Lateral Epicondylitis (Tennis Elbow)
Tennis elbow is the most common elbow condition seen in orthopedic and sports medicine practice, affecting approximately 1–3% of the general population each year. Despite its name, fewer than 10% of patients are tennis players; the condition affects office workers, manual laborers, musicians, and anyone performing repetitive gripping or wrist extension. At Maryland Orthopedic Specialists, we offer a full spectrum of evidence-based treatments (from structured physical therapy and advanced injection options to surgical debridement for refractory cases) at our Bethesda and Germantown offices.
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What is lateral epicondylitis (tennis elbow)?
Lateral epicondylitis is a degenerative tendinopathy of the extensor carpi radialis brevis (ECRB) origin at the lateral epicondyle of the humerus. Histologically, the tissue demonstrates angiofibroblastic tendinosis: disordered collagen, vascular hyperplasia, fibroblast proliferation, and a conspicuous absence of inflammatory cells.
Lateral epicondylitis is a degenerative tendinopathy of the extensor carpi radialis brevis (ECRB) origin at the lateral epicondyle of the humerus. Histologically, the tissue demonstrates angiofibroblastic tendinosis: disordered collagen, vascular hyperplasia, fibroblast proliferation, and a conspicuous absence of inflammatory cells. Despite the suffix "-itis," the condition is not inflammatory in the classic sense. This has important implications for treatment.
The ECRB origin is the primary affected structure. It occupies the deep, anterior surface of the common extensor origin and is vulnerable because of its poor vascularity and the high tensile loads applied during wrist extension and forearm supination. Repetitive microtrauma from backhand strokes, computer mouse use, screwdriving, or meat-cutting are classic precipitants.
Symptoms — do you recognize these?
- Lateral elbow pain at or just distal to the lateral epicondyle
- Pain radiating down the dorsal forearm
- Worsened by gripping, carrying, or wrist extension (e.g., shaking hands, lifting a coffee cup)
- Point tenderness over the ECRB origin, approximately 1 cm distal and anterior to the lateral epicondyle
- Grip strength weakness
- Morning stiffness
Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.
How we diagnose it
Clinical Examination
- Lateral Cozen test: The examiner resists active wrist extension with the elbow extended and the forearm pronated; reproduction of lateral epicondyle pain is a positive result.
- Mill's test: Passive full wrist flexion and forearm pronation with the elbow extended stretches the ECRB and reproduces lateral pain; sensitivity ~54%.
- Middle finger extension test: Resisted extension of the middle finger with the elbow extended stresses the ECRB (which assists in this motion) and can provoke symptoms. It is also useful for distinguishing from radial tunnel syndrome (tenderness more distal in RTS).
- Maudsley test (resisted middle finger extension): Similar to middle finger test; positive if lateral epicondyle pain is reproduced.
Imaging
- Plain radiographs: Usually normal; calcification at the lateral epicondyle in ~20% of chronic cases.
- MRI: Gold standard for confirming ECRB tendinopathy (T2 signal increase at the lateral epicondyle), grading disease severity, and evaluating for complete tear or associated pathology (posterolateral rotatory instability, radiocapitellar OA).
- Ultrasound: Dynamic real-time assessment of tendon thickness, hypoechogenicity, and neovascularity; cost-effective and can guide injections.
Treatment options
Conservative Management (First-Line)
Physical therapy (PT): PT is the single most effective long-term treatment for tennis elbow. PT should be the mainstay of treatment from the outset. Counterforce (epicondyle) bracing: A proximal forearm strap redistributes tensile forces away from the injured tendon during activity. Corticosteroid injection: Provides excellent short-term (4–8 week) pain relief and is appropriate for acute flares and patients needing quick symptomatic relief. However, RCTs consistently demonstrate that corticosteroid is inferior to PT at 1 year and may be associated with higher recurrence rates at 6–12 months and higher rate of surgery. Other modalities: Ultrasound-guided percutaneous needle tenotomy (Tenex), dry needling, topical nitroglycerin, and autologous blood injection
Platlet Rich Plasma
Platelet-rich plasma (PRP): A growing body of RCT evidence supports PRP over corticosteroid injection for medium-to-long-term outcomes. Multiple high-quality trials demonstrate superiority of PRP at 6 and 12 months for pain reduction and functional scores. PRP is a preferred option for patients who have had suboptimal results with corticosteroid injection or who prefer a durable, biologically based treatment.
Extracorporeal shockwave therapy (ESWT)
Extracorporeal shockwave therapy (ESWT): A non-invasive treatment that delivers high-energy acoustic waves to the affected tendon, stimulating neovascularization and cellular repair. Multiple meta-analyses support ESWT as superior to sham for pain reduction at 3 and 6 months; it is a reasonable second-line option before surgical intervention.
Tennis Elbow Release (Lateral Epicondyle Debridement)
Open surgical débridement of the degenerative extensor carpi radialis brevis origin at the lateral epicondyle. Reserved for patients with refractory lateral epicondylitis that has failed at least six months of non-operative treatment.
Click for more Surgical ProcedureElbow Arthroscopy
Minimally invasive joint scope to address loose bodies, osteochondritis dissecans, posterior impingement, and selected cases of refractory lateral epicondylitis through small portals at the elbow.
Click for moreRecovery & rehabilitation
- Conservative management: Meaningful improvement in 6–12 weeks of structured PT; full resolution by 6–18 months in most patients.
- Post-surgical: Protective splinting for 1–2 weeks; formal PT from week 2–3; return to light activity at 6–8 weeks; return to sport or heavy labor at 4–6 months.
Frequently Asked Questions
Why doesn't my tennis elbow respond to anti-inflammatories?
Should I get a cortisone shot?
What makes PRP different from cortisone?
How do I know if I need surgery?
Can I keep working during treatment?
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Related conditions
References
- Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751–1767. https://doi.org/10.1016/S0140-6736(10)61160-9
- Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. American Journal of Sports Medicine (AJSM). 2013;41(6):1435–1446. https://doi.org/10.1177/0363546512473205
- Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. https://doi.org/10.1136/bmj.38961.584653.AE
- American Academy of Orthopaedic Surgeons. Tennis Elbow (Lateral Epicondylitis). OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis (accessed May 2026).
- Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: current concepts. Journal of the American Academy of Orthopaedic Surgeons (JAAOS). 2008;16(1):19–29. https://doi.org/10.5435/00124635-200801000-00004