Tennis Elbow, medically known as Lateral Epicondylitis, is a painful condition caused by overuse of the forearm muscles and tendons. Despite its name, it affects far more than just tennis players.
While tennis elbow is commonly associated with racket sports, it can affect anyone who performs repetitive gripping or wrist extension activities from painters and plumbers to office workers and chefs.
Understanding your condition is the first step toward recovery. Whether you want to return to your sport or simply lift a coffee cup without pain, this guide covers everything from anatomy to advanced physiotherapy rehabilitation.
The elbow is a hinge joint where the upper arm bone (humerus) meets the two forearm bones (radius and ulna). On the outer side of the elbow is a bony prominence called the lateral epicondyle the attachment point for the forearm extensor muscles.
Key Structure Involved:
The Extensor Carpi Radialis Brevis (ECRB) is the primary tendon affected in tennis elbow. It runs from the lateral epicondyle down the forearm and plays a vital role in wrist extension and stabilization during gripping activities.
Key Functions of the Forearm Extensors:
Wrist Extension: Lifting the back of the hand upward.
Grip Stabilization: Keeping the wrist steady while gripping objects.
Forearm Control: Coordinating rotation and load-bearing during arm movements.
In tennis elbow, repetitive stress causes microscopic tears and degeneration at the tendon origin, leading to pain and reduced function.
If you have tennis elbow, you may notice the following signs:
A dull ache or sharp pain on the outside of the elbow, which may radiate down the forearm.
Difficulty gripping objects, shaking hands, or turning a door handle.
Pain when lifting even light objects, especially with the elbow extended and palm facing down.
Stiffness and discomfort around the elbow joint, particularly in the morning or after rest.
Sensitivity when pressing on the bony outer part of the elbow (lateral epicondyle).
Symptoms are aggravated by activities like typing, wringing a towel, using a screwdriver, or playing racket sports.
Contrary to popular belief, you do not need to play tennis to develop tennis elbow. The condition develops gradually due to repetitive stress on the forearm tendons, not from a single injury.
Repetitive Gripping: Prolonged gripping activities such as using tools, gardening, or. racket sports.
Repetitive Wrist Extension: Repeated lifting or extending the wrist against resistance.
Poor Technique: Incorrect backhand technique in racket sports placing excessive strain on the tendon.
Sudden Increase in Activity: A rapid increase in training volume or introducing a new physical task.
Occupational Overuse: Repetitive manual tasks in jobs such as carpentry, painting, cooking, or computer work.
Certain factors may increase your likelihood of developing tennis elbow:
Age: Most commonly affects adults between 35 and 54 years of age.
Occupation: Jobs involving repetitive forearm and wrist movements painters, plumbers, butchers, and desk workers.
Sport: Racket sports players, especially those with poor technique or ill fitting equipment.
Physical Conditioning: Weak forearm and shoulder muscles increase tendon load and injury risk.
Equipment: Using a racket with an incorrect grip size or string tension.
If left untreated or poorly managed, tennis elbow can lead to:
Chronic Pain: Persistent pain lasting months to years with ongoing functional limitation.
Tendon Rupture: In severe or long-standing cases, the tendon may partially or fully tear, requiring surgical intervention.
Reduced Grip Strength: Progressive weakness affecting daily tasks and work performance.
Recurrence: Without addressing the underlying cause and building adequate tendon strength, tennis elbow has a high recurrence rate.
While tennis elbow can be difficult to avoid entirely, you can significantly reduce your risk by:
Strengthening: Regularly strengthen the forearm extensors, flexors, and shoulder muscles to build tendon resilience.
Warm-Up: Always perform a dynamic warm up before sports or manual tasks.
Technique: Learn and maintain proper technique in racket sports especially the backhand stroke.
Equipment: Use appropriate grip size, string tension, and ergonomic tools suited to your hand size and activity.
Gradual Progression: Avoid sudden spikes in training volume or introducing new repetitive tasks without gradual build up.
Rest and Recovery: Allow adequate rest between repetitive activities to give tendons time to recover.
A proper diagnosis is essential to determine the severity of your condition and guide the most effective treatment plan.
Physical Examination
Your physiotherapist will assess both arms, comparing the affected side with the unaffected one, and check for tenderness, grip strength, and range of motion.
Special Tests
Therapists use specific tests to confirm the diagnosis:
Cozen’s Test: You are asked to extend your wrist against resistance with the elbow straight. Reproduction of lateral elbow pain indicates a positive test.
Mill’s Test: Your therapist passively flexes your wrist while your elbow is extended and forearm turned inward. Pain at the lateral epicondyle is a positive finding.
Maudsley’s Test: Resisted extension of the middle finger with the elbow extended provokes pain at the lateral epicondyle.
Grip Strength Test: Grip strength is measured using a dynamometer and compared between both hands. Reduced and painful grip on the affected side supports the diagnosis.
Imaging
Ultrasound: The preferred first-line imaging. It can identify tendon thickening, degenerative changes, calcifications, and increased blood flow (neovascularization) around the tendon.
MRI: Used for complex or refractory cases to rule out partial or complete tendon tears and assess surrounding structures.
X-Ray: Rarely diagnostic but may detect calcific deposits at the lateral epicondyle in chronic cases.
Grading of Tennis Elbow
Grade 1: Mild tendon irritation. Pain only with strenuous activity. No functional limitation at rest.
Grade 2: Moderate tendon degeneration. Pain with everyday tasks such as gripping and lifting. Some functional limitation.
Grade 3: Severe degeneration or partial tendon tear. Constant pain significantly limiting daily activities, with possible rest and night pain.
Treatment depends on the severity of your condition, your activity demands, and your personal goals.
Suitable for the majority of patients, as 80–90% of tennis elbow cases resolve with conservative management.
PEACE & LOVE Protocol
Immediately After Onset: PEACE
Protection: Reduce provocative activities for the first few days to calm tendon irritability.
Elevation: Elevate the arm when resting to help reduce swelling if present.
Avoid Anti-inflammatories: Avoid ice and anti-inflammatory medications in the early stage the body’s natural response supports tendon healing.
Compression: A counterforce forearm brace (tennis elbow strap) can offload the tendon and reduce pain during activity.
Education: Understand your condition and avoid passive treatments alone active recovery is key.
After the First Few Days: LOVE
Load: Gradually reintroduce tendon loading guided by your pain levels.
Optimism: A positive mindset significantly influences recovery outcomes.
Vascularisation: Begin pain-free cardiovascular activity to promote blood flow and healing.
Exercise: Start a structured, progressive tendon loading program to rebuild strength and capacity.
Injection Therapy
Corticosteroid Injection: Provides effective short-term pain relief but is associated with higher recurrence rates with repeated use. Best used to enable participation in rehabilitation, not as a standalone treatment.
Platelet-Rich Plasma (PRP): An emerging regenerative therapy showing promising medium to long-term outcomes by stimulating tendon repair.
Reserved for refractory cases that have not improved after 6–12 months of comprehensive conservative treatment. Surgery involves debridement of the degenerated tendon tissue, with high success rates of 70–90%. Recovery following surgery takes several months.
Whether you opt for conservative management or post-surgical rehabilitation, physiotherapy is the cornerstone of recovery. Your physiotherapist will design a tailored treatment plan based on your specific goals and lifestyle.
Patient Education
We ensure you understand your condition, the recovery timeline, and the milestones required to return safely to your activities.
Manual Therapy
Hands-on techniques including soft tissue release, joint mobilization, and Mobilisation with Movement (MWM) to reduce pain, restore range of motion, and improve tendon function.
Pain Management
Use of modalities such as TENS, therapeutic ultrasound, and dry needling to manage pain and support tissue healing.
Strengthening Exercises
Progressive tendon loading is the most important component of tennis elbow rehabilitation.
Early Stage: Isometric wrist extension exercises to load the tendon with minimal stress and reduce pain.
Progressive Stage: Isotonic wrist extension and flexion with dumbbells or resistance bands, forearm pronation and supination, grip strengthening with putty or hand gripper.
Proprioception & Neuromuscular Control
Retraining the coordination and control of the forearm and elbow to improve load management and prevent recurrence.
Functional & Sport-Specific Training
Once strength and pain are well controlled, we bridge the gap to full performance:
Grip and Load Progression: Gradually increasing load to match occupational or sporting demands.
Sport-Specific Drills: Racket technique correction, serving mechanics, and progressive on-court training.
Return to Work: Simulation of manual tasks with graded exposure to ensure safe return to occupational duties.
Wrist circles are a simple, dynamic stretching and warm up exercise designed to mobilize the wrist joint, lubricate the surrounding connective tissues, and prepare the arms for activity.
This is a simple and effective stretch designed to relieve tension and tightness along the top of your forearm and wrist.
Book a consultation to get personalized treatment advice for your condition.
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