Lateral Epicondylitis / Tennis Elbow



Lateral : Medial 9:1




4th & 5th decades

- M = F

- 75% dominant arm 


50% of regular tennis players

- especially > 2 hrs / week




Insertion pathology / Enthesopathy


Over-extension of the elbow with supination / pronation




Lateral epicondyle

- anconeus from posterior face

- ECRB and EDC from anterior face (CEO)

- ECRL and BR from lateral supracondylar ridge


Differentiate ECRB from ECRL

- ECRB tendinous insertion onto lateral epicondyle

- ECRL still muscular at this point (arises more proximally)



- apex of lateral epicondyle



- radial nerve between brachialis and BR

- divides at level of radial head

- enters supinator at this level (radial tunnel)




1.  OCD capitellum / radial head

2.  Radial tunnel / supinator / PIN syndrome

3.  PLRI

4.  OA, RA

5.  Referred Pain / C6-7 radiculopathy

6.  Enthesopathy

7.  Annular ligament tears


Risk factors



- poor technique

- poor grip

- hard court surfaces

- strings too taut



- plumbers

- painters




Starts as micro-tear in ECRB 

Get high grade partial tear




Angiofibrotic hyperplasia

- marked fibroblast proliferation

- extensive vascular hyperplasia

- disorganised collagen production

- may go on to dystrophic calcification


Disruption of parallel orientation of collagen fibres 

- invasion of fibroblasts and vascular granulation type tissue

- without an acute or chronic inflammatory component




History of overuse

Pain lateral elbow

Backhand in tennis main problem




Localised Swelling



- few degrees loss of extension = CEO

- >15-20° loss is intra-articular pathology


Tender ECRB

- 5 mm distal and anterior to CEO



- pain with resisted wrist dorsiflexion with elbow extended


Examine for Stability - PLRI

Examine Supination / Pronation - radiocapitellar OA

Examine C spine




Radial Tunnel Syndrome

- tenderness 3-4 cm distal to lateral epicondyle

- pain with resisted thumb / IF and supination




Usually normal

25% soft tissue calcification


Tennis Elbow CalcificationTennis Elbow Bone Spur








Will demonstrate tears and oedema on T2


Elbow MRI Lateral Epicondylitis


High grade partial tear


Tennis elbow High grade tear MRI




Non Operative




6-9 months

- successful ~ 75- 85%


Rest Phase


Complete rest lasting for 3-6/52

-  avoid precipitating factors



- oral or topical



- wrist in extension

- cock up wrist splint


Forearm tennis band

- limit muscle expansion

- may create new force direction


HCLA injection

- find patient's maximum tenderness deep to fascia 

- repeat 2-3 times over 6-12 months

- peri not intra-tendinous

- must then rest the tendon for it to work long term

- risks of local skin depigmentation and CEO rupture


Conditioning Phase


Once pain settled

- Extensor origin stretching 

- Wrist extension exercises (1lb increments)

- eccentric muscle training

- ART (active release technique)

- Activity modification / change racquet and stroke


Tyler et al J Should Elbow Surg 2010

- RCT using eccentric muscle training

- significant improvement in outcome


Adjuctive Therapy


1.  Shock wave lithotripsy


Meta-analysis of RCT

- minimal effect comparted with placebo


2.  Autologous Blood / PRP Injections


Peerbooms et al Am J Sports Med 2010

- RCT autologous blood v corticosteroid

- superior outomes with plasma cell injections at one year


3.  Botox Injections


Improvements compared with placebo

Inferior to corticosterioid


Operative Management




Failure of good non-operative management

- > 6 - 12/12



- open debridement

- percutaneous tenotomy

- arthroscopic

- radiofrequency microtenotomy


Open debridement


3 cm incision 

- centred on CEO

- ECRB is deep and posterior to ECRL

- ECRL muscular at this point


Surgical dissection

- Detach ECRB

- Debride degenerative tissue

- Decorticate underlying CEO

- +/- reattach ECRB


Tennis Elbow ReleaseTennis Elbow Release 2


Tennis Elbow Release 3Tennis Elbow 4



- Z lengthen

- denervate sensory nerves to epicondyle

- combine with decompression PIN

- cover with anconeus flap in chronic or recurrent cases



- splint 10 days

- gentle ROM to 6/52

- then strengthening exercises


Arthroscopic Release


Arthroscopic Tennis Elbow Release 1Arthroscopic Tennis Elbow Release 2Arthroscopic Tennis Elbow Release 3





- inadvertant release LCL



- posterior cutaneous nerve forearm

- runs 1.5 cm anterior to lateral epicondyle on BR fascia



- rare, but can be devastating




Dunn et al Am J Sports Med 2008

- retrospective study of 92 elbows over 12 years

- open release

- 84% good to excellent results


Baker et al Am J Sports Med 2008

- 42 patients with arthroscopic resection followed up for 10 years average

- 87% patient satisfaction


Dunkow et al JBJS Br 2004

- RCT open v percutaneous tenotomy

- earlier return to work and faster recovery


Meknas et al Am J Sports Med 2008

- RCT of open release v microfrequency tenotomy

- no difference in pain relief

- better grip strength at 12 weeks