What tennis elbow is
Lateral epicondylalgia, commonly called tennis elbow, is pain and tenderness at the bony point on the outside of the elbow, where the common extensor tendon of the forearm attaches. It hurts on gripping, lifting a kettle, shaking hands and turning a doorknob.
Medial epicondylalgia, or golfer's elbow, is the same process on the inside of the elbow at the common flexor origin. It is less common, and behaves and responds in much the same way.
The tissue change is degenerative rather than inflammatory, which is why the older name "epicondylitis" has largely been dropped. Under the microscope the tendon shows disorganised collagen and increased ground substance, with very few inflammatory cells. That distinction explains why anti-inflammatory approaches disappoint over the long run while loading works.
What causes it
The mechanism is repeated gripping and wrist extension beyond what the tendon is currently conditioned for. Racket sports do it, and so do plumbing, decorating, hairdressing, long days with a mouse, and a new pull-up or deadlift habit.
Peak incidence sits between 35 and 55, and the dominant arm is affected most of the time. Most cases have no single moment of injury, only a fortnight of doing more of something than usual.
Common triggers
- A sudden increase in gripping load at work or in the gym
- Racket sports, particularly a new racket, a change of grip size, or heavy backhand volume
- Manual trades involving repeated wrist extension and gripping
- Long hours with a mouse or a phone held in one position
- Weakness in the shoulder and scapular muscles, which increases forearm workload
- A previous episode, which strongly predicts another
Pain-free grip strength, measured with a dynamometer at a set elbow angle, is the most useful single measure for tracking this condition. It changes before the pain does. A patient who feels no better but has gone from 18 kg to 24 kg of pain-free grip is improving, and knowing that is often what keeps them doing the exercises through the weeks where progress is invisible.
What the evidence says
The natural history is that around 80 to 90 per cent of cases resolve within a year without any treatment. That matters when interpreting claims, since many treatments will look effective against a background of spontaneous improvement.
The best-known trial in this area compared corticosteroid injection, physiotherapy and wait-and-see. At six weeks injection was clearly best. At 52 weeks it was clearly worst, with a recurrence rate around 72 per cent against 8 per cent for physiotherapy. Steroid injection has since been broadly discouraged for this condition.
Progressive resistance training for the wrist extensors, whether eccentric, isotonic or heavy slow resistance, has the strongest evidence for lasting improvement. Adding shoulder and scapular strengthening improves results further.
Extracorporeal shockwave therapy has mixed evidence overall, with better results in chronic cases that have failed a proper loading programme. It is a reasonable second-line option rather than a first move.
Counterforce bracing gives modest short-term symptom relief and does not change the outcome on its own. It is useful for getting through a working day while the loading programme does the actual work.
Recovery timeline
Cases caught early, within about six weeks of onset, often settle in two to three months with load management and a proper programme. Cases that have run for six months or more commonly take six to twelve months, and need patience with a programme that appears to do nothing for the first month.
Pain-free grip is the metric to watch. Expect measurable change in it by week four, well before the elbow feels normal.
| Stage | ✓ Do this | ✗ Avoid this |
|---|---|---|
| Weeks 1–2 | Isometric wrist extension holds for pain relief. Modify grip: fatter handles, lighter loads, break up long tasks. | Complete rest, which weakens the tendon further |
| Weeks 2–8 | Progressive resistance for the wrist extensors, three times a week, plus shoulder and scapular strength. | Deep frictions or aggressive massage of the tendon as the main treatment |
| Weeks 8–16 | Increase load steadily. Reintroduce sport-specific or work-specific gripping in graded steps. | Returning to full racket volume in one week because it felt fine on Saturday |
| If stuck at 3 months | Reassess. Consider shockwave, and check the shoulder and neck as contributors. | Requesting a repeat steroid injection |
How we treat it at Kingsway
Treating an elbow that grips badly
Assessment covers the elbow itself, grip strength measurement, and a screen of the neck and shoulder, since referred pain from the neck can mimic this closely.
- Pain-free grip strength measured and recorded as a baseline
- Neck and shoulder screen to exclude referred pain and identify contributing weakness
- IASTM and soft tissue release through the forearm extensor mass
- Dry needling into the extensor carpi radialis brevis where trigger points reproduce your pain
- Radial shockwave therapy for cases that have run more than three months
- A progressive loading programme with a written progression rule, plus advice on grip size and task modification
Four to six sessions across three months is typical, with a review of grip strength at each. Where shockwave is used, a course of three to five weekly sessions is standard alongside the loading programme.
When to get it checked
Book an assessment if elbow pain has lasted more than three weeks, if it is affecting your grip at work, or if it has come back after settling before. Earlier is better, since cases treated within the first six weeks generally resolve considerably faster.
See a doctor or go to A&E if
- Pins and needles or numbness in the hand or fingers, which suggests nerve involvement
- Elbow locking, catching or giving way
- Marked swelling, redness or heat around the joint
- Pain following a fall or direct impact, which needs a fracture excluded
- Night pain that is severe and unrelated to activity
Common questions
Should I have a steroid injection?
The evidence argues against it for this condition. Injection outperforms everything at six weeks and then does worse than wait-and-see at a year, with recurrence rates above 70 per cent in the best-known trial.
If pain is severe enough to block you from starting a loading programme, it is a conversation worth having with your GP, with the trade-off understood.
Do those elbow straps work?
They give modest short-term relief for many people by changing where load transfers through the tendon, which can make a working day manageable.
They do not change the outcome on their own. Treat a strap as a way to keep working while the exercise programme does the actual job.
Can I keep playing tennis?
Often yes, at reduced volume. Complete withdrawal from sport is rarely necessary and tends to make the return harder.
Practical adjustments that help: a slightly larger grip, lower string tension, fewer one-handed backhands for a few weeks, and shorter sessions more often rather than one long one.
How long before the exercises start working?
Grip strength usually changes measurably by week four. Pain often lags a further two to four weeks behind that.
The most common reason a loading programme fails is that it was stopped at week three for lack of visible progress.