Tennis elbow is a painful tendon condition affecting the outside of the elbow where the forearm extensor muscles attach to the lateral epicondyle. It causes pain with gripping, lifting, and twisting movements and is most accurately described as a tendinopathy, a failed healing response in the tendon, rather than an inflammatory “tendinitis.” Despite its name, fewer than 10% of people diagnosed with tennis elbow actually play tennis.
What’s really happening inside the tendon?
The term “lateral epicondylitis” implies inflammation, but histological studies consistently show something different. Biopsies of affected tendons reveal disorganised collagen fibres, increased ground substance, and neovascularisation (new blood vessel growth into the tendon), but very little inflammatory cell infiltration. This is why the condition is now more accurately called lateral epicondylar tendinopathy.
The extensor carpi radialis brevis (ECRB) is almost always the tendon involved. It sits deepest among the wrist extensors at their common origin on the lateral epicondyle, and it bears the highest mechanical load during gripping. When the tendon’s capacity to handle repetitive load is exceeded, the collagen matrix begins to break down. The resulting pain is the tendon’s way of signalling that it can’t cope with the demands being placed on it.
This distinction matters for treatment. Anti-inflammatory approaches, including cortisone injections, target a process that isn’t primarily inflammatory. A systematic review by Coombes et al. (2010) in The Lancet found that corticosteroid injections provided short-term relief at 4-6 weeks but led to significantly worse outcomes at 6 and 12 months compared to a wait-and-see approach (Coombes et al., 2010, The Lancet). The tendon needs loading, not suppression.
Who gets tennis elbow?
Peak incidence falls between ages 35 and 54. Manual workers, particularly those in trades like plumbing, painting, carpentry, and butchery, are disproportionately affected. On the Costa del Sol, Costa Health sees tennis elbow frequently in padel players, golfers with poor grip technique, and expats undertaking DIY renovation projects on their properties.
Office workers are not immune. Prolonged mouse use with a tensed wrist extensor grip is an increasingly recognised cause, especially when combined with poor workstation ergonomics. The common thread is repetitive, sustained wrist extension and gripping, not the force of a single event.
What does tennis elbow feel like?
Pain on the outside of the elbow is the defining symptom. Gripping a coffee mug, turning a doorknob, shaking hands, or lifting a bag of shopping can all reproduce it. The pain is usually sharply localised to a small area on the lateral epicondyle, though it may radiate down the forearm in more irritable cases.
Grip strength is often significantly reduced. Many patients report dropping objects unexpectedly, not from a nerve problem, but from pain inhibiting their grip. Morning stiffness in the elbow that eases with gentle movement is common.
One important clinical point: pain on the outside of the elbow isn’t always tennis elbow. Radial nerve entrapment (posterior interosseous nerve syndrome) produces very similar symptoms but in a slightly different location, and it won’t respond to the same treatment approach. Cervical spine problems referring pain to the lateral elbow are another mimic. Thorough assessment by a skilled clinician rules these out before treatment begins.
How is tennis elbow treated effectively?
Progressive tendon loading is the cornerstone of evidence-based treatment. The tendon needs to be gradually exposed to increasing mechanical load so it can remodel its collagen structure and rebuild capacity. This isn’t a quick fix. Tendon remodelling takes time, typically 3 to 6 months for meaningful structural change.
Physiotherapy at Costa Health begins with isometric exercises (sustained holds) that can provide pain relief while starting the loading process. Daniele Delicati then progresses patients through eccentric loading (slow lowering movements), heavy slow resistance exercises, and eventually plyometric and sport-specific drills. The Tyler Twist exercise using a FlexBar is a well-researched tool for home-based eccentric loading.
Chiropractic and osteopathic assessment of the cervical spine and thoracic spine is a valuable part of treatment. Restricted neck or upper back mobility can alter nerve dynamics in the upper limb and contribute to lateral elbow pain. Manual therapy addressing these areas often improves treatment response.
Sports massage for the forearm extensors, wrist flexors, and upper arm musculature reduces the muscle tension that compounds tendon loading. Trigger point release in the ECRB and extensor digitorum can provide short-term relief, but it works best as a complement to the active loading programme.
Braces and counterforce straps can reduce pain during activities by offloading the tendon attachment. They’re useful as a management tool during rehabilitation but shouldn’t replace the strengthening work.
What about PRP and shockwave therapy?
Platelet-rich plasma (PRP) injections have shown mixed results in clinical trials. Some studies suggest benefit for chronic cases that haven’t responded to exercise alone, but the evidence isn’t yet strong enough to recommend PRP as a standard first-line treatment. Extracorporeal shockwave therapy has a growing evidence base for recalcitrant cases and is an option worth discussing when standard rehabilitation plateaus.
When should someone get assessed?
Outer elbow pain that persists beyond two to three weeks of rest, or that limits daily tasks like gripping, lifting, or typing, warrants assessment. Pain that wakes you at night, significant grip weakness, or numbness and tingling in the fingers suggests a more complex presentation that needs professional evaluation.
Costa Health’s team in Marbella and Riviera del Sol treats tennis elbow with structured, progressive rehabilitation programmes. Book a consultation to start your recovery. For comparison with a related condition, see the page on golfer’s elbow.