Understanding and Managing Chronic Tennis Elbow

May 16, 2024

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As a medical professional, I often see patients struggling with persistent elbow pain that limits their daily activities and quality of life. One of the most common causes of this type of pain is chronic tennis elbow, also known as lateral epicondylitis. In this article, we’ll dive deep into what chronic tennis elbow is, its causes, symptoms, and the various treatment options available to help you find relief and get back to the activities you love.

What is Chronic Tennis Elbow?

Chronic tennis elbow is a condition characterized by persistent pain and tenderness on the outside of the elbow due to overuse or repetitive strain of the forearm muscles and tendons. While acute tennis elbow typically resolves within a few months with conservative treatment, chronic cases last longer than 6-12 months and can significantly impact a person’s daily life[1].

The term “tennis elbow” is somewhat misleading, as the condition can affect anyone who engages in repetitive arm and wrist motions, not just tennis players. In fact, less than 5% of all tennis elbow cases are related to actual tennis playing[2].

Anatomy of the Elbow and Forearm

To better understand chronic tennis elbow, let’s take a closer look at the anatomy involved. The elbow joint is where the upper arm bone (humerus) meets the two forearm bones (radius and ulna). The bony bumps at the bottom of the humerus are called epicondyles, with the lateral epicondyle being on the outer side of the elbow.

Several forearm muscles responsible for extending the wrist and fingers originate from the lateral epicondyle. The main tendon involved in tennis elbow is the extensor carpi radialis brevis (ECRB), which attaches the ECRB muscle to the lateral epicondyle[3]. Repetitive stress on this tendon is what leads to the pain and inflammation associated with chronic tennis elbow.

Causes and Risk Factors

Chronic tennis elbow is primarily an overuse injury resulting from repetitive stress on the forearm muscles and tendons. Some common activities that can lead to this condition include:

  • Manual labor jobs (e.g., plumbing, carpentry, painting)
  • Racquet sports (e.g., tennis, racquetball, squash)
  • Weight lifting
  • Typing and computer use

Certain factors can increase your risk of developing chronic tennis elbow[4]:

  • Age (most common between 30-50 years old)
  • Occupations involving repetitive wrist and arm motions
  • Improper technique or equipment in racquet sports
  • Smoking
  • Obesity

Signs and Symptoms

The hallmark symptom of chronic tennis elbow is persistent pain and tenderness on the outside of the elbow, which may radiate down the forearm. Other common signs and symptoms include[5]:

  • Weakness in the forearm and wrist
  • Stiffness in the elbow joint
  • Pain or difficulty with gripping objects
  • Increased pain with activity and relief with rest

Symptoms often develop gradually and may be more noticeable with certain activities, such as shaking hands, turning a doorknob, or holding a coffee cup.

Diagnosis and Evaluation

If you’ve been experiencing persistent elbow pain, it’s essential to consult with a healthcare provider for an accurate diagnosis. Your doctor will perform a thorough physical examination, assessing your elbow for tenderness, swelling, and range of motion. They may also ask you to perform specific movements to evaluate your pain and strength.

Imaging tests may be ordered to rule out other conditions or assess the extent of tendon damage:

  • X-rays: Can help identify elbow arthritis or bone spurs
  • MRI or ultrasound: Provide detailed images of soft tissues like tendons and muscles

In some cases, your doctor may recommend additional tests, such as electromyography (EMG), to check for nerve compression that can mimic tennis elbow symptoms.

Conservative Treatment Options

The good news is that the vast majority (80-95%) of chronic tennis elbow cases can be effectively managed with conservative, non-surgical treatments[1]. The primary goals of treatment are to reduce pain and inflammation, promote healing, and gradually restore strength and function.

Rest and Activity Modification

One of the most important aspects of treating chronic tennis elbow is giving your arm adequate rest and avoiding activities that aggravate your symptoms. This may involve taking a break from sports, modifying your work setup, or using assistive devices to reduce stress on your elbow.

While complete rest is not necessary, it’s essential to listen to your body and pace yourself to prevent further damage and promote healing.

Ice and Heat Therapy

Applying ice to your elbow for 15-20 minutes several times a day can help reduce pain and inflammation, especially after activity. Once the initial inflammation subsides, heat therapy may be recommended to increase blood flow and promote healing.

Be sure to protect your skin by wrapping ice or heat packs in a thin towel, and never apply them directly to the skin.

Pain Medications and NSAIDs

Over-the-counter pain relievers like acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can help manage pain and reduce inflammation. Be sure to follow the recommended dosage and consult with your doctor if you have any medical conditions or concerns.

In some cases, your doctor may prescribe stronger pain medications or oral corticosteroids to help control severe symptoms.

Physical Therapy and Exercises

Working with a physical therapist is a crucial component of treating chronic tennis elbow. Your therapist will design a customized program to help:

  • Stretch and strengthen the forearm muscles
  • Improve flexibility and range of motion
  • Correct any muscle imbalances or poor techniques
  • Gradually return to normal activities

Common exercises for chronic tennis elbow include[6]:

Wrist extensionGently bend your wrist backwards with your elbow straight, hold for 15-30 seconds
Wrist flexionGently bend your wrist forwards with your elbow straight, hold for 15-30 seconds
Grip strengtheningSqueeze a soft ball or putty in your hand for 5-10 seconds, repeat 10-15 times
Eccentric exercisesSlowly lower a light weight from a wrist extended position to a flexed position

Remember to start slowly and progressively increase the intensity and duration of your exercises as your symptoms improve. If any exercise causes a significant increase in pain, stop and consult with your therapist.

Braces and Splints

Wearing a counterforce brace or wrist splint can help reduce stress on the affected tendon and provide support during activities. These devices are particularly helpful for athletes returning to sport or individuals whose jobs involve repetitive arm motions.

Your doctor or therapist can help you select the appropriate brace and provide guidance on when and how long to wear it.

Injections and Regenerative Therapies

For patients who don’t respond to initial conservative treatments, several injection options may be considered:

  • Corticosteroid injections: Can provide short-term pain relief and reduce inflammation, but repeated injections may weaken the tendon over time.
  • Platelet-rich plasma (PRP): Involves injecting a concentrated sample of your own platelets into the affected area to promote healing. Some studies have shown PRP to be more effective than corticosteroids for chronic tennis elbow[7].
  • Stem cell therapy: A newer regenerative treatment that involves injecting stem cells derived from your own bone marrow or fat tissue into the damaged tendon to stimulate repair. More research is needed to establish its long-term efficacy.
  • Botulinum toxin (Botox) injections: Can help reduce muscle spasms and pain by temporarily paralyzing the affected muscles. This treatment is typically reserved for severe cases that haven’t responded to other therapies.

It’s essential to discuss the potential risks and benefits of these injections with your healthcare provider to determine if they’re appropriate for your specific case.

Surgical Treatment for Refractory Cases

In the small percentage of patients (5-10%) who don’t respond to conservative treatment after 6-12 months, surgery may be recommended as a last resort. The goal of surgery is to remove damaged tendon tissue and promote healing.

Common surgical techniques include:

  • Open debridement: The most traditional approach, involving a single incision over the lateral epicondyle to remove damaged tissue and repair the tendon.
  • Arthroscopic debridement: A less invasive technique using small incisions and a camera to visualize and remove damaged tissue. This approach may result in faster recovery times[8].
  • Percutaneous tenotomy: A minimally invasive procedure using ultrasound guidance to break down and remove damaged tissue with a small needle.

After surgery, patients typically require a period of immobilization followed by physical therapy to regain strength and range of motion. Full recovery may take several months, and it’s crucial to adhere to your surgeon’s post-operative instructions and rehabilitation plan.

Preventing Chronic Tennis Elbow

While it’s not always possible to prevent chronic tennis elbow, there are several steps you can take to reduce your risk:

  • Maintain proper form and technique during sports and work activities
  • Use appropriate equipment (e.g., properly sized tennis racquets with cushioned grips)
  • Gradually increase the intensity and duration of new activities
  • Take frequent breaks and stretch your forearms regularly
  • Strengthen your forearm muscles with exercises like wrist curls and reverse curls
  • Maintain a healthy weight and lifestyle

If you start to experience elbow pain, it’s essential to address it early and give your arm adequate rest to prevent the development of chronic tennis elbow.

Living with Chronic Tennis Elbow

Dealing with chronic tennis elbow can be challenging, but it’s important to stay positive and proactive in your recovery. In addition to following your treatment plan, consider these tips for managing your symptoms and improving your overall well-being:

  • Pace yourself and listen to your body
  • Use assistive devices or ergonomic equipment when needed
  • Apply ice or heat as directed for pain relief
  • Stay active with low-impact exercises like walking or swimming
  • Maintain a healthy diet and sleep schedule
  • Practice stress-reduction techniques like deep breathing or meditation
  • Join a support group or seek counseling if needed

Remember, recovery from chronic tennis elbow is a gradual process that requires patience and persistence. Celebrate your progress, no matter how small, and don’t hesitate to reach out to your healthcare team for guidance and support along the way.

When to Seek Medical Attention

While minor elbow pain can often be managed at home, it’s important to consult with a healthcare provider if:

  • Your pain persists for more than a few weeks despite rest and self-care measures
  • Your pain is severe or interferes with daily activities
  • You experience numbness, tingling, or weakness in your arm or hand
  • You have a visible deformity or significant swelling in your elbow
  • You develop fever, redness, or warmth around your elbow

Prompt evaluation and treatment can help prevent chronic tennis elbow from developing or progressing.

The Importance of a Multidisciplinary Approach

Effectively managing chronic tennis elbow often requires a team approach involving various healthcare professionals. In addition to your primary care doctor, you may benefit from working with:

  • Orthopedic surgeons or sports medicine specialists
  • Physical therapists or occupational therapists
  • Pain management specialists
  • Radiologists for imaging interpretation
  • Mental health professionals for coping strategies and emotional support

By collaborating and communicating with your healthcare team, you can ensure that you receive comprehensive, individualized care that addresses all aspects of your condition.

Emerging Treatments and Research

As our understanding of chronic tennis elbow continues to evolve, researchers are exploring new treatment options and refining existing techniques. Some emerging areas of interest include:

  • Regenerative medicine: Advancements in stem cell therapy and other regenerative approaches may offer new hope for patients with chronic tennis elbow by promoting tendon healing and reducing inflammation.
  • Targeted drug delivery: Researchers are investigating ways to deliver medications directly to the affected area using nanotechnology or other methods, potentially reducing systemic side effects.
  • Personalized rehabilitation: The use of wearable sensors and artificial intelligence may allow for more precise, individualized rehabilitation programs that adapt to each patient’s progress and needs.
  • Genetics and precision medicine: Studies are exploring the genetic factors that may contribute to the development of chronic tennis elbow, which could lead to more targeted prevention and treatment strategies.

While these developments are promising, more research is needed to establish their safety and efficacy in clinical practice.

Conclusion and Key Takeaways

Chronic tennis elbow can be a frustrating and debilitating condition, but with the right approach and support, most patients can find relief and return to the activities they enjoy. Remember these key points:

  • Chronic tennis elbow is an overuse injury that causes persistent pain and tenderness on the outside of the elbow
  • Conservative treatments like rest, ice, physical therapy, and braces are effective for the majority of patients
  • A small percentage of cases may require surgery if symptoms don’t improve after 6-12 months of conservative care
  • Prevention strategies include proper form, appropriate equipment, and gradual progression of activities
  • A multidisciplinary healthcare team can provide comprehensive, individualized care for optimal outcomes
  • Emerging treatments and research offer hope for new and improved management options in the future

If you’re struggling with chronic tennis elbow, don’t hesitate to reach out to a healthcare provider for guidance and support. With patience, persistence, and the right treatment plan, you can overcome this challenging condition and get back to the life you love.

Remember, you’re not alone in this journey. By staying informed, proactive, and connected with your healthcare team and support system, you can take control of your elbow health and find the relief you deserve.


  1. Lai, W. C., Erickson, B. J., Mlynarek, R. A., & Wang, D. (2018). Chronic lateral epicondylitis: challenges and solutions. Open Access Rheumatology: Research and Reviews, 10, 243-251.
  2. Tosti, R., Jennings, J., & Sewards, J. M. (2013). Lateral epicondylitis of the elbow. American Journal of Medicine, 126(4), 357.e1-357.e6.
  3. Bernard, F. M., & Regan, W. D. (2009). Elbow Tendinopathies and Tendon Ruptures. In S. I. Suryavanshi (Ed.), Essentials of Physical Medicine and Rehabilitation (4th ed.). Elsevier.
  4. Sanders, T. L., Jr, Maradit Kremers, H., Bryan, A. J., Ransom, J. E., Smith, J., & Morrey, B. F. (2015). The Epidemiology and Health Care Burden of Tennis Elbow: A Population-Based Study. The American Journal of Sports Medicine, 43(5), 1066-1071.
  5. Vaquero-Picado, A., Barco, R., & Antuña, S. A. (2016). Lateral Epicondylitis of the Elbow. EFORT Open Reviews, 1(11), 391-397.
  6. Stasinopoulos, D., Stasinopoulos, I., Pantelis, M., & Stasinopoulou, K. (2015). Comparable Effects of Eccentric Training Combined with Either Dry Needling or Transverse Friction in the Treatment of Chronic Lateral Elbow Tendinopathy. Evidence-Based Complementary and Alternative Medicine, 2015, 645390.
  7. Mishra, A. K., Skrepnik, N. V., Edwards, S. G., Jones, G. L., Sampson, S., Vermillion, D. A., … & Connell, D. A. (2014). Efficacy of Platelet-Rich Plasma for Chronic Tennis Elbow: A Double-Blind, Prospective, Multicenter, Randomized Controlled Trial of 230 Patients. The American Journal of Sports Medicine, 42(2), 463-471.
  8. Solheim, E., Hegna, J., Øyen, J., Inderhaug, E., Harlem, T., & Strand, T. (2016). Arthroscopic Treatment of Lateral Epicondylitis: Tenotomy Versus Debridement. Orthopaedic Journal of Sports Medicine, 4(3), 2325967116673033.
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