Musculoskeletal Medicine & Physiotherapy & Family Medicine
Tennis elbow
Lateral epicondylitis - commonly known as tennis elbow - is a painful tendinopathy of the insertion of the lateral epicondylar muscles on the lateral epicondyle of the humerus, mainly at the level of the extensor carpi radialis brevis (CERC). Despite the suffix «-ite» suggesting inflammation, histopathological studies demonstrate the absence of the classic inflammatory infiltrate in chronic forms: the anatomopathological picture is that of angiofibroblastic tendinosis (Nirschl 1979) - degeneration of type I collagen into disorganized type III collagen, neovascularization, fibrosis - a degenerative process linked to repetitive mechanical overload rather than true inflammation. This distinction has important therapeutic implications: anti-inflammatory drugs and corticosteroids, highly effective in the short term, do not act on the underlying degenerative process, and are associated with high relapse rates at 12 months. Lateral epicondylitis affects 1 to 3 % of adults between the ages of 35 and 55, with peak incidence between 40 and 50. Contrary to its name, less than 10 % of cases occur in tennis players - the vast majority involve workers performing repetitive forearm movements (IT specialists, musicians, plumbers, mechanics, cooks). The natural course is generally favorable: 80 to 90 % of patients heal spontaneously within 12 to 18 months, but pain and functional disability can be significant during this period, justifying active management.
Clinical Presentation and Differential Diagnosis
- Typical presentation: localized pain at the lateral epicondyle of the humerus, sometimes radiating to the dorsal forearm; gradual onset related to repetitive activity (wrist extension, gripping, tennis forehand with faulty technique, prolonged computer mouse use) or after unusual exertion; maximal pain during gripping objects (handshake, lifting a coffee cup, tightening a tool) and with resisted wrist extension; painful palpation of the lateral epicondyle and 0.5–1 cm distally (common extensor origin); grip strength reduced by 20 to 40 % on the affected side
- Diagnostic clinical trials Cozen's test (resisted wrist extension with closed fist, elbow extended — sensitivity 84 %, specificity 78 %); Mill's test (passive stretch of extensors — forearm pronated + wrist flexed + elbow extended — reproduces pain); Chair test (lifting a chair by the back, elbow extended, forearm pronated — reproduces epicondylar pain); grip strength dynamometer: significant reduction vs. healthy side
- Differential diagnoses to know: Radial tunnel syndrome (posterior interosseous nerve compression—a branch of the radial nerve—3 to 5 cm distal to the epicondyle + painful resisted supination + possible paresthesias—may coexist with epicondylitis in 5 to 10 % of cases—electromyogram for confirmation); medial epicondylitis (golfer's elbow—medial epicondyle—painful resisted wrist flexion); elbow osteoarthritis (limited joint mobility + swelling); radial neuropathy (C6–C7); epicondylar bursitis; C6–C7 cervical pathology (referred pain)
- Risk factors: Age 35–55; strenuous work with repetitive motions (handling, vibrating tools); intensive computer work; incorrect sports technique (tennis — grip too small or too large, strings too tight, forehand with wrist flexion); smoking; obesity; diabetes (tendons more vulnerable to degeneration); hypercholesterolemia (lipid deposits in tendons)
- Imaging : not indicated for routine clinical diagnosis; musculoskeletal ultrasound: tendon thickening + hypoechogenicity + neovascularization on color Doppler — useful if diagnostic doubt or to guide injection; MRI: superior for detecting a partial or complete tear of the rotator cuff (potential surgical indication) — reserved for refractory cases >6 months
Treatment
| Treatment | Mechanism, technique and procedures | Effectiveness, duration and precautions |
|---|---|---|
| Physical Therapy — Eccentric and Isometric Exercises First-line treatment — best long-term prognosis |
Eccentric wrist extensor exercises (Tyler twist - Therabar or flexible stick): eccentric contraction - lengthening of tendon under load → stimulation of type I collagen synthesis + tendon remodeling; standard protocol: 3 sets × 15 repetitions × 2 times/d × 6 to 12 weeks - pain ≤5/10 tolerated during exercise (no pain >5/10 after exercise); acute phase isometric exercises (Rio 2015): isometric contraction of extensors 5 × 45 seconds - immediate analgesic effect demonstrated (corticospinal inhibition of pain) - particularly useful for acute episodes or as a complement to eccentrics; HSR exercises (heavy slow resistance - Coombes 2013 Lancet): progression to heavy loads at slow speed - superior results to eccentrics alone on tendon structure; manual therapy elbow manipulation (HVBA - high velocity low amplitude) to complement exercises (Bisset 2006 BMJ - 65 % cure at 12 months vs 69 % corticosteroids but lower relapse rate) | Gold standard for long-term benefit — superior to corticosteroids at 12 months despite slower initial improvement (Bisset 2006 BMJ); not reimbursed by RAMQ outside of CNESST or SAAQ context — approximate cost $70–$100 $/session in a private clinic in Quebec — expect 6 to 12 sessions on average; supervised exercise programs preferable to home exercises alone for adherence and load progression; gradual return to sport or work as soon as pain is ≤3/10 during activity — do not wait for complete healing; avoid identified aggravating movements (ergonomic modification of workstation: desk height, mouse type, keyboard — ergonomic assessment recommended if work-related cause) |
| Bracing and activity modification Mechanical unloading — short-term relief |
Counter-force brace (epicondyle strap): elastic band applied 2-3 cm distal to the epicondyle — compresses the extensor muscle belly → reduces traction on the epicondylar insertion site → partial unloading of the tendon WRIST BRACE: Wrist brace in slight extension (10–15°): immobilizes the wrist in a resting position → reduces stress on the extensors — most useful at night or during specific activities; activity modification: identification and temporary reduction of aggravating movements (no complete cessation of activity — maintaining pain-free activity recommended); sports ergonomics (tennis): check grip (appropriate handle size — ring finger test), string tension (18–20 kg tension — avoid excessive tension), racket (medium head size — avoid overly stiff rackets), technique (avoid wrist extension during forehand) | Short-term benefit demonstrated (Struijs 2002 Cochrane) — no long-term benefit demonstrated in monotherapy; orthoses are an adjunct to exercises — do not use alone as the primary treatment; recommended duration of use: acute phase and during provocative activities (do not wear constantly — risk of muscle atrophy with prolonged continuous wear); available at pharmacies and from physiotherapists — low cost (15–40 $); not covered by RAMQ but reimbursable by private insurance |
| Pain relief — Topical and oral NSAIDs Short-term pain relief |
NSAIDs: diclofenac gel 1% (%) (Voltaren Emulgel) applied 3 to 4 times/day to the epicondyle × 4 weeks - superior analgesic efficacy to placebo (Cochrane Derry 2015) with minimal systemic effects - first-line if isolated moderate pain or if contraindications to oral NSAIDs (CKD, history of PUD, anticoagulants); oral NSAIDs: ibuprofen 400 mg × 3/day or naproxen 250–500 mg × 2/day × 5 to 10 days - slightly superior to placebo short-term - to be used only for acute painful flare-ups (not for continuous treatment - no demonstrated benefit beyond 2 weeks) - CI: CKD, active peptic ulcer disease, heart failure, anticoagulants - PPI for gastric protection if >5 days or age >65 years; acetaminophen 500–1000 mg × 3–4/day: analgesic adjuvant - less effective alone but useful in combination with NSAIDs; local ice 10–15 min × 3–4/day: local analgesic and anti-inflammatory effect | NSAIDs act on pain but not on the underlying tendinous degenerative process — do not prolong beyond 2 weeks without re-evaluation; topical NSAIDs are preferable to oral NSAIDs if the goal is local analgesia with reduced systemic risk; do not combine two NSAIDs (increased gastrointestinal and renal risk without additional analgesic benefit); inform the patient that NSAIDs improve symptoms but do not speed up tendon healing — eccentric exercises remain the fundamental treatment |
| Corticosteroid infiltration Short-term efficacy — 12-month rebound effect |
Local corticosteroid injection (triamcinolone 10–20 mg or methylprednisolone 20–40 mg) + local anesthetic (lidocaine 1 % — 0.5 to 1 mL) directly at the painful epicondyle site — «peppering» technique (multiple tendon punctures) or single peritendinous injection; ultrasound guidance recommended to improve accuracy (especially if previous infiltration unsuccessful or difficult anatomy); maximum 2 to 3 injections spaced at least 6 to 8 weeks apart — beyond this, risk of skin atrophy, depigmentation, and tendon weakening (risk of tendon rupture if direct intratendinous injection); post-injection flare: increased pain in the 24 to 48 hours following injection (acute reaction to corticosteroid — reassure the patient) | Short-term effectiveness (6 weeks) superior to physiotherapy and placebo — NNT ≈ 2 (Smidt 2002 BMJ) — relief in 70–80 % of cases at 6 weeks; reversed effect at 12 months: infiltrated patients have more relapses and poorer outcomes at 12 months than those treated with physiotherapy alone (Bisset 2006 BMJ) — «rebound» phenomenon linked to the masking effect of corticosteroids on pain without treatment of the underlying degenerative process; always associate with an eccentric exercise program started from the 2nd week post-injection (pain reduction facilitates engagement in exercises); local side effects: skin atrophy (10–20 % after repeated injections) + skin depigmentation (particularly visible in darker skin tones) + tendon rupture (rare but possible if direct intratendinous injection); reimbursed by RAMQ if performed by a physician |
| Second-line treatments and surgery Refractory forms after 6–12 months |
PRP (platelet-rich plasma): injection of autologous plasma concentrated in growth factors (PDGF, TGF-β, IGF-1) into the degenerated common extensor origin tendon → stimulation of tendon regeneration — superior efficacy to corticosteroids at 12 months in some studies (Mi 2017 Am J Sports Med) but heterogeneity of results — not reimbursed by RAMQ — cost $300 to $600 $/injection — 1 to 3 injections spaced 4 weeks apart; extracorporeal shockwave therapy (ESWT): 3 to 5 sessions — neuromodulation mechanism + stimulation of healing — moderate efficacy (Rompe 2007 Am J Sports Med) — not reimbursed by RAMQ — available in private clinics; surgery (Nirschl tenotomy): resection of angiofibroblastic degenerated tissue from the common extensor origin tendon by arthroscopy or open surgery — reserved for refractory forms after >12 months of well-managed conservative treatment — success 85 to 90 % at 2 years — return to work 6 to 12 weeks — reimbursed by RAMQ | Before considering surgery, verify that conservative treatment has been properly conducted (supervised eccentric exercises × 12 weeks + 1-2 injections + ergonomic modification) and that the diagnosis is correct (rule out radial tunnel syndrome — EMG — cervical pathology or elbow osteoarthritis); percutaneous needle tenotomy (tendon fenestration — PENS) is a minimally invasive alternative to open surgery available in some specialized centers; postoperative rehabilitation is essential (physiotherapy for a minimum of 3 months) — without rehabilitation, the recurrence rate increases; refer to orthopedics or hand surgery after failure of 12 months of well-documented, comprehensive conservative treatment |
ℹ️
Radial Tunnel Syndrome - a diagnosis not to be missed: Radial tunnel syndrome is compression of the posterior interosseous nerve (deep branch of the radial nerve) in the radial tunnel, located 3 to 5 cm distal to the lateral epicondyle. It coexists with epicondylitis in 5 to 10 % of cases ( «double crush» syndrome). Distinguishing features include maximal pain on palpation 3 to 5 cm distal to the epicondyle (not on the epicondyle itself), pain with resisted forearm supination (compression at the level of the Fröhse arcade), and paresthesias radiating to the back of the hand. EMG/NCS confirms the diagnosis. Epicondylar injections and eccentric exercises are ineffective for radial tunnel syndrome — surgical decompression is often necessary. A missed differential diagnosis explains many «failures» of epicondylitis treatment.
Signs requiring medical re-evaluation
Consult your doctor if your epicondylitis presents with: Weakness or paresthesias of the hand (Associated nerve compression — radial tunnel syndrome — not to be missed); ; Elbow joint swelling + limitation of flexion-extension (arthritis, joint foreign body, fracture - urgent imaging); ; No improvement after 6 to 8 weeks well-managed (diagnostic and therapeutic reassessment); ; Nocturnal pain at rest, intense unrelated to the activity (mentioning a bone tumor or cervical pathology).
Consult at Clinique Omicron
Clinique Omicron physicians evaluate and treat lateral epicondylitis—clinical diagnosis, prescription of physiotherapy, pain management, corticosteroid injections if indicated, and referral to orthopedics or hand surgery for refractory cases. Consultations are available at our service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not constitute medical advice, diagnosis, or treatment. Neurological deficits or treatment-resistant pain should be re-evaluated by a medical professional.
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