Tennis Elbow (Lateral Epicondylitis) Treatment

The muscles that lift the wrist and fingers attach through a common tendon to the bony prominence on the outside of the elbow, the lateral epicondyle. Repetitive strain and degeneration of this tendon, particularly the extensor carpi radialis brevis (ECRB) portion, is called lateral epicondylitis, commonly tennis elbow.

Despite the '-itis' suffix, inflammation in the traditional sense is not the dominant process. Microscopic examination shows disorganisation of tendon fibres and inadequate repair; the condition is therefore now treated as a tendinopathy (tendon degeneration). Understanding this changes treatment: pain relief alone is insufficient; the tendon must gradually relearn how to tolerate loading.

Most patients have never played tennis. Common triggers in Ordu and the surrounding area include hazelnut picking and cracking, tea-growing and gardening, carpentry, painting, butchery, repairs involving screwdrivers and spanners, hairdressing and prolonged keyboard and mouse use. The shared factor is repeated loading of the wrist in the same direction while gripping. It occurs most often between ages 35–55, in the dominant arm.

Symptoms usually develop gradually over weeks, though some begin suddenly after strenuous work. The most commonly described pattern is:

• Localised tenderness directly over the bony prominence on the outside of the elbow
• Pain increases when opening jars, turning handles or holding a bag or glass of water
• Pain spreading along the outside of the forearm towards the wrist
• Reduced grip strength; dropping objects from the hand
• Stiffness with the first movements in the morning and pain that increases with activity during the day
• Elbow bending and straightening are usually unrestricted; movement is preserved, while gripping causes pain

Diagnosis is largely based on history and examination. Tenderness over the lateral epicondyle is located; reproducing the same pain when extending the wrist or middle finger against resistance is typical. Grip strength is compared between sides.

Imaging is not required for every patient. X-rays may be requested in persistent cases to exclude calcium deposits within the tendon, joint wear or another bone problem. Ultrasound and MRI are used when the diagnosis is uncertain, a tendon tear is suspected or treatment has not helped. If numbness and weakness predominate, nerve conduction testing (EMG) may be requested to distinguish nerve-related conditions.

Pain on the inner side of the elbow is not tennis elbow; it suggests golfer's elbow (medial epicondylitis), which affects the attachment of the muscles that bend the wrist. Numbness extending into the little and ring fingers suggests compression of the nerve in the elbow tunnel and is discussed under hand surgery. Catching, locking or an inability to fully straighten the elbow suggests an obstruction inside the joint or joint wear. Nerve compression in the neck can also cause pain along the outside of the arm, so neck movements are assessed during examination.

• Elbow Pain and Elbow Conditions
• Hand Surgery and Wrist Conditions

Tennis elbow is largely treated without surgery; many patients improve with an appropriate programme. The programme has three elements: adjusting load, gradually strengthening the tendon and managing pain. Rest alone is usually insufficient; pain decreases but returns on resuming work.

Surgery is not the first option for tennis elbow. It is considered when symptoms continue for six months to a year despite consistent exercise and load modification, pain substantially affects work and sleep, and imaging shows advanced tendon degeneration or a tear.

During surgery, damaged tendon tissue is removed and, where necessary, healthy tendon is reattached to the bone. The procedure may be open or arthroscopic; the choice depends on the tendon and accompanying problems. A short period of protection is followed by gradual movement and strengthening; returning to work involving heavy gripping generally takes several months. A substantial reduction in pain is expected in most patients, but no surgical result can be promised in advance. Possible risks and recovery are discussed in detail at the consultation.

Tennis elbow requires patience. Symptoms decrease substantially over weeks to a few months in most patients, but recovery can approach a year in some. Common reasons for delay are inconsistent exercise, returning too early to full-load aggravating work, and relying solely on painkillers or a support strap.

If symptoms do not improve within the expected period, the diagnosis is reviewed: a tendon tear, nerve-related condition, intra-articular problem or neck-related pain may coexist. Imaging, changes to the programme or a different treatment step are then discussed.

Take more frequent breaks during work requiring a strong grip, and avoid repeating the same movement for hours. Thick, non-slip tool handles, carrying weights with the palm facing upwards and alternating hands help protect the tendon. A few weeks of preparatory exercise before intensive seasonal work such as cracking hazelnuts, pruning or painting reduces strain risk.

Do not stop exercises immediately when pain resolves; continuing strengthening for a while reduces recurrence. If pain returns, reducing load and seeking early assessment helps prevent a prolonged problem.