Tennis & Golfer’s Elbow

Tennis elbow (lateral epicondylalgia) and golfer`s elbow (medial epicondylalgia) are overuse tendinopathies of the common extensor and common flexor origins at the lateral and medial epicondyle of the humerus respectively. Despite their colloquial names, both conditions affect far more non-athletes than athletes — office workers, manual labourers, and recreational players are commonly affected. The underlying pathology is degenerative tendinosis (not tendinitis), characterised by disorganised collagen, fibroblast proliferation, and angiofibroblastic hyperplasia without significant acute inflammatory infiltrate.

• Tennis elbow (lateral epicondylalgia) incidence: approximately 1–3% of the population per year; peak incidence 35–55 years; equal sex incidence; the dominant arm is most commonly affected; affects approximately 50% of all tennis players at some point, but most cases are occupational or non-sport-related
• Tendon involved in tennis elbow: the extensor carpi radialis brevis (ECRB) is the primary tendon involved — its origin at the lateral epicondyle is the site of maximum pathological change; the ECRB undergoes the highest tensile stress with wrist extension and is positioned at the leading edge of the common extensor origin where it is vulnerable to shear stress; ECRP (extensor digitorum communis) may also be involved but ECRB is the primary structure
• Golfer`s elbow (medial epicondylalgia): less common than tennis elbow; the flexor-pronator origin (primarily flexor carpi radialis and pronator teres) is involved; medial elbow pain; the ulnar nerve must always be assessed in medial epicondylalgia — cubital tunnel syndrome may coexist (approximately 20–30% of cases)
• Pathology (Nirschl): the pathological finding is not inflammation but angiofibroblastic dysplasia — immature fibroblasts, disorganised type III collagen, and vascular hyperplasia (neovascularisation); this is identical to Achilles and patellar tendinopathy; the term "epicondylitis" is therefore a misnomer

• Tennis elbow clinical features: lateral elbow pain; tenderness at or just distal to the lateral epicondyle (over the ECRB origin); pain with wrist extension and gripping (shaking hands, turning a key, lifting objects with elbow extended); pain aggravated by activities requiring wrist extension against resistance; may radiate down the forearm
• Cozen test (resisted wrist extension test): patient`s elbow is extended; examiner stabilises the lateral epicondyle with one thumb; patient extends the wrist against resistance; positive if pain is reproduced at the lateral epicondyle; highly sensitive and the most commonly used clinical test for tennis elbow
• Mill`s test: elbow fully extended, wrist fully flexed, forearm pronated; examiner stretches the ECRB by passively extending the wrist; positive if lateral epicondyle pain reproduced; a passive stretch test complementing the active Cozen test
• Chair-lift test (Maudsley test): patient lifts a chair with the elbow extended and the forearm pronated; positive if lateral epicondyle pain reproduced
• Golfer`s elbow clinical features: medial elbow pain; tenderness at the medial epicondyle and common flexor origin (FCR and pronator teres); pain with wrist flexion and forearm pronation against resistance; pronation and grip-related pain
• Golfer`s elbow + ulnar nerve: always test ulnar nerve function in medial epicondylalgia — ring and little finger paraesthesia, Tinel sign at the cubital tunnel, elbow flexion test positive; cubital tunnel syndrome coexists in approximately 20–30% of golfer`s elbow cases; failure to recognise and treat the ulnar nerve component leads to incomplete symptom relief after local treatment
• MCL assessment in golfer`s elbow: assess medial collateral ligament stability (valgus stress test at 30°); MCL injury and medial epicondylalgia can coexist in overhead throwing athletes; palpate over the MCL (distal to the common flexor origin)

• Clinical diagnosis in most cases — investigations are not required for straightforward tennis or golfer`s elbow
• Plain radiographs: usually normal; may show calcification at the tendon origin in chronic cases (approximately 20–25%); assess for lateral or medial epicondyle avulsion, OA, loose bodies
• Ultrasound: shows hypoechoic degeneration within the ECRB origin (lateral epicondyle) or flexor-pronator origin (medial); neovascularisation on power Doppler; tendon thickening; confirms the diagnosis when clinical uncertainty exists; guides injection therapy; useful for distinguishing between tendinopathy and epicondyle stress fracture (rare)
• MRI: for atypical presentations, suspected associated pathology (osteochondritis dissecans of the capitellum, loose bodies, MCL injury, posterior interosseous nerve entrapment at the radial tunnel); high signal within the ECRB origin on fat-suppressed sequences in tennis elbow
• Posterior interosseous nerve (PIN) / Radial tunnel syndrome: the PIN (deep branch of the radial nerve) passes through the radial tunnel (formed by the extensor muscle group) and can be compressed at the arcade of Frohse (proximal edge of the supinator) — radial tunnel syndrome; presents with lateral elbow pain (similar to tennis elbow) but the maximal tenderness is 4–5 cm distal to the lateral epicondyle (over the radial tunnel) rather than at the epicondyle; weakness of finger and wrist extension in severe cases; must be distinguished from tennis elbow

Approximately 80–90% of patients with tennis elbow resolve with non-operative treatment over 12–18 months. The natural history is resolution, though the process is slow and symptoms can be debilitating in the interim.

• Physiotherapy and eccentric loading: the cornerstone of treatment; eccentric wrist extension exercises for tennis elbow (Tyler Twist programme using a flexible bar — FlexBar; Theraband); progressive tendon loading to stimulate collagen remodelling; graded return to aggravating activities
• Counterforce bracing: tennis elbow clasp (epicondylitis strap) worn 2–3 cm distal to the lateral epicondyle; redistributes load away from the ECRB origin; provides symptomatic relief during activity; widely used and well tolerated
• Corticosteroid injection: short-term (6–12 weeks) pain relief in approximately 70–80% of patients; USS-guided injection into the region of maximum tendon degeneration at the ECRB origin; however, multiple RCTs (Coombes et al. Lancet 2013) show that corticosteroid injection is associated with WORSE long-term outcomes and higher recurrence compared to physiotherapy or wait-and-see — the short-term benefit is at the cost of long-term prognosis; not recommended as routine first-line management; reserve for patients with severely limiting pain preventing engagement with physiotherapy
• PRP (platelet-rich plasma) injection: growing evidence; may be superior to corticosteroid for long-term outcomes; Mishra et al. — PRP superior to corticosteroid at 6 months; considered after failure of physiotherapy and before surgery in many centres; USS-guided
• Activity modification: identify and modify aggravating activities; ergonomic assessment for occupational cases; equipment modification for tennis players (larger grip, softer strings, lighter racket)

• Indications: failure of 6–12 months structured non-operative treatment; persistent severe symptoms; confirmed tendinosis on imaging with no response to conservative measures
• Open lateral release (Nirschl procedure): the pathological angiofibroblastic tissue at the ECRB origin is excised; the origin is débrided and healthy bleeding bone is exposed (bony decortication stimulates revascularisation and healing); the origin is repaired to the bone; this procedure addresses the underlying pathology directly; reported success rates of 85–90% at 5 years; the gold standard surgical procedure for recalcitrant tennis elbow
• Arthroscopic débridement: arthroscopic debridement and release of the undersurface of the ECRB origin; allows assessment of the radiohumeral joint for associated intra-articular pathology (synovial plica, osteochondral lesion); comparable results to open surgery; increasingly performed
• Percutaneous tenotomy: ultrasound-guided percutaneous needle fenestration or percutaneous tendon release at the ECRB origin; minimal access; growing evidence; useful for patients wishing to avoid formal surgery
• Golfer`s elbow surgery: open medial epicondyle release and debridement of the flexor-pronator origin; less commonly required than for tennis elbow as most cases resolve non-operatively; simultaneous cubital tunnel decompression if ulnar nerve symptoms are present

• Coombes et al. Lancet RCT (2013): landmark three-arm RCT comparing corticosteroid injection vs physiotherapy vs wait-and-see for tennis elbow; at 12 months, the corticosteroid group had significantly worse outcomes (higher recurrence, lower complete recovery rate) compared to physiotherapy alone or wait-and-see; this study fundamentally changed practice — corticosteroid injection should not be a routine early intervention for tennis elbow; physiotherapy-first or watchful waiting is the preferred approach
• Radial tunnel syndrome vs tennis elbow: the distinction is clinically important — tenderness at the lateral epicondyle = tennis elbow; tenderness 4–5 cm distal to the epicondyle over the radial tunnel = radial tunnel syndrome (PIN compression); resisted middle finger extension is classically positive in radial tunnel syndrome (due to extensor digitorum communis contraction at the arcade of Frohse); EMG/NCS may show PIN slowing but are often normal in mild cases; surgical decompression of the PIN at the arcade of Frohse if non-operative treatment fails
• UCL (medial collateral ligament) injury in overhead athletes: golfer`s elbow in a baseball pitcher or javelin thrower may mask or coexist with UCL insufficiency; the UCL is the primary restraint to valgus stress; medial elbow pain + valgus instability at 30° + MRI showing UCL signal change = UCL injury; UCL reconstruction (Tommy John procedure — palmaris longus or gracilis graft through bone tunnels in the medial epicondyle and sublime tubercle of the ulna) is required for overhead athletes wishing to return to sport; medial epicondylalgia alone does not require UCL reconstruction
• Dry needling and barbotage: used in some centres for recalcitrant tennis elbow; ultrasound-guided insertion of multiple needle passes into the degenerate tendon origin (fenestration) creates a haematoma and stimulates healing; evidence is growing; mechanism similar to PRP but without injection of biological adjuvant

• Tennis elbow = lateral epicondylalgia; ECRB is the primary tendon involved; angiofibroblastic dysplasia (tendinosis), NOT tendinitis
• Cozen test: resisted wrist extension with elbow extended; most commonly used test; positive if lateral epicondyle pain reproduced
• Golfer`s elbow: medial epicondyle and common flexor origin; ALWAYS assess ulnar nerve — 20–30% have coexisting cubital tunnel syndrome; failure to treat both = incomplete relief
• Corticosteroid injection: short-term benefit; worse long-term outcomes vs physiotherapy (Coombes Lancet 2013); reserve for severe pain preventing physiotherapy engagement; not routine first-line
• PRP injection: growing evidence; superior to steroid at 6 months in some RCTs; option after physiotherapy failure, before surgery
• 80–90% resolve non-operatively over 12–18 months; surgery for <10–20% refractory cases
• Nirschl procedure (open lateral release): excision of angiofibroblastic tissue + decortication + repair; 85–90% success at 5 years
• Radial tunnel syndrome: maximal tenderness 4–5 cm distal to lateral epicondyle; positive resisted middle finger extension; distinguish from tennis elbow (epicondyle tenderness); decompress PIN at arcade of Frohse if non-operative fails
• UCL injury in overhead athletes: golfer`s elbow + valgus instability + MRI UCL change = UCL insufficiency; Tommy John procedure for return to sport
• Counterforce brace: epicondylitis strap 2–3 cm distal to epicondyle; redistributes load; symptomatic relief during activity