Tennis elbow is pain on the outside of the elbow from an overloaded tendon, and most of the people I meet who have it have never played a set of tennis. The medical name is lateral epicondylitis. It shows up in painters, plumbers, framing crews, and anyone who grips a tool all day.
I am a hip and knee surgeon, so this is not a condition I operate on. But after more than twenty years in practice, including time in our general orthopaedic injury clinic, I have had this conversation many times, usually with a patient who came in for a knee.
What is tennis elbow (lateral epicondylitis)?
Tennis elbow is irritation and breakdown of the tendon that anchors your forearm muscles to the bony bump on the outside of your elbow. That bump is the lateral epicondyle. The muscles attached there lift your wrist and fingers, and they fire hard every time you grip.
One tendon takes most of the abuse: the extensor carpi radialis brevis, or ECRB, which steadies your wrist when your elbow is straight. Repeated gripping pulls on that attachment until tiny tears form faster than your body can repair them.
This surprises most patients: it is not really inflammation. Under a microscope the tendon shows disorganized collagen and worn-out tissue, not inflammatory cells. The accurate word is tendinosis, and it explains why anti-inflammatory pills alone rarely fix it. Golfer’s elbow is the same problem on the inside of the joint.
What does tennis elbow feel like?
Tennis elbow feels like a burning ache on the outer elbow that gets worse when you grip, lift, or twist. The pain usually starts mild and builds over weeks or months with no single injury to blame.
The pattern I hear most often in clinic:
- Pain or burning on the outside of the elbow that can travel down the forearm toward the wrist
- A weaker grip, or dropping things you would not normally drop
- Pain with everyday tasks: shaking hands, turning a doorknob, lifting a full coffee cup, opening a jar
- Pain at night or first thing in the morning, usually in the dominant arm
When is outer elbow pain something more serious?
Most outer elbow pain is a tendon problem, not an emergency. Same-day attention is needed for an elbow that is swollen, hot, and red with a fever, an elbow that looks deformed or will not bend, or a fall you think may have broken a bone.
Numbness and tingling are a different flag, because tennis elbow does not cause them. They point to a pinched nerve in the neck or near the elbow, which can coexist with tennis elbow in up to 15 percent of cases. Say so at your appointment.
What causes tennis elbow if you do not play tennis?
Tennis elbow is caused by repeated, forceful gripping combined with lifting or twisting the wrist, especially with the elbow straight. Tennis is one way to produce that load, not the main one.
Tennis players make up only about 10 percent of people with the condition. The rest comes from work and daily life: painting, plumbing, carpentry, driving screws, cutting meat, lifting palm down, and long hours on a computer mouse. On the courts, a one-handed backhand with poor form and the pickleball boom around Franklin and Nashville add a steady stream of cases.
Who gets tennis elbow most often?
Tennis elbow peaks between ages 30 and 50 and shows up in about 1 to 3 percent of adults each year. It is the most common cause of elbow pain I see. Smoking, extra body weight, repetitive hand motion for more than two hours a day, and regularly handling loads over about 44 pounds all raise the risk.
How is tennis elbow diagnosed?
Tennis elbow is diagnosed in the exam room, from your story and a hands-on physical exam, not from a scan. The tenderness sits right on the lateral epicondyle or a fingertip’s width below it.
What is Cozen’s test for tennis elbow?
Cozen’s test is the standard exam maneuver for tennis elbow. You sit with the elbow straight, forearm turned palm down, and hand in a fist. I steady your elbow with one hand while my thumb rests on the lateral epicondyle. Then you try to lift the back of your hand toward the ceiling while I push down against it.
If that resisted wrist lift produces sharp pain at the outer elbow, the test is positive. Cozen’s test picks up about 91 percent of true cases, which makes it a reliable first-visit screen.
Two companion tests, Mill’s test and Maudsley’s test, load the same tendon in different ways. When all three line up with tenderness on the bump, the diagnosis is rarely in doubt.
Do you need an X-ray or MRI for tennis elbow?
Most patients do not. An X-ray can rule out elbow arthritis or an old fracture; the tendon itself does not show on it. Ultrasound and MRI are reserved for cases that are not improving after months of proper treatment.
How do you treat tennis elbow? Six proven steps
Tennis elbow treatment starts by unloading the tendon and then rebuilding it, in that order. Between 80 and 95 percent of patients get better without an operation. It takes patience, and most people quit too early.
- Change the load, do not stop moving. Cut back the motion that hurts: heavy palm-down lifting and hard gripping. Complete rest is not the goal, because tendons need some load to heal.
- Fix your grip and your tools. A larger, softer grip reduces how hard you squeeze. Lift with your palms up and elbows bent.
- Use a counterforce strap. A forearm band worn about two finger widths below the elbow spreads the pull away from the sore attachment point.
- Ice and short-term pain relief. Ice after activity for 15 minutes. A short course of an over-the-counter anti-inflammatory, or a topical anti-inflammatory gel, makes it comfortable enough to exercise.
- Do the eccentric strengthening. This is the part that works, and the part people skip. Eccentric loading means lowering a light weight slowly, over three to five seconds, letting the wrist drop under control. Add forearm stretches with the elbow straight and finger extensions against a rubber band.
- Consider an injection only after the basics fail. A cortisone shot eases pain for about six to eight weeks, but in a one-year trial patients who got a steroid injection were more likely to have their pain return than patients who got a placebo shot, and repeated injections can weaken the tendon. Platelet-rich plasma (PRP) injections have shown more durable results in tendon conditions, though the evidence is still mixed.
For stubborn cases, shock wave therapy and needle tenotomy are office options. The AAOS therapeutic exercise handout for epicondylitis is a good printable starting point.
How long does tennis elbow take to heal?
Most cases improve over six weeks to six months with consistent treatment, and 80 to 90 percent resolve within one to two years. Tendons have a poor blood supply and remodel slowly.
The honest timeline I give: sharp pain settles within a few weeks once you change the load, grip strength takes two to three months, and a full return to hard tennis or heavy manual work takes three to six months. What sets people back is pushing through real pain, then taking a week off, then repeating the cycle.
When does tennis elbow need surgery?
Surgery is considered only after six to twelve months of nonsurgical care has failed and pain still limits work or daily life. Fewer than one in ten patients ever reaches that point.
The operation removes the degenerated part of the ECRB tendon and reattaches healthy tissue to bone, through a small open incision or an arthroscope, as an outpatient. Recovery means a week in a splint, strengthening at about two months, and a return to sport at four to six months. It succeeds in 80 to 90 percent of patients.
Hand, upper extremity, and sports medicine specialists perform this surgery. I do not. At the Bone and Joint Institute of Tennessee we have thirteen fellowship-trained surgeons, and elbow tendon problems go to the partners who treat them every week.
How do you keep tennis elbow from coming back?
Prevention means keeping the tendon strong and never letting activity jump too far, too fast.
- Keep doing the exercises after the pain is gone. Two or three sessions a week holds the gains.
- Build up gradually. The first cool Saturday in Franklin is not the day for three hours of pickleball after a summer off.
- Respect early pain. Two days of modified activity at the first twinge beats three months of rehab.
Getting help for elbow pain in Franklin and Middle Tennessee
If your outer elbow has hurt for more than six weeks, or it affects your grip, work, or sleep, get it looked at. Tennis elbow responds well to treatment, and it responds better early.
The Bone and Joint Institute of Tennessee serves patients from Franklin, Nashville, Columbia, Spring Hill, and across Middle Tennessee, with imaging, rehabilitation, and specialists under one roof.
Call (615) 791-2630 or schedule a consultation at 3000 Edward Curd Lane, Franklin, TN 37067. No referral required.
Want Dr. Calendine’s articles to stand out in your Google and AI search results? Add him as a preferred source (one tap).
Watch: how Cozen’s test for tennis elbow is done
In this short video I walk through Cozen’s test step by step: where my thumb sits, how the wrist is positioned, and what a positive result feels like. If lifting your fist against resistance reproduces pain at that outer bump, that is the answer we are looking for.
Medical disclaimer: This article is for educational purposes and is not a substitute for in-person medical advice. Tennis elbow can resemble other conditions, including nerve compression, elbow arthritis, and ligament injury. Always talk with your physician or an orthopaedic specialist about your symptoms. In a medical emergency, call 911.
References
- Buchanan BK, Varacallo MA. Lateral Epicondylitis (Tennis Elbow). StatPearls. Treasure Island (FL): StatPearls Publishing; updated August 4, 2023. NCBI Bookshelf NBK431092
- Degen RM, Conti MS, Camp CL, Altchek DW, Dines JS, Werner BC. Epidemiology and disease burden of lateral epicondylitis in the USA: analysis of 85,318 patients. HSS Journal. 2018;14(1):9-14. doi:10.1007/s11420-017-9559-3
- Shiri R, Viikari-Juntura E, Varonen H, Heliovaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. American Journal of Epidemiology. 2006;164(11):1065-1074. doi:10.1093/aje/kwj325
- Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. Journal of Bone and Joint Surgery American Volume. 1999;81(2):259-278. PMID 10073590
- Karanasios S, Korakakis V, Moutzouri M, et al. Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET): a systematic review. Journal of Hand Therapy. 2022;35(4):541-551. doi:10.1016/j.jht.2021.02.002
- Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461-469. doi:10.1001/jama.2013.129
