Tennis Elbow/Common Extensor Tendinopathy
1. Introduction
Tennis elbow is one of the most common causes of elbow pain seen in general practice (4). Some of the muscles that control the movement of your wrist, hand and fingers attach to the outside of your elbow via a thick, strong tendon. Sometimes this tendon becomes irritable and painful. Tennis elbow can often be seen in people who perform repetitive daily activities, such as carpenters, plumbers and people who work at a computer. However, it is also seen in people who play sport and those who are also inactive (5).
Tendon pain is dose-dependent which means the pain will be aggravated based on the amount of load it is subjected to (6). If you load the tendon excessively by exposing it to higher tensile forces, or by performing repetitive movements in a relatively short period of time, the tendon cannot adapt quickly enough and may begin to become irritable, leading to pain and the risk of developing tennis elbow.
Frequently Asked Questions
- Tennis elbow is a condition that causes pain around the outside of the elbow. It often happens after overuse or repeated action of the muscles of the forearm, near the elbow joint.
- Tennis elbow (also known as lateral elbow tendinopathy and lateral epicondylitis) is estimated to affect between 1%-3% of the population (1).
- It is the most common cause of persistent elbow pain, accounting for two-thirds of cases in general practice (1).
- No.
- With appropriate rehabilitation and time, tendinopathies generally recover well and are not linked to other serious pathology.
- Women and men are affected equally (2, 3).
- Tennis elbow usually occurs between 35–54 years of age (2, 3).
- Occupational movements that require forceful activities and high force, combined with high repetition (11).
- Localised pain around the outside of the elbow.
- Pain when gripping or lifting an object.
- Normally feels worse as you begin activity but easing after a short period of time.
- Modify or avoid activities that cause your pain.
- Carry things with the palm up.
- Carry things close to the body.
- Progressive and appropriate loading of the tendon has been shown to be one of the most effective treatments.
- Advice by a qualified musculoskeletal physiotherapist will be helpful in most cases.
- This will depend upon several factors including, but not limited to medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation, etc.
- Tennis elbow improves in about 80%–90% of people over 6-24 months (4).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Localised pain around the outside of the elbow.
- Pain when gripping or lifting an object.
- Normally worse as you begin activity but easing after a short period of time.
3. Causes
Tennis elbow, like any form of tendon pain, is caused by the relationship between the demand placed on the tendon (load) and the rate at which the tendon can adapt or regenerate (repair) (6, 7). Tissue samples taken from people with tendon pain tend to show similar findings, which suggest the tendon has tried and failed, to regenerate and cope with the load placed upon it (6). This in turn can lead to pain and weakness with activities that place further demand on the tendon. It is important to note that rarely is there evidence of tendon “damage” and findings on medical images do not correlate well with pain or function (8).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing tennis elbow. It does not mean everyone with these risk factors will develop symptoms.
- Tennis elbow usually occurs between 35–54 years of age (2, 3).
- Occupational movements that require forceful activities and high force, combined with high repetition (11).
- Sudden changes in load or activity such as a weekend doing the garden or DIY.
- Other medical conditions such as diabetes, high cholesterol or smoking, can make tendons more vulnerable to load.
- Taking certain types of medication can lead to the development of tendon pain.
5. Prevalence
- Tennis elbow (also known as lateral elbow tendinopathy and lateral epicondylitis) is estimated to affect between 1%-3% of the population (1).
- It is the most common cause of persistent elbow pain, accounting for two-thirds of cases in general practice (1).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like magnetic resonance imaging (MRI) or ultrasound scan are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help recovery from your tennis elbow. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.
8. Rehabilitation
Research is very clear that modifying the load that goes through the tendon is the key element that stimulates recovery (9). Recovery can take some time as the speed of tendon regeneration is much slower than other structures in the body.
Below are three rehabilitation programmes created by our specialist musculoskeletal physiotherapists targeted at addressing tennis elbow. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Tennis Elbow/Common Extensor Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining a range of movement around the wrist and elbow and appropriate early loading of the affected tendon. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows. We can work into pain during these exercises but ideally, this should not exceed any more than 4/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
Progress onto this programme once the early programme no longer becomes challenging and pain during aggravating activities has settled to between 0-3 on the pain scale. More focus is given to progressive loading of the tendon with an increased number of repetitions, greater levels of resistance or performing the exercise through a bigger range of movement. This should not exceed any more than 5/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive loading of the affected tendon complex to enable your tendon to manage the demands of day-to-day activities. This should not exceed any more than 5/10 on your perceived pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
Steroid injections may be offered to help manage pain in the short term but have been shown to be inadequate for long-term recovery (4, 10). Surgery should be the last option if all other treatment attempts have been exhausted (4).
References
- Descatha, A., Despréaux, T., Calfee, R.P., Evanoff, B. & Saint-Lary, O. (2016). “Progressive elbow pain”, BMJ (Clinical research ed.), 353, 1391-i1391.
- Coombes, B.K., Bisset, L. & Vicenzino, B. (2012). Thermal hyperalgesia distinguishes those with severe pain and disability in unilateral lateral epicondylalgia. The Clinical journal of pain, 28, 595-601.
- Taylor, S.A. & Hannafin, J.A. (2012). Evaluation and management of elbow tendinopathy. Sports Health 4, 384-393.
- NICE: CKS Knowledge Guides: Tennis Elbow (2017) Available online: https://cks.nice.org.uk/topics/tennis-elbow/references/.
- Ahmad, Z., Siddiqui, N., Malik, S.S., Abdus-Samee, M., Tytherleigh-Strong, G. & Rushton, N. (2013). Lateral epicondylitis: a review of pathology and management. The bone & joint journal, 95, 1158-1164.
- Cook, J. L. & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43, 409-41
- Cook, J.L. and Purdam, C. (2012). Is compressive load a factor in the development of tendinopathy?. British journal of sports medicine, 46, pp.163-168.
- Drew, B.T., Smith, T.O., Littlewood, C. & Sturrock, B. (2014). Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. British journal of sports medicine, 48, 966-972.
- Karanasios, S., Korakakis, V., Whiteley, R., Vasilogeorgis, I., Woodbridge, S. & Gioftsos, G. (2020). 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. British Journal of Sports Medicine.
- Coombes, B., Bisset, L. & Vicenzino, B. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. 376, 1751-1767.
- Rahman, S., & Eira, V. (2011). “Lateral and medial epicondylitis: Role of occupational factors”, Best practice & research. Clinical rheumatology, 25, 43-57.