Epicondylitis, commonly known as tennis elbow, is a painful condition affecting the tendons on the outer side of the elbow. It affects approximately 1 to 3 percent of the adult population, with peak incidence between ages 30 and 50, and accounts for up to 40 percent of all elbow injuries in tennis players. While the name implies a tennis-specific problem, this condition affects office workers, plumbers, painters, and anyone performing repetitive arm and wrist movements with equal frequency.
Unlike an acute sprain, epicondylitis develops gradually over weeks or months, often without a clear single-incident trauma. This silent progression explains why many patients only consult a sports medicine doctor once the pain becomes disabling. Early diagnosis leads to better outcomes.
Anatomy and Mechanism of Injury
To understand epicondylitis, you first need to understand the anatomy. The lateral epicondyle is a small bony prominence on the outer elbow, serving as the attachment point for several muscles responsible for wrist and finger extension.
The extensors of the forearm, particularly the extensor carpi radialis brevis (ECRB), attach to this epicondyle. During repetitive movements (tennis backhand, computer work, tool use), these tendons sustain micro-tears. Normally, the body repairs these micro-tears. But with repeated strain, the repair process cannot keep up with demand. The tendon changes: collagen fibers disorganize, neovascularization occurs, and sometimes calcifications develop.
This is not classic inflammation, it is tendinosis (tendon degeneration). Pain occurs with direct pressure on the epicondyle and during resisted contractions of the wrist extensors.
Symptoms and Diagnosis
Typical clinical signs of epicondylitis include:
- Pain on direct pressure of the lateral epicondyle (a precise tender point)
- Pain during resisted wrist extension and finger extension
- Pain when lifting objects with an extended arm (bottle, tray, child)
- Sensation of weakness during grip
- Pain radiating down the forearm, especially at the end of the day
Diagnosis is primarily clinical: a thorough physical examination is sufficient in most cases. Your doctor or physiotherapist may use Cozen test (resisted wrist extension with elbow bent at 90 degrees) or Thomson test (wrist flexed downward, resistance to upward motion) to confirm the diagnosis.
Musculoskeletal ultrasound can reveal tendon abnormalities (thickening, hypoechogenicity, calcifications) and rule out other pathologies like partial tendon tears. Your sports medicine doctor at Clinique Sport Sante Laurentides has this technology on site.
Risk Factors
Several factors increase the risk of developing epicondylitis:
Sports factors: backhand in tennis (specifically with a flat grip), badminton, squash, golf, and any activity requiring repetitive wrist and forearm movements.
Occupational factors: manual trades (plumbing, electrical work, painting, carpentry) as well as repetitive workstations in manufacturing or food service. Office workers are not spared: poor ergonomics and intensive mouse use are recognized contributing factors.
Age and fitness: peak risk is between 35 and 55 years. Suboptimal general fitness can also compromise the tendons capacity to tolerate load.
Treatment Options
Treatment of epicondylitis follows a progressive approach, from conservative to interventional:
Relative rest and activity modification: the first step is to identify and modify provoking activities. Complete rest is not recommended (it can further weaken the tendon). Ice application and anti-inflammatory medication can relieve acute symptoms.
Physiotherapy: the cornerstone of treatment. Eccentric exercises (progressive stretching under load) are particularly effective at remodeling the tendon. A physiotherapist can also correct biomechanics (tennis technique, workstation ergonomics) and use modalities such as taping, manual therapy, and therapeutic laser.
Extracorporeal shockwave therapy: a non-invasive treatment using acoustic waves to stimulate tendon healing. Particularly useful for refractory cases that have failed first-line physiotherapy.
Cortisone injection: an ultrasound-guided cortisone injection can reduce pain in the short term (maximum effect around 4-6 weeks). Long-term results (3-6 months) are however mixed, and repeated injections carry a risk of tendon damage. Learn more: Cortisone Infiltration: Complete Guide
Platelet-rich plasma (PRP) injection: a more modern approach where the patient own blood is centrifuged to extract a high concentration of platelets, then injected into the tendon to promote healing. Effective in chronic cases, but less accessible and more costly. Learn more: PRP Injection: Complete Guide
Surgery: reserved for refractory cases after 6-12 months of failed conservative treatment. Options include tendinotomy, release, or tendon repair. Post-operative recovery requires 3-6 months of rehabilitation.
When to See a Sports Medicine Doctor
Consult a sports medicine doctor if:
- Elbow pain persists beyond 2-3 weeks
- Pain interferes with your work or sporting activities
- You experience marked weakness in grip or wrist extension
- Basic measures (rest, ice, anti-inflammatories) provide no relief
Red flags: intense nighttime pain, fever, local redness or warmth, a growing mass, these signs require urgent medical evaluation.
Dr Danny Labrecque-Sauve, sports medicine physician at Clinique Sport Sante Laurentides, offers specialized consultations for epicondylitis. On-site diagnostic ultrasound allows for an accurate diagnosis from the first visit.
Prevention and Exercises
Epicondylitis prevention rests on three pillars: technique optimization, ergonomics, and strengthening.
For tennis: consult a professional to correct your backhand technique. A semi-western grip can reduce stress on the lateral epicondyle. Ensure you use appropriate string tension and correctly sized grip.
At work: adjust your desk and chair height so that forearms remain parallel to the floor. Use a wrist rest with your mouse. Take regular breaks (every 30-45 minutes) to stretch and mobilize the wrist.
Gradual progression: increase the intensity and duration of your sports activities gradually, no more than 10-20 percent per week. If pain returns, temporarily reduce activity.
Rehabilitation Exercises for Extensors:
1. Wrist Flexion Stretch: Hold wrist in flexed position with elbow extended (fingers pointing toward the floor), 30 seconds, 3 to 5 reps, several times daily.
2. Eccentric Loading Exercise: Forearm supported on table, wrist extended, slowly lower a weight (light dumbbell) using the opposite hand only, then raise back with the assisting hand. Start with 1 kg, 3 sets, 15 reps daily.
3. Wrist Extension Strengthening: Progress to active strengthening as pain permits, using heavier weights (2-3 kg), 3 sets, 12 reps.
Important: Stop any exercise that increases pain. Consult a physiotherapist before beginning these exercises with significant pain present.
FAQ
Q: Can epicondylitis resolve on its own?
R: Without treatment, epicondylitis can persist 6 to 24 months. The earlier conservative treatment begins, the better the prognosis. Early physiotherapy intervention significantly accelerates recovery.
Q: Do I need imaging (MRI, X-ray) to confirm the diagnosis?
R: In most cases, no. Diagnosis is clinical. Ultrasound or MRI may be ordered if the diagnosis is uncertain or to plan surgical intervention.
Q: How long does it take to recover from epicondylitis?
R: Most patients respond favorably to conservative treatment in 3 to 6 months. Chronic cases may require 6 to 12 months of intensive treatment. Patience is essential: tendon remodeling takes time.
Q: Can I keep playing tennis during treatment?
R: This depends on severity. During the acute phase, it is recommended to reduce or stop provoking activities. Gradual return with corrected technique is possible once pain resolves. Avoid playing while in pain.
Q: Is surgery effective for epicondylitis?
R: Surgical procedures (tendon repair, tendon release) show good results in 80-90 percent of refractory cases, but post-operative recovery requires 3-6 months of rehabilitation. Surgery is only considered after 6-12 months of failed conservative treatment.
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