Tennis Elbow (Lateral Epicondylitis)

The suffix -itis is misleading. Tissue samples from chronic tennis elbow show disorganised collagen and failed healing rather than inflammatory cells. This is why rest, ice and anti-inflammatory medication relieve symptoms for a period and rarely resolve the problem.

What the tendon needs is graded load. Loading stimulates the repair process that stalled, and that is the mechanism behind every treatment with good evidence for this condition.

Pain on the outer elbow, worse gripping, lifting with the palm down, shaking hands or turning a door handle. Tenderness over a specific point on the lateral epicondyle. Grip strength is reduced, often markedly, and this is measurable.

It is usually related to a period of unaccustomed load — a new job task, a new racket, a decorating weekend. It affects far more non-players than players.

Progressive resistance work for the wrist extensors, typically starting with isometric holds for pain relief and moving to eccentric and then heavy slow resistance loading. Load is increased on a schedule rather than on how the elbow feels that day.

Alongside it: reducing the aggravating load temporarily rather than resting completely, and correcting technique or equipment where those caused it. A brace can help symptoms in the short term and does not treat the tendon.

Improvement is measured in months. Most people improve substantially by three months and some take longer 1. The most common reason it becomes chronic is stopping the loading programme when the pain settles, before the tendon has adapted.

Corticosteroid injection gives good short-term relief and is associated with worse outcomes at one year than exercise or than doing nothing 3. We will tell you that before offering it.

Because the problem is failed tendon healing rather than inflammation, the intervention that changes it is progressive loading of the tendon itself. Slow, heavy, controlled wrist extension work, increased over weeks, is what produces durable change.

It is deliberately uncomfortable at a tolerable level, and pain during the exercise that settles soon afterwards is acceptable rather than a sign of harm. This is counterintuitive enough that people abandon it without being told, which is why it is explained before it starts.

A counterforce strap worn below the elbow can reduce pain during gripping by changing where load is transmitted. It helps some people get through a working day and it does not treat the tendon.

Wrist splints are occasionally used at night in severe cases. Neither replaces the loading programme, and relying on a brace while avoiding all loading leaves the tendon exactly as weak as it was.

Corticosteroid injection reduces pain substantially in the first weeks. Beyond that the picture reverses: by twelve months, people who had an injection do worse than those who did not, with higher recurrence 3.

That trade-off has to be explained rather than glossed over. There are situations where short-term relief is worth it, but an injection given as a first step, without the loading programme that follows, tends to buy a few good weeks at the cost of a longer overall course.

Tendon remodelling is slow. Meaningful change typically takes eight to twelve weeks of consistent loading, and full resolution often longer. Most people who report that nothing worked stopped at four to six weeks 1.

Grip strength is measured at the start and repeated, because it changes before pain does and gives an objective signal that the programme is working when it does not yet feel like it.