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Tennis Elbow (Lateral Epicondylitis)

Mar 30
12 min read

Updated: Apr 9

Many people complain of a sharp or burning pain on the outer side of their elbow in daily life. Sudden tenderness is felt in the elbow when opening a door, lifting a cup, or gripping something firmly. This condition is often referred to as "tennis elbow" (lateral epicondylitis) . However, this name is actually quite misleading.


The term tennis elbow originates from the fact that this problem was first identified in tennis players. However, modern epidemiological studies show that only a small percentage of cases actually occur in people who play tennis. In fact, only about half of all tennis players experience this problem at least once during their careers, and only about 5% of all cases are directly related to tennis . In other words, tennis elbow is actually more of a musculoskeletal problem associated with daily life and work activities than a sports-related injury .


Tennis elbow is quite common in the general population. Studies indicate that it affects approximately 1–3% of the general population . The condition most frequently occurs in individuals aged 20–65 , with its incidence peaking between the ages of 40–50 . Interestingly, there is no significant difference between men and women, and the condition occurs at similar rates across different ethnic groups.


The impact of this condition on society is not limited to individual pain or decreased athletic performance. Tennis elbow also constitutes a significant socioeconomic burden. In particular, for individuals working in physically demanding professions, the pain can severely affect work performance and lead to prolonged absenteeism. The higher incidence of this problem among individuals working in the construction, manufacturing, and retail sectors is a significant indicator of this.


However, what makes tennis elbow truly interesting is not just its prevalence. For many years, it was considered "tendinitis," or inflammation of the tendons . But recent histological and biomechanical studies have revealed that the problem is often not classic inflammation. Instead, the problem is considered a degenerative tendinopathy resulting from microscopic damage, structural deterioration, and inadequate healing processes in the tendon tissue.



This article will examine tennis elbow not only as a pain syndrome but also from the perspectives of elbow biomechanics, tendon biology, and load-bearing physics . First, we will explore the anatomy of the elbow and why this condition specifically affects certain tendons. Then, we will explain the true pathophysiology, risk factors, diagnostic methods, and modern treatment approaches in light of scientific data.


Because this elbow pain, which seems simple to most people, actually tells a very instructive biological story about the body's load management and tissue adaptation mechanisms.



ELBOW ANATOMY - WHERE THE PROBLEM BEGINS

To understand why tennis elbow occurs, it's essential to first understand the anatomy of the elbow, and especially the tendons that play a role in this condition. The elbow joint is a complex but highly stable joint composed of three bones: the humerus (upper arm bone), the radius, and the ulna (forearm bones) . Working together, these bones enable the bending, straightening, and rotational movements of the forearm.



The bony protrusion located on the outer side of the elbow, at the distal end of the humerus, is called the lateral epicondyle . This area is clinically extremely important because the tendons of the muscles that allow the forearm to extend the wrist and fingers attach to the bone here. The structure where these tendons attach is called the common extensor tendon .


In the vast majority of tennis elbow cases, the affected structure is the extensor carpi radialis brevis (ECRB) tendon , which is part of this tendon complex . Studies show that this tendon is involved in over 95% of cases . In rarer cases, the tendons of other extensor muscles such as the extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris may also be involved.


The primary function of the ECRB muscle is to extend the wrist , that is, to lift the wrist upwards. In addition, it plays an important stabilizing role during gripping movements. For example, this muscle is actively working when firmly holding an object or gripping a racket. Therefore, activities involving repetitive gripping, wrist extension, or forearm rotation place repetitive mechanical stress on the tendon.


One reason the ECRB tendon is particularly sensitive is its anatomical location. Blood flow is limited where the tendon attaches to the bone , which can make it difficult for microtraumas to heal. Over time, repetitive loading can lead to the accumulation of microscopic damage in the tendon tissue, eventually resulting in a condition clinically known as tennis elbow.


Therefore, tennis elbow is not simply a "sports injury," but rather the result of a biological response of the tendons around the elbow to mechanical stress .



THE TRUE NATURE OF THE DISEASE - NOT INFLAMMATION, BUT TENDON DEGENERATION

For many years, tennis elbow was considered an inflammation of the tendons (tendinitis) . Therefore, the name lateral epicondylitis was also used. However, recent histological and biomechanical studies have shown that this condition is often not a classic inflammation.


Modern research indicates that tennis elbow is actually a tendinopathy , a degenerative process that develops in the tendon tissue . Repetitive mechanical stress causes micro-injuries in the tendon tissue, and these injuries accumulate over time. Normally, tendon tissue can repair such micro-traumas; however, under excessive or continuous stress, this repair mechanism may become insufficient.


During this process , there is increased proliferation in tenocytes (tendon cells) , changes in intercellular matrix production, and irregularity in the tendon collagen structure. Over time, the tendon tissue becomes thicker, more irregular, and mechanically weaker. Additionally, neovascularization , or the formation of new but irregular blood vessels, another common finding in degenerative tendinopathies, may also occur.


Therefore, tennis elbow is no longer considered merely an "inflammatory disease," but rather a result of structural damage to the tendon tissue caused by repetitive mechanical stress . In other words, the problem is that the tendon is constantly under stress, and this stress alters the tendon's biological and mechanical structure over time.


This approach has also significantly changed treatment strategies for the disease. If the problem is primarily tendon degeneration rather than inflammation, the goal of treatment should not only be to suppress pain but also to enable the tendon to regain load tolerance . Therefore, exercise therapies and load management play an important role in modern treatment approaches.



WHO GETS TENNIS ELBOW?

Tennis elbow is not usually caused by a single factor. In most cases, the problem develops as a result of an imbalance between repetitive mechanical stress and the biological capacity of the tendon tissue . Therefore, certain activities and professions can increase the risk of developing the condition by placing more stress on the tendon.


SPORTS AND REPETITIVE MOVEMENTS

Although tennis elbow is most commonly associated with racket sports like tennis, many different sports and physical activities can actually cause it. Movements that require wrist extension and strong grips, in particular , place a constant load on the tendon. In tennis, incorrect backhand technique, excessive forearm pronation, or excessive wrist flexion during a serve can put excessive stress on the elbow tendons.


Additionally, equipment factors such as racket weight, grip size, string tension, and ball characteristics can also affect the biomechanical load on the elbow.


OCCUPATIONAL RISK FACTORS

Tennis elbow is actually more common in working populations than athletes . The risk increases significantly, especially in professions that involve intensive use of the hand, wrist, and forearm. The condition is more frequently seen in individuals working in sectors such as construction, manufacturing, and retail.


Scientific studies show that the following types of activities significantly increase the risk of tennis elbow:

  • Repetitive screw turning or rotating movements

  • Prolonged wrist flexion and extension throughout the day

  • Grasping movements requiring high force

  • Long-term hand and forearm strain

These types of activities create both high mechanical stress and repetitive microtraumas on the tendon.


BIOMECHANICAL LOADING

Tendon tissue can adapt to a certain level of load. However, when the amount of load is too high or the resting period is insufficient, microscopic damage begins to accumulate in the tendon tissue. This is especially pronounced in the extensor carpi radialis brevis (ECRB) tendon due to its anatomical structure.


Therefore, tennis elbow is often an "overuse" injury that develops as a result of repetitive loading over a long period of time, rather than a sudden trauma .



HOW TO RECOGNIZE TENNIS ELBOW? - CLINICAL FINDINGS AND DIAGNOSIS

Tennis elbow often presents with a fairly typical clinical picture. Patients usually describe pain localized on the outer side of the elbow . This pain is particularly noticeable during gripping movements or activities requiring wrist extension. For example, the pain may become more pronounced during everyday activities such as lifting a cup, turning a doorknob, or holding a heavy object.


Pain is most often felt in the lateral epicondyle region and can sometimes radiate down the forearm. In the early stages, the pain only occurs during activity, but in advanced stages, it can be felt even at rest. Many patients also notice a decrease in grip strength. This is because the pain limits the normal function of the wrist extensor muscles.


PHYSICAL EXAMINATION

The diagnosis can often be made with a detailed physical examination. The most important finding is tenderness when pressure is applied to the lateral epicondyle on the outer side of the elbow . In addition, some provocative tests are also used.


Cozen test: The test is considered positive if lateral elbow pain occurs when the patient extends their wrist and applies resistance.

Mill test: Pain when the wrist is flexed and the forearm is forced into pronation suggests tennis elbow.

Maudsley test: Pain during resisted extension of the middle finger suggests possible involvement of the extensor tendons.


The aim of these tests is to re-induce pain, particularly by putting the extensor carpi radialis brevis tendon under load.


IMAGING METHODS - ARE THEY NECESSARY?

In most cases, tennis elbow is a clinically diagnosed condition , and imaging techniques are not necessary for the initial assessment. However, in some cases, imaging may be used to confirm the diagnosis or rule out other conditions.


Ultrasonography (US): Thickening of the tendon, disruption of the fibrillar structure, and areas of low echogenicity may be observed. These findings support tendon degeneration.

Magnetic resonance imaging (MRI): MRI can show degenerative changes in tendon tissue in more detail. Tendon thickening and increased intratendinous signal are commonly seen.

Imaging is preferred, especially in the following situations:

  • Pain that persists for a long time despite treatment

  • Suspicion of alternative diagnoses

  • Surgical planning


Other conditions to consider in the differential diagnosis include posterior interosseous nerve compression, osteochondral lesions, lateral ligament injuries, and elbow arthritis .


In conclusion, tennis elbow is most often diagnosed by evaluating the patient's history and physical examination findings together . Imaging techniques are generally used only in selected cases.



NATURAL COURSE OF EVENTS

Although tennis elbow often looks frightening, the natural course of the condition is generally benign . In most cases, it tends to resolve spontaneously. Clinical studies show that approximately 80% of patients experience significant improvement within six months , and about 90% within a year . Therefore, for many patients, the initial approach is weight management and conservative treatment rather than aggressive therapies .


However, in some patients, symptoms may last longer. Particularly in cases where degenerative changes in the tendon tissue have progressed, pain may persist for two years or more . These chronic cases are usually seen when there is continued repetitive mechanical loading or when the tendon's healing capacity is limited.


Several factors that can influence the course of the disease have also been identified. Severe pain at initial presentation , significant loss of function, or the presence of accompanying shoulder and neck pain have been associated with a more aggressive diagnosis. Furthermore, in individuals engaged in physically demanding work, the continued load on the tendon may prolong the healing process.


Therefore, one of the most important principles in the management of tennis elbow is balancing the mechanical load on the tendon . Complete rest is often not necessary; however, reducing activities that trigger pain and controlled reloading of the tendon can support the healing process.



TREATMENT: SURGERY OR CONSERVATIVE APPROACH?

Tennis elbow treatment is one of the most debated topics in medicine. The main reason for this is that the disease cannot be explained by a single mechanism and exhibits different clinical courses in different patients. Currently, the treatment approach is generally a step-by-step strategy, starting with the simplest methods and progressing to more advanced options when necessary .


The first step in treatment usually involves activity modification . The aim of this approach is to reduce excessive mechanical stress on the elbow tendons. Temporarily reducing or modifying movements that trigger pain is particularly important. However, complete immobilization is not recommended, as controlled loading is necessary for tendon tissue to heal.


In modern treatment approaches, the strongest scientific evidence is found for exercise therapy . Strengthening exercises and eccentric exercise programs , particularly those targeting the wrist extensor muscles, can help the tendon tissue regain load tolerance. Exercise programs stimulate the tendon's biological adaptation, contributing to both pain reduction and improved function.


In some patients, nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to control symptoms . These drugs can be particularly helpful in reducing pain in the early stages of the disease. However, since the underlying mechanism of tennis elbow is tendon degeneration rather than inflammation, these drugs may have a limited effect on long-term recovery.


In some cases, injection therapies may also be used. The main injection methods used in clinical practice include corticosteroid injections, platelet-rich plasma (PRP), and autologous blood injections . Although corticosteroid injections can rapidly reduce pain in the short term, studies show that this treatment may lead to worse outcomes in the long term. Therefore, the use of steroid injections has become increasingly cautious today.


Another treatment option is known as extracorporeal shockwave therapy . In this method, it is thought that mechanical waves applied to the tendon area can stimulate the healing process. However, the results of scientific studies have not yet reached a complete consensus on the effectiveness of this treatment.


In most patients, conservative treatment methods are sufficient. However, in some patients, symptoms may persist for a long time. In such cases, surgical treatment may be considered. Surgery is generally recommended for patients who do not achieve significant improvement despite conservative treatments applied for at least 6–12 months . The main goal of surgical intervention is to clean the damaged tendon tissue and create a suitable environment for tendon regeneration.


Three main surgical techniques have been described in the literature: open surgery, percutaneous methods, and arthroscopic surgery . In open surgery, the damaged tendon tissue is directly removed, while in percutaneous techniques, the tendon's bone attachment can be freed through a small incision. Arthroscopic surgery, on the other hand, allows for the removal of tendon tissue by entering the joint using a minimally invasive approach. Studies show that most of these methods have good or excellent outcome rates of approximately 80–90% .


However, it is also important to understand why tennis elbow persists for a long time in some patients. There are several reasons for this. Firstly, the tendon tissue has limited blood supply , so the healing process is slower compared to other tissues. Furthermore, the continued mechanical stress on the tendon during daily activities or work can delay healing. In some chronic cases, the pain may be related not only to tendon damage but also to increased sensitivity (sensitization) in the nervous system .


Therefore, successful management of tennis elbow requires a holistic approach that aims not only to reduce pain but also to reorganize the biomechanical loading of the tendon and gradually increase its functional capacity.



HOW CAN TENNIS ELBOW BE PREVENTED?

Tennis elbow often develops from the accumulation of microscopic damage in the tendon tissue caused by repetitive mechanical stress. Therefore, the main goal of prevention is to properly manage the load on the tendon.


In athletes , especially in racket sports, the correct use of technique is of great importance. Incorrect backhand movements or improper wrist use can put excessive stress on the elbow tendons. Furthermore, appropriate equipment specifications such as racket weight, grip size, and string tension can also reduce the biomechanical load on the elbow.


For working individuals , ergonomics plays a crucial role. In jobs involving repetitive hand and wrist movements, optimizing work routines, taking regular breaks, and distributing the load evenly can prevent excessive strain on the tendons.



CONCLUSION

Although tennis elbow is often perceived as simple elbow pain, it is in reality the result of a rather complex biomechanical and biological process. For many years, it was considered an inflammation developing in the tendons. However, current research shows that the condition is often a tendinopathy associated with degenerative changes in the tendon tissue rather than classic inflammation .


This perspective has significantly changed the understanding of the disease and treatment strategies. Tennis elbow is no longer considered merely a problem of pain suppression, but a mechanical disorder related to load management and tissue adaptation .


Tendon tissue can adapt to a certain level of load; however, when this capacity is exceeded, micro-damage begins to accumulate, and clinical symptoms appear over time.

This understanding underlies modern treatment approaches. Today, the most effective treatment strategies are based on controlling the excessive load on the tendon and enabling the tendon to regain load tolerance through appropriate exercise programs . Therefore, exercise-based rehabilitation programs and activity modification are central to treatment.


In conclusion, tennis elbow is a significant clinical example demonstrating how a problem arising in a small tendon structure is actually related to a vast biomechanical system. With proper load management, appropriate exercise, and biomechanical awareness, both treatment and prevention of this condition are largely possible.



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