopping any rehabilitation, and we advise against repeating it [3].
Do I need a scan?
Usually not. The diagnosis is made in the room and imaging does not change the first months of treatment. We ask for it if there has been an injury, if the joint is locking or swollen, or if a proper course of loading has not worked.
Should I stop using the arm?
Reduce the load, do not remove it. Rest settles the pain and weakens the tendon at the same time, which is why it returns when normal life resumes. Change how you carry and grip, keep the loading exercises going, and rebuild the hand-heavy work in steps.
Will a strap fix it?
A counterforce strap makes gripping more comfortable for many people, though the trials are too small to say how much [12]. Wear one for the hand-heavy parts of the day if it helps. It is a symptom aid while the loading does the work, not a treatment on its own.
How long until I can play again?
It depends how long you have had it and how far grip strength has to come. As a rule of thumb, we want everyday gripping pain free and pain-free grip close to the other side before a graded return, with technique or equipment adjusted so the same load does not land the same way. For most people that is a matter of months rather than weeks [1].
Is it really tennis elbow if I do not play tennis?
Yes. The name describes where it hurts, not what caused it. Most people who get it have never held a racquet; in the population study the strongest links were with repetitive, forceful hand work and with smoking [5].

Further reading

Sources

Guidelines, systematic reviews and trials only. Each number in the text links to the entry here.

  1. 1.Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. pubmed.ncbi.nlm.nih.gov ↗
  2. 2.Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. 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. pubmed.ncbi.nlm.nih.gov ↗
  3. 3.Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751-1767. pubmed.ncbi.nlm.nih.gov ↗
  4. 4.Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359(9307):657-662. pubmed.ncbi.nlm.nih.gov ↗
  5. 5.Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164(11):1065-1074. pubmed.ncbi.nlm.nih.gov ↗
  6. 6.Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81(2):259-278. pubmed.ncbi.nlm.nih.gov ↗
  7. 7.Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625-635. pubmed.ncbi.nlm.nih.gov ↗
  8. 8.Kroslak M, Murrell GAC. Surgical treatment of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med. 2018;46(5):1106-1113. pubmed.ncbi.nlm.nih.gov ↗
  9. 9.Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev. 2005;(4):CD003524. pubmed.ncbi.nlm.nih.gov ↗
  10. 10.Pattanittum P, Turner T, Green S, Buchbinder R. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2013;5:CD003686. pubmed.ncbi.nlm.nih.gov ↗
  11. 11.Karanasios S, Korakakis V, Whiteley R, Vasilogeorgis I, Woodbridge S, Gioftsos G. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. Br J Sports Med. 2021;55(9):477-485. pubmed.ncbi.nlm.nih.gov ↗
  12. 12.Struijs PA, Smidt N, Arola H, van Dijk CN, Buchbinder R, Assendelft WJ. Orthotic devices for the treatment of tennis elbow. Cochrane Database Syst Rev. 2002;(1):CD001821. pubmed.ncbi.nlm.nih.gov ↗
  13. 13.Sanders TL Jr, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey BF. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med. 2015;43(5):1066-1071. pubmed.ncbi.nlm.nih.gov ↗
  14. 14.Karjalainen TV, Silagy M, O'Bryan E, Johnston RV, Cyril S, Buchbinder R. Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain. Cochrane Database Syst Rev. 2021;9:CD010951. pubmed.ncbi.nlm.nih.gov ↗

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