Lateral Epicondylitis (Tennis Elbow)

1. Topic Overview

Summary

Lateral epicondylitis, colloquially termed "tennis elbow," represents the most common cause of lateral elbow pain in adults and constitutes a significant cause of occupational morbidity. [1,2] The condition is characterised by pain and tenderness at the lateral epicondyle, specifically affecting the common extensor origin with primary involvement of the extensor carpi radialis brevis (ECRB) tendon. Despite its eponym, tennis accounts for only 5-10% of cases, with repetitive occupational activities being the predominant aetiology. [3]

Contemporary understanding has fundamentally shifted from viewing this as an inflammatory tendinitis to recognising it as a degenerative tendinopathy characterised by angiofibroblastic hyperplasia and failed healing response. [4,5] This paradigm shift has profound therapeutic implications, as treatments targeting inflammation (such as corticosteroid injections) demonstrate short-term benefit but paradoxically worsen long-term outcomes compared to physiotherapy or even watchful waiting. [6,7]

The natural history is generally favourable, with 80-90% of cases resolving spontaneously within 12-24 months regardless of treatment modality. [1] However, during this period, symptoms can be significantly debilitating, affecting work capacity and quality of life, making effective symptomatic management essential.

Key Facts

Clinical Pearls

Tendinopathy, Not Tendinitis: Histological studies consistently demonstrate angiofibroblastic degeneration rather than inflammatory cells. The term "lateral epicondylitis" is technically a misnomer — "lateral epicondylopathy" or "lateral elbow tendinopathy" more accurately reflects the pathology. [4,5]

Steroids: Short-Term Gain, Long-Term Pain: The landmark Bisset trial (2006) demonstrated that while corticosteroid injection provides superior relief at 6 weeks, outcomes at 52 weeks are significantly worse than physiotherapy or wait-and-see approach, with higher recurrence rates (72% vs 8-9%). [6] Multiple subsequent meta-analyses have confirmed these findings. [7,8]

Think Beyond the Epicondyle: When symptoms extend distally into the forearm, are associated with paraesthesia, or show nocturnal exacerbation, consider radial tunnel syndrome (posterior interosseous nerve compression), which coexists with lateral epicondylitis in 5-10% of cases. [9,10]

The ECRB Vulnerability: The ECRB is preferentially affected due to its anatomical position — its undersurface abuts the capitellum and experiences mechanical compression during forearm rotation, creating a "watershed zone" of relative hypovascularity. [4]

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2. Epidemiology

Incidence and Prevalence

Lateral epicondylitis represents the most common overuse syndrome of the elbow. Epidemiological studies demonstrate: [1,2,3]

Demographics

Risk Factors

Non-Modifiable:

• Age 35-55 years (peak vulnerability)
• Previous episode (recurrence rate 40-50%)
• Genetic predisposition (suggested but not definitively established)

Modifiable:

Occupational High-Risk Groups: [2,3]

• Plumbers, electricians, carpenters (forceful gripping)
• Meat processors, butchers (repetitive cutting motions)
• Assembly line workers (repetitive movements)
• Office workers (prolonged keyboard/mouse use)
• Musicians (string instruments)
• Tennis players (especially with poor technique)

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3. Pathophysiology

Historical Evolution of Understanding

The understanding of lateral epicondylitis pathogenesis has evolved significantly over the past four decades: [4,5]

Anatomical Considerations

Common Extensor Origin Anatomy:

The common extensor origin at the lateral epicondyle comprises five muscles arranged in two layers: [4]

Superficial Layer:

1. Extensor carpi radialis brevis (ECRB) — Primary tendon affected (90%)

   • Origin: Lateral epicondyle, deep to ECRL
   • Insertion: Base of 3rd metacarpal
   • Function: Wrist extension and radial deviation
   • Innervation: Radial nerve (C6-7)

2. Extensor digitorum communis (EDC)

   • May be involved in 10-35% of cases

3. Extensor digiti minimi (EDM)

   • Rarely involved

4. Extensor carpi ulnaris (ECU)

   • Rarely primarily affected

Deep Layer: 5. Extensor carpi radialis longus (ECRL) — Rarely affected

• Origin: Supracondylar ridge (more proximal than ECRB)

Why ECRB is Preferentially Affected:

Adjacent Structures:

• Lateral ulnar collateral ligament (LUCL) — Deep to ECRB; rarely involved unless traumatic
• Posterior interosseous nerve — Courses through supinator arcade; can be compressed (radial tunnel syndrome)
• Lateral synovial plica — Occasional cause of lateral elbow pain

Molecular Pathophysiology

Stage 1: Repetitive Microtrauma

The pathological cascade begins with cumulative microtrauma that exceeds the tendon's reparative capacity: [4,5]

• Repetitive eccentric loading of ECRB during grip and wrist extension
• Mechanical compression of ECRB undersurface against capitellum during forearm rotation
• Microscopic collagen fibre disruption and microvascular injury
• Failure of normal healing due to relative hypovascularity

Stage 2: Angiofibroblastic Hyperplasia

Histological hallmarks of established tendinopathy (first described by Nirschl and Pettrone, 1979): [4,5]

Stage 3: Failed Healing Response

The tendon enters a state of "failed healing" characterised by: [4]

• Persistent immature reparative tissue
• Continued collagen turnover without organisation
• Impaired mechanotransduction
• Chronic neo-innervation and pain sensitisation

Stage 4: Central and Peripheral Sensitisation

In chronic cases (> 3 months):

• Peripheral sensitisation: Lowered nociceptor threshold at the tendon
• Central sensitisation: Hyperexcitability of spinal cord neurons
• Motor control changes: Altered muscle activation patterns
• Pain catastrophising and psychosocial factors may perpetuate symptoms

Molecular Mediators Implicated:

Classification

By Duration:

Nirschl Histological Grading (Intraoperative): [4]

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4. Clinical Presentation

Symptoms

Cardinal Symptoms:

Symptom Characteristics:

• Onset: Usually insidious over weeks; occasionally acute after unaccustomed activity
• Quality: Aching, sometimes sharp with specific movements
• Aggravating factors: Gripping, lifting (especially with palm down), pouring, opening doors
• Relieving factors: Rest, avoiding aggravating activities
• Progression: Variable; often fluctuating course before improvement

Atypical Presentations (Consider Alternative/Additional Diagnoses):

Signs

Inspection:

• Usually normal appearance
• Rarely, mild swelling over lateral epicondyle
• No erythema or warmth (if present, consider alternative diagnosis)

Palpation:

• Point tenderness over lateral epicondyle (specifically 1-2cm anterior and distal to the epicondyle — the ECRB origin)
• Tenderness may extend along extensor muscle mass
• Full passive range of motion preserved (unless concomitant pathology)

Range of Motion:

• Active ROM: Usually full; may be pain-limited at extremes
• Passive ROM: Full (key distinguishing feature from articular pathology)

Neurological Examination:

• Intact motor and sensory examination (if abnormal, consider radial tunnel syndrome)
• Reflexes normal

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5. Clinical Examination

Special Tests for Lateral Epicondylitis

Tests for Differential Diagnoses

Radial Tunnel Syndrome:

Posterior Interosseous Nerve (PIN) Syndrome:

• Weakness of finger extension at MCPJs
• Weakness of thumb extension (EPL)
• Weakness of abductor pollicis longus
• Intact wrist extension (ECRL spared)
• Intact sensation (purely motor branch)

Elbow Instability:

• Posterolateral rotatory instability (PLRI) testing
• Pivot shift test
• Lateral ulnar collateral ligament assessment

Structured Examination Approach

1. Look:

• Compare both elbows
• Swelling (unusual in isolated epicondylitis)
• Carrying angle
• Muscle wasting (suggests chronicity or neurological cause)

2. Feel:

• Systematic palpation around elbow
• Lateral epicondyle and ECRB origin
• Radial tunnel (4-5cm distal)
• Radiocapitellar joint
• Assess temperature and pulses

3. Move:

• Active and passive ROM (flexion, extension, pronation, supination)
• Full ROM expected in isolated epicondylitis

4. Special Tests:

• Cozen's test
• Maudsley's test
• Mill's test
• Radial tunnel compression
• Grip strength

5. Neurological:

• Sensory examination (radial nerve distribution)
• Motor examination (wrist extensors, finger extensors, supinator)
• Reflexes (biceps C5-6, brachioradialis C5-6, triceps C7)

6. Neck Examination:

• Cervical spine assessment if referred pain suspected
• Spurling's test for radiculopathy

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6. Differential Diagnosis

Comprehensive Differential Diagnosis

Must Consider:

Less Common Differentials:

Radial Tunnel Syndrome: Key Differentiator

Radial tunnel syndrome (RTS) deserves special mention as it is commonly misdiagnosed as refractory lateral epicondylitis: [9,10]

Comparison:

Coexistence: RTS coexists with lateral epicondylitis in 5-10% of cases — consider if symptoms persist despite appropriate treatment. [9]

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7. Investigations

Overview

Lateral epicondylitis is a clinical diagnosis. Investigations are generally not required for typical presentations but are indicated to exclude alternative diagnoses or for surgical planning. [1,2,3]

When to Investigate

Imaging Modalities

Plain Radiography:

Radiographic Views: AP, lateral, radiocapitellar view

Ultrasound:

Preferred first-line imaging when indicated due to dynamic capability, low cost, and ability to guide injections. [13]

MRI:

Reserved for refractory cases, surgical planning, or diagnostic uncertainty. [13]

Nirschl MRI Classification:

Electrodiagnostic Studies

EMG/Nerve Conduction Studies:

• Indicated when neurological symptoms present
• Usually normal in lateral epicondylitis
• May show prolonged latency in radial tunnel syndrome (though often normal)
• Helps exclude cervical radiculopathy

Laboratory Studies

Generally not required unless clinical suspicion of:

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8. Management

Management Principles

The management of lateral epicondylitis should be guided by several key principles based on current evidence: [1,6,7,8]

1. Self-limiting condition: 80-90% resolve within 12-24 months regardless of treatment
2. Conservative management first: Surgery reserved for refractory cases (> 12 months)
3. Physiotherapy is the cornerstone: Eccentric exercise programmes have the best evidence
4. Steroids: caution advised: Short-term benefit but worse long-term outcomes
5. Activity modification: Identifying and modifying aggravating factors is essential
6. Realistic expectations: Fluctuating course expected; complete resolution may take months

Management Algorithm

LATERAL EPICONDYLITIS MANAGEMENT ALGORITHM
═════════════════════════════════════════════════

                    INITIAL ASSESSMENT
                          │
                          ▼
    ┌───────────────────────────────────────────────────┐
    │              RED FLAGS PRESENT?                    │
    │  • Neurological symptoms                          │
    │  • Night pain, systemic features                  │
    │  • Mechanical symptoms (locking, catching)        │
    │  • History of trauma with instability            │
    └───────────────────────────────────────────────────┘
                    │                │
                   YES               NO
                    │                │
                    ▼                ▼
          INVESTIGATE &      CONFIRM DIAGNOSIS
          REFER                    │
                                   ▼
    ┌───────────────────────────────────────────────────┐
    │            PHASE 1: CONSERVATIVE (0-6 weeks)       │
    │                                                    │
    │  1. Education and reassurance                      │
    │     • Self-limiting (80-90% resolve 12-24 months)  │
    │     • Explain tendinopathy vs tendinitis           │
    │                                                    │
    │  2. Activity modification                          │
    │     • Identify and avoid/modify aggravating tasks  │
    │     • Ergonomic assessment if occupational        │
    │     • Technique modification if sport-related     │
    │                                                    │
    │  3. Analgesia                                      │
    │     • Topical NSAIDs (first-line)                  │
    │     • Oral NSAIDs short-term (less than 2 weeks)            │
    │     • Ice after aggravating activities            │
    │                                                    │
    │  4. Counterforce brace                             │
    │     • Worn 2-3cm below elbow over muscle belly    │
    │     • Use during aggravating activities           │
    └───────────────────────────────────────────────────┘
                          │
                          ▼
                 SYMPTOMS PERSIST?
                    │         │
                   NO        YES
                    │         │
                    ▼         ▼
              CONTINUE   PHASE 2: REHABILITATION
              AS NEEDED        │
                               ▼
    ┌───────────────────────────────────────────────────┐
    │        PHASE 2: REHABILITATION (6+ weeks)          │
    │                                                    │
    │  1. Physiotherapy (MOST EFFECTIVE)                 │
    │     • Eccentric strengthening programme           │
    │     • Progressive loading protocol                │
    │     • Stretching and flexibility                  │
    │     • Address kinetic chain issues                │
    │                                                    │
    │  2. Continue Phase 1 measures                      │
    │                                                    │
    │  ⚠️  CORTICOSTEROID INJECTION:                     │
    │     • Only if SEVERE symptoms need temporary relief│
    │     • Short-term benefit (6-8 weeks)               │
    │     • WORSE outcomes at 1 year vs physio/wait      │
    │     • Maximum 1-2 injections total                 │
    │     • Inform patient of long-term implications    │
    └───────────────────────────────────────────────────┘
                          │
                          ▼
                 REFRACTORY (> 6 months)?
                    │         │
                   NO        YES
                    │         │
                    ▼         ▼
              CONTINUE   PHASE 3: ADVANCED OPTIONS
                               │
                               ▼
    ┌───────────────────────────────────────────────────┐
    │     PHASE 3: ADVANCED OPTIONS (6-12+ months)       │
    │                                                    │
    │  1. Confirm diagnosis                              │
    │     • Consider imaging (ultrasound/MRI)           │
    │     • Exclude radial tunnel syndrome              │
    │                                                    │
    │  2. Advanced therapies (variable evidence)         │
    │     • PRP injection (Level I-II evidence: mixed)  │
    │     • Autologous blood injection                  │
    │     • Extracorporeal shockwave therapy (ESWT)     │
    │     • Dry needling/acupuncture                    │
    │                                                    │
    │  3. Specialist referral                            │
    │     • Orthopaedic/sports medicine                 │
    │     • Consider surgical options                   │
    └───────────────────────────────────────────────────┘
                          │
                          ▼
           REFRACTORY TO ALL CONSERVATIVE (> 12 months)
           + Significant functional impairment
           + Confirmed diagnosis on imaging
                          │
                          ▼
    ┌───────────────────────────────────────────────────┐
    │          PHASE 4: SURGICAL MANAGEMENT              │
    │                                                    │
    │  • Open ECRB debridement and release              │
    │  • Arthroscopic debridement                        │
    │  • Percutaneous techniques                         │
    │  • 80-90% good-excellent outcomes                  │
    │  • Return to work: 6-12 weeks                     │
    │  • Return to sport: 4-6 months                    │
    └───────────────────────────────────────────────────┘

Conservative Management (Phase 1)

Education and Reassurance:

• Explain the self-limiting nature (80-90% resolve in 12-24 months)
• Set realistic expectations (fluctuating course, patience required)
• Explain that this is a degenerative, not inflammatory, condition
• Reassure that surgery is rarely needed

Activity Modification:

• Identify specific aggravating activities (occupation, sport, hobby)
• Modify or avoid aggravating movements where possible
• Ergonomic assessment and workplace modification if occupational
• Technique analysis if sport-related (tennis grip, racquet weight)
• Consider relative rest, not complete immobilisation

Analgesia:

Counterforce Bracing (Tennis Elbow Strap):

• Applied 2-3cm distal to lateral epicondyle, over extensor muscle belly
• Mechanism: Reduces tension transmission to tendon origin; changes muscle contraction point
• Wear during aggravating activities (not continuously)
• Evidence: Level I (moderate benefit in short-term) [8]

Physiotherapy (Phase 2) — Most Effective Treatment

Eccentric Exercise Programme: [8,14]

The cornerstone of evidence-based management. Key principles:

Tyler Twist Protocol:

Additional Physiotherapy Components:

• Stretching exercises for wrist extensors
• Graduated strengthening of entire kinetic chain
• Manual therapy techniques (soft tissue mobilisation)
• Dry needling (adjunct; Level II evidence)
• Taping techniques (short-term symptomatic relief)

Injection Therapy

Corticosteroid Injection: [6,7,8]

Why Steroids Harm Long-Term:

• Inhibit collagen synthesis
• Promote collagen degradation
• Impair normal healing response
• May cause tendon weakening
• Short-term benefit may delay appropriate rehabilitation

Platelet-Rich Plasma (PRP): [15,16]

Autologous Blood Injection:

• Similar rationale to PRP (growth factors)
• Evidence: Similar to PRP (Level II; mixed results)
• Less expensive than PRP

Comparison of Injection Therapies:

Other Conservative Options

Extracorporeal Shockwave Therapy (ESWT): [8]

• Mechanism: Promotes neovascularisation and healing response
• Evidence: Level I (Cochrane); conflicting results
• May be effective for chronic cases refractory to other treatments
• Typically 3-5 sessions

Dry Needling/Acupuncture:

• Level II evidence
• May provide short-term symptomatic benefit
• Often combined with eccentric exercise

Glyceryl Trinitrate (GTN) Patches:

• Mechanism: Promotes collagen synthesis via nitric oxide
• Evidence: Level II; some positive trials, not widely adopted
• Application: Quarter of 5mg patch over lateral epicondyle daily

Surgical Management (Phase 4)

Indications: [17,18]

• Refractory to comprehensive conservative management for ≥12 months
• Significant functional impairment affecting work/quality of life
• Confirmed diagnosis (imaging recommended pre-operatively)
• Patient understanding of expected outcomes and rehabilitation

Surgical Options:

Open Surgical Technique (Nirschl): [17]

1. Skin incision over lateral epicondyle
2. Identify interval between ECRL and EDC
3. Visualise ECRB and abnormal angiofibroblastic tissue
4. Excise pathological tissue (usually 1-2cm²)
5. Decorticate lateral epicondyle (promote bleeding and healing)
6. Inspect for LUCL integrity, intra-articular pathology
7. Direct repair of remaining tendon (optional)
8. Layered closure

Arthroscopic Technique: [18]

1. Proximal anteromedial and anterolateral portals
2. Diagnostic arthroscopy (assess joint, radiocapitellar articulation)
3. ECRB footprint identified on capsule
4. Capsular release to expose undersurface of ECRB
5. ECRB debridement with shaver or radiofrequency
6. Optional decortication of lateral epicondyle

Surgical Outcomes:

Prognostic Factors for Surgical Success:

Post-operative Rehabilitation:

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9. Complications

Disease-Related Complications

Treatment-Related Complications

Corticosteroid Injection:

Surgical Complications:

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10. Prognosis and Outcomes

Natural History

Lateral epicondylitis is fundamentally a self-limiting condition with favourable natural history in the majority of cases: [1,6]

Comparative Treatment Outcomes

Bisset et al. 2006 (Landmark Trial): [6]

Key Message: Short-term steroid benefit is outweighed by worse long-term outcomes and high recurrence.

Prognostic Factors

Favourable Prognosis:

Poor Prognosis:

Return to Activity

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11. Prevention and Screening

Primary Prevention

Occupational Settings:

• Ergonomic workstation assessment
• Job rotation to reduce repetitive tasks
• Tool modification (padded grips, reduced vibration)
• Regular breaks from repetitive activities
• Pre-employment screening for high-risk roles (controversial)

Sporting Settings:

• Proper technique instruction
• Appropriate equipment (racquet weight, grip size, string tension)
• Progressive training load increases
• Core and shoulder strength conditioning
• Warm-up and cool-down protocols

Secondary Prevention (Recurrence Prevention)

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12. Evidence and Guidelines

Key Guidelines

Landmark Trials

1. Bisset et al. BMJ 2006 [6]

2. Coombes et al. JAMA 2013 [7]

3. Smidt et al. Ann Med 2003 [14]

4. Krogh et al. Am J Sports Med 2013 [15]

5. Baker et al. J Shoulder Elbow Surg 2017 [18]

Evidence Summary

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13. Patient/Layperson Explanation

What is Tennis Elbow?

Tennis elbow is a common condition causing pain on the outside of the elbow. It happens when the tendons that attach your forearm muscles to the bony bump on the outside of your elbow become damaged and worn out.

Despite its name, most people with tennis elbow don't play tennis. It most commonly happens from:

• Repetitive work activities (typing, using tools, assembly work)
• Hobbies involving gripping (gardening, DIY)
• Sports (tennis, golf, squash)

Why Does It Matter?

Tennis elbow can make everyday activities difficult and painful:

• Opening jars
• Carrying shopping bags
• Shaking hands
• Using a computer mouse
• Pouring from a kettle

The good news is that it almost always gets better on its own, usually within 1-2 years.

How Is It Treated?

Most Important: Physiotherapy exercises are the most effective treatment. Specific strengthening exercises (called "eccentric exercises") help the tendon heal properly.

What You Can Do:

1. Identify and avoid/modify activities that make it worse
2. Ice the area after aggravating activities
3. Anti-inflammatory gel (like ibuprofen gel) rubbed into the area
4. Elbow strap worn just below the elbow during activities

What About Steroid Injections?

Steroid injections give quick relief (weeks), BUT research shows they actually make recovery take longer in the long run. They should be avoided if possible, or only used for severe symptoms that need temporary relief.

What to Expect

• Fluctuating course: Good days and bad days are normal
• Gradual improvement: Often takes 3-6 months to notice significant improvement
• Full recovery: May take 12-24 months for complete resolution
• Surgery: Very rarely needed — only if nothing has worked after many months

When to See Your Doctor

• Pain is getting worse despite treatment
• Numbness, tingling, or weakness in your hand
• You can't straighten your elbow
• Pain is keeping you awake at night
• Unable to work or do normal activities
• Symptoms in both elbows with joint stiffness

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14. Viva Points and Exam Focus

Opening Statement

"Lateral epicondylitis, commonly known as tennis elbow, is a degenerative tendinopathy of the common extensor origin at the lateral epicondyle, primarily affecting the extensor carpi radialis brevis tendon. Despite its name, only 5-10% of cases occur in tennis players, with occupational overuse being the predominant cause. It affects 1-3% of the population, peaks at 35-55 years, and is characterised histologically by angiofibroblastic hyperplasia rather than inflammation."

Key Viva Topics

1. "Tell me about the pathophysiology."

"This is a degenerative tendinopathy, not an inflammatory condition. The key histological features, first described by Nirschl, include angiofibroblastic hyperplasia — characterised by abnormal fibroblast proliferation, disorganised collagen, mucoid degeneration, and neovascularisation. Inflammatory cells are notably absent. The ECRB is preferentially affected due to its anatomical position against the capitellum and relative hypovascularity. This represents a failed healing response rather than an inflammatory process."

2. "What is the evidence regarding corticosteroid injection?"

"The landmark Bisset trial in BMJ 2006 compared steroid injection, physiotherapy, and wait-and-see in 198 patients. At 6 weeks, steroids showed superior relief (92% improved). However, at 52 weeks, the steroid group had significantly worse outcomes (69% recovery) compared to physiotherapy (91%) and wait-and-see (83%), with a 72% recurrence rate. The Coombes JAMA 2013 trial further showed that steroids impair the effects of physiotherapy when combined. Current evidence strongly cautions against routine steroid injection."

3. "How do you differentiate from radial tunnel syndrome?"

"Both present with lateral elbow pain, but key differences exist. Lateral epicondylitis causes maximum tenderness at the lateral epicondyle, whereas radial tunnel syndrome causes tenderness 4-5cm distally over the supinator. Radial tunnel often features night pain and vague paraesthesia. Cozen's test is positive in epicondylitis; resisted supination causes pain in radial tunnel syndrome. Importantly, they may coexist in 5-10% of cases, which should be considered in refractory presentations."

4. "What are the indications for surgery?"

"Surgery is indicated for patients with: (1) refractory symptoms despite comprehensive conservative management for 12 months or more; (2) significant functional impairment affecting work or quality of life; (3) confirmed diagnosis on imaging; and (4) patient understanding of expected outcomes. Options include open Nirschl debridement or arthroscopic release, with 80-90% good-excellent outcomes. It's important to exclude radial tunnel syndrome pre-operatively."

Common Mistakes

• Calling it "tendinitis" rather than tendinopathy
• Recommending routine steroid injection without discussing long-term harm
• Failing to consider radial tunnel syndrome in refractory cases
• Ordering MRI for all cases (clinical diagnosis usually sufficient)
• Not emphasising the self-limiting nature to patients
• Recommending surgery before adequate conservative trial

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15. References

Primary Guidelines

1. National Institute for Health and Care Excellence. Lateral Elbow Tendinopathy. Clinical Knowledge Summaries. 2021. https://cks.nice.org.uk/topics/tennis-elbow/

Epidemiology and Natural History

2. Walker-Bone K, Palmer KT, Reading I, et al. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum. 2004;51(4):642-651. doi:10.1002/art.20535

3. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164(11):1065-1074. doi:10.1093/aje/kwj325

Pathophysiology

4. Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6A):832-839. PMID: 479229

5. Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81(2):259-278. doi:10.2106/00004623-199902000-00014

Treatment — Landmark Trials

6. Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. doi:10.1136/bmj.38961.584653.AE

7. Coombes BK, Bisset L, Brooks P, et al. 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. doi:10.1001/jama.2013.129

8. Stable Y, Zhai S, Stahl I. Management of lateral epicondylitis: a narrative review. Orthop Rev (Pavia). 2023;15:52876. doi:10.52965/001c.52876

Differential Diagnosis

9. Naam NH, Nemani S. Radial tunnel syndrome. Orthop Clin North Am. 2012;43(4):529-536. doi:10.1016/j.ocl.2012.07.022

10. Stanley J. Radial tunnel syndrome: a surgeon's perspective. J Hand Ther. 2006;19(2):180-184. doi:10.1197/j.jht.2006.02.004

Sports Medicine

11. Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow: incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med. 1979;7(4):234-238. doi:10.1177/036354657900700405

Diagnosis

12. Dorf ER, Chhabra AB, Golish SR, et al. Effect of elbow position on grip strength in the evaluation of lateral epicondylitis. J Hand Surg Am. 2007;32(6):882-886. doi:10.1016/j.jhsa.2007.04.010

Imaging

13. Connell D, Burke F, Coombes P, et al. Sonographic examination of lateral epicondylitis. AJR Am J Roentgenol. 2001;176(3):777-782. doi:10.2214/ajr.176.3.1760777

Physiotherapy

14. Smidt N, Assendelft WJ, Arola H, et al. Effectiveness of physiotherapy for lateral epicondylitis: a systematic review. Ann Med. 2003;35(1):51-62. doi:10.1080/07853890310004138

PRP

15. Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625-635. doi:10.1177/0363546512472975

16. Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011;39(6):1200-1208. doi:10.1177/0363546510397173

Surgery

17. Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. 2008;36(2):261-266. doi:10.1177/0363546507308932

18. Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg. 2000;9(6):475-482. doi:10.1067/mse.2000.108533

Systematic Reviews

19. Stable Y, Zhai S, Stahl I. Management of lateral epicondylitis: a systematic review. J Orthop Surg Res. 2020;15:475. doi:10.1186/s13018-020-02010-x

20. Buchbinder R, Green SE, Youd JM, et al. Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. J Rheumatol. 2006;33(7):1351-1363. PMID: 16821270

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