Tennis elbow when you don't play tennis

Of all the people we have treated for tennis elbow, we would guess fewer than one in ten actually plays tennis. The ones who come through the door are plumbers, hairdressers, carpenters, people who spent a weekend painting a ceiling, and — very often — new parents who have been lifting a growing baby in and out of a car seat forty times a day. The name is genuinely unhelpful, and we think it stops people from recognizing what they have.

The pain sits on the bony point on the outside of the elbow and often spreads a few inches down the forearm. It shows up when you grip something, shake a hand, lift a kettle, turn a doorknob or hold a phone. Sometimes the first sign is dropping things, because gripping hurts and the hand quietly gives up.

What is happening is a problem in the tendon that anchors your wrist extensor muscles onto that bony point. The old name for it was lateral epicondylitis, and the -itis ending implies inflammation. That turns out to be misleading for most cases. When these tendons are examined, what is usually found is not an angry inflammatory process but a disorganized, poorly structured tendon that has not kept up with what is being asked of it. That is why the word tendinopathy has largely replaced tendinitis, and it matters enormously for treatment, because you treat a load problem completely differently from an inflammation problem.

Here is the practical consequence. If it were inflammation, rest and anti-inflammatories would be the answer. Because it is a capacity problem, rest just lowers the tendon's capacity further, which is why so many people tell me they rested it for six weeks, felt fine, went back to work and were sore again by the second day. Rest removes the symptom without changing the thing causing the symptom.

What does change it is loading the tendon deliberately, in a controlled way, and building up. In practice that means specific wrist and forearm exercises, usually starting with slow, heavy, controlled work in a range that does not flare you up, then progressing the weight over weeks. Grip strength is both the symptom and the tool — it is what hurts, and it is also what we measure to know whether we are winning. Alongside that we look further up the chain, because a shoulder or a mid-back that is not contributing means the forearm takes more than its share.

A word on the counterforce strap, the band that sits just below the elbow. They can help a lot with getting through a workday, and I am happy for people to use one. But it is a bridge, not a treatment. It changes where load goes; it does not build tendon capacity. If the strap is the only thing in the plan, you will still be wearing it next year.

Corticosteroid injections deserve an honest mention because people ask about them frequently. They usually work impressively in the short term, over the first few weeks. The uncomfortable part is that the medium and longer term results are consistently worse than doing nothing at all or doing a loading program, with higher recurrence rates. That does not make them never appropriate, but I want people going in with clear eyes about the trade being made.

The last thing, and the part nobody wants to hear, is the timeline. Tendons adapt slowly. A reasonable expectation for a stubborn tennis elbow is three to six months of consistent work, sometimes longer if it has been going on for a year before you sought help. The trajectory is usually good and steady, but it is measured in months, not sessions. Knowing that up front makes the whole thing far less discouraging, because the slow weeks stop feeling like failure.

Hopefully you found this information helpful. Feel free to contact us for more information or questions! If there are topics you would like to see us cover, definitely drop us an email and it may be featured during a future blog post.

‍

Fady Rofail PT

‍

References

1. 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.
2. 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.

‍