Tennis Elbow (Lateral Epicondylitis): Symptoms, Causes and Treatment

Tennis elbow, medically termed lateral epicondylitis, is a degenerative condition affecting the tendons that attach to the lateral epicondyle of the humerus, primarily due to repetitive wrist and forearm movements causing microtears and localized inflammation.

Lateral epicondylitis symptoms and causes involve progressive pain on the outer elbow, reduced grip strength, and discomfort during activities such as lifting or twisting. The condition is commonly associated with repetitive strain, occupational overuse, and improper biomechanics.

Tennis elbow diagnosis and treatment methods include clinical examination, imaging when necessary, and conservative management such as rest, physical therapy, nonsteroidal anti-inflammatory drugs, and bracing to reduce tendon load and promote healing.

Tennis elbow prevention and rehabilitation strategies focus on ergonomic adjustments, strengthening and stretching exercises for forearm muscles, gradual return to activity, and education on proper technique to minimize recurrence and ensure long-term musculoskeletal health.

What Is Tennis Elbow and Why Is It Called This?

Tennis elbow is a painful condition that occurs at the bony prominence on the outer side of the elbow joint known as the “lateral epicondyle.” From an anatomical perspective, the muscle group that allows us to lift our wrist upward, extend our fingers, and grip objects firmly attaches to this outer point of the elbow via a common tendon structure. In particular, the tendon of the muscle we call the “Extensor Carpi Radialis Brevis” lies at the center of this condition.

The reason the disease is associated with the sport of tennis is that the load placed on this muscle group by the “backhand” stroke technique used especially in racket sports clearly summarizes the mechanism by which the disease develops. However, in clinical practice, the vast majority of patients we see are individuals who have never held a racket in their lives. The real issue is not a specific sport, but the stress created on the tendon by repetitive movements in which the wrist is bent backward. Tendons are like ropes that transmit the force generated by muscles to the bone. Over time, as a result of continuous repetitive strain, microscopic ruptures and damage occur in the fibers of this rope. Although the body tries to repair these micro-injuries, healing cannot be completed as long as the strain continues, and a chronic pain condition settles in the area.

Is Inflammation or Degeneration Responsible for the Development of Tennis Elbow?

This question is the most critical point in determining the direction of treatment. In medical terminology, diseases ending with “-itis” (for example, appendicitis, tonsillitis) generally indicate an infection or acute inflammation. For this reason, the term Lateral Epicondylitis has long been perceived as an “inflammatory” problem. However, the reality shown to us by modern medicine and advanced microscopic examinations is this: in chronic tennis elbow cases, there are almost no active inflammatory cells present.

What we are actually dealing with is a degeneration process called “Tendinosis” or “Tendinopathy,” meaning tissue deterioration. In a healthy tendon, collagen fibers are arranged neatly side by side like pearls, whereas in tissue affected by tennis elbow, these fibers become disorganized, lose their structure, and take on a gel-like consistency. Blood supply in the area is impaired, and the body tries to patch the region with low-quality scar tissue.

Why is it important to understand that the disease is not an inflammation but rather a process of “decay” or “wear”? Because if the problem were inflammation, strong anti-inflammatory medications or ice application would resolve it at the root. However, since the issue is deterioration of tissue structure, the main goal of treatment should not be to dry up inflammation but to “repair” and restructure the damaged tissue. This is exactly where the logic of turning to regenerative methods becomes clear when classical drug treatments prove insufficient.

Who Gets Tennis Elbow and What Are the Risk Factors?

This condition can affect anyone who uses their wrist and forearm muscles in a repetitive, forceful, and resistive manner. It is more commonly seen in individuals between the ages of 30 and 50 because as age advances, the elasticity of tendons and their capacity for self-repair naturally decrease. However, age is not the only determining factor; the nature of the work performed is also decisive.

Occupations and activities in the risk group include:

• Painters
• Plasterers
• Plumbers
• Carpenters
• Auto mechanics
• Butchers
• Cooks
• Information technology professionals
• People who knit
• Homemakers
• Racket sport athletes

The common feature of these occupational groups is that they perform wrist extension (backward bending) and strong gripping movements for hours during the day. For example, the load placed on the wrist of a painter while moving a brush up and down, or the force exerted by a plumber while tightening a wrench, creates a constant pulling force at the point where the tendon attaches to the bone. In office workers, the situation is slightly different; although there is no heavy load, keeping the fingers suspended and performing thousands of small clicking movements while using a mouse and keyboard leads to what we call “cumulative trauma.” In homemakers, actions such as wringing cloths, opening jars, or lifting heavy pots can be triggering factors.

What Are the Symptoms of Tennis Elbow?

The most characteristic symptom of the disease, and the one that brings the patient to the physician, is pain. This pain may begin insidiously or appear suddenly after a strain. It is usually localized just above the bony prominence on the outer side of the elbow. However, the pain does not remain confined there; it can radiate downward along the forearm muscles to the wrist and sometimes even to the fingers. In rare cases, it may also radiate upward toward the upper arm.

The characteristics and triggers of the pain include:

• Tenderness on the outer edge of the elbow
• Burning ache radiating into the forearm
• Noticeable decrease in grip strength
• A feeling of stiffness in the elbow in the mornings
• A tendency to drop objects while carrying them
• Increased pain when shaking hands
• Difficulty when turning a door handle
• A stabbing sensation when lifting a pitcher

Patients often summarize the situation with expressions such as “My arm hurts even when I brush my teeth” or “I can’t lift the teapot; it’s as if the strength has gone out of my arm.” Pain that usually decreases at rest intensifies with use of the arm. Night pain, on the other hand, is more commonly encountered in cases where the disease has progressed and become chronic, and it can impair sleep quality.

How Is Tennis Elbow Diagnosed and Why Is Imaging Important?

The diagnostic process begins with the patient’s history and a detailed physical examination performed by the physician. There are certain provocation tests we apply in the outpatient setting. For example, if we ask the patient to keep the elbow straight and apply resistance while they bend the wrist backward, and a sharp pain occurs on the outer edge of the elbow, this test is considered positive. Additionally, the patient’s flinching from pain when pressure is applied with a finger to the bony prominence in that area is also a typical finding.

However, in modern medicine—especially if interventional treatments are being planned—it is not the right approach to rely solely on physical examination. Imaging methods are essential to confirm the diagnosis and rule out other problems. X-rays show the bone structure and help us determine whether there is arthritis, but they do not visualize tendons. This is where Ultrasonography (USG) comes into play.

Ultrasound is our “seeing eye” in musculoskeletal system diseases. We can very clearly evaluate the structure of the tendon, its thickness, the size of tears within it, the degree of degeneration, and increased blood flow in the area (neovascularization) with ultrasound. MRI also provides detailed information, but ultrasound has the advantage of being dynamic, meaning it allows imaging during movement. In addition, ultrasonographic imaging is critically important in treatment planning to determine exactly where the needle should be placed.

What Treatments Can Be Applied at Home for Tennis Elbow?

In the early stages of the disease and in mild cases, non-surgical simple measures and home-based treatments have quite high success rates. The first and most important step of treatment is to avoid activities that trigger the pain. This does not mean completely immobilizing the arm; on the contrary, gentle movements support healing. However, lifting heavy objects, performing squeezing movements, or straining the wrist will reset the process.

Basic methods that can be applied at home include:

• Activity modification
• Cold compress application
• Use of an epicondylitis strap
• Use of a wrist splint
• Simple pain relievers
• Stretching exercises

Cold application can be performed several times a day for 10–15 minutes, especially during periods when pain is intense; it reduces edema and raises the pain threshold. Special supports called “epicondylitis straps,” worn approximately 4–5 finger breadths below the elbow, distribute the contraction force of the muscles and reduce the load on the damaged tendon. Simple pain-relieving gels or tablets available at pharmacies can also provide short-term relief. However, it should be remembered that these methods are most effective within the first few weeks after symptoms begin. If the pain has been ongoing for months, more advanced treatments will be needed.

Why Are Cortisone Injections Not a Permanent Solution?

When tennis elbow is mentioned, the first injection treatment that comes to mind is usually cortisone (steroid) injections. Cortisone is a very powerful anti-edema and pain-relieving agent. From the moment it is administered, it provides very rapid relief for the patient. The patient may think, “I have miraculously recovered.” However, this sense of improvement is often misleading and temporary.

The scientific facts regarding the long-term effects of cortisone are as follows:

• Suppression of tissue healing
• Weakening of tendon structure
• Risk of recurrent pain
• Lightening of skin color
• Atrophy of fatty tissue

Cortisone is an agent that “extinguishes inflammation.” However, as mentioned above, the main problem in chronic tennis elbow is not inflammation but tissue degeneration. Cortisone not only fails to treat the degenerative process but can further reduce the tendon’s capacity for self-repair by inhibiting collagen synthesis. Studies have shown that patients who receive cortisone experience significant relief in the first month, but at the 3-month and 1-year follow-ups, their pain recurs and they may even be in worse condition than untreated groups. Therefore, in the modern approach, cortisone may be considered “once only” in acute cases with very severe pain, but it is not a preferred method for permanent treatment (cure).

What Kind of Approach Do Regenerative Medicine and Interventional Methods Offer?

In the wide gray area where classical treatments and cortisone are insufficient, but the patient is not a surgical candidate, “Interventional Radiology” and “Regenerative Medicine” come into play. The philosophy of this approach is not to “mask” but to “repair.” It aims to restructure damaged tissue by using the body’s own healing mechanisms. We call these “Orthobiological Treatments.”

The agents used in these treatments are generally obtained from the patient’s own blood or tissue, so they carry no risk of allergy. The goal is to send a signal to the chronically damaged area—one that the body has essentially forgotten and given up on healing—saying, “There is damage here, come and repair it.” Thanks to this signal, fresh blood flow is provided to the area, growth factors rush in, and tendon fibers begin to be rewoven.

How Does the Healing Process Work with PRP Treatment?

PRP (Platelet Rich Plasma) is one of the most popular and effective regenerative treatment methods of recent years. During the procedure, a small amount of blood is drawn from the patient and centrifuged in special tubes. This process separates and concentrates the platelets, which are the healing cells in the blood. This plasma fluid, which has a platelet concentration 5 to 10 times higher than that found in normal blood, is injected into the damaged tendon.

The stages of PRP treatment are as follows:

• Venous blood collection
• Separation by centrifugation
• Preparation of the plasma
• Targeting with ultrasound
• Intra-tendinous injection

Platelets carry powerful protein packets called “growth factors” that initiate tissue repair. When these factors are delivered into the tendon, they stimulate stem cells there, support new blood vessel formation, and increase collagen production. The effect of PRP does not begin immediately like cortisone. In the first days, there may even be a slight increase in pain because a healing battle begins in that area. However, as the tissue renews itself over the weeks, the pain decreases permanently. Depending on the severity of the disease, several sessions are usually recommended at intervals of 2–3 weeks.

Is Prolotherapy (Sugar Water) Treatment Effective?

Another method whose name may sound technical but whose logic is quite simple and effective is Prolotherapy. In this treatment, a concentrated sugar water (hypertonic dextrose) solution with an irritating property for tissue is used. It may sound strange, but the goal here is to create controlled and temporary inflammation in the damaged area.

In chronic tennis elbow, the body has essentially stopped repairing that area. With prolotherapy, we make the area “acute” again, drawing the body’s attention back to it. The irritation created by the injected solution attracts immune system cells to the area and initiates a natural healing cascade.

The characteristics of prolotherapy application are as follows:

• It is an economical method
• It has very few side effects
• The peppering technique is used
• It is applied in sessions
• It provides permanent healing

In this treatment, multiple small entries are made not only into the tendon but also into the points where the tendon attaches to the bone using a technique called “peppering.” Contact of the needle tip with the periosteum also creates an additional stimulatory effect. Scientific studies have proven that prolotherapy is quite successful in reducing pain scores and restoring arm function.

Embolization Method for Tennis Elbow

It is an embolization procedure that numbs the nerves of the damaged tissue in that area, applied in a patient group with very severe pain or who have not benefited from methods such as prolotherapy or PRP. It is an angiographic treatment that causes no harm to normal tissues, provides the longest-lasting relief, and is completed in 30 minutes.

In Which Situations Is Stem Cell Therapy Preferred?

Stem cell therapies can be considered the “heavy artillery” of regenerative medicine. They are generally preferred in patients who do not respond to methods such as PRP or prolotherapy and who have severe tears or advanced degeneration in the tendon. Stem cells are primary cells with the ability to differentiate and that secrete powerful signals to heal surrounding tissue.

In this procedure, stem cells obtained from the patient’s own abdominal fat (adipose-derived) are generally used as the source. Adipose tissue is richer in stem cells than even bone marrow. This cell cocktail (SVF), separated from fat through special processes, is injected into the damaged area. It not only promotes tendon healing but also improves the quality of the surrounding tissue and prevents scar tissue formation.

What Is the Importance of Ultrasound Guidance in Treatment?

This is perhaps the most critical point of this article. No matter which “miraculous” drug or method you use, if that substance does not reach the center of the damaged tissue, the chance of treatment success decreases. In tennis elbow, the damaged area may sometimes be only a few millimeters in diameter. In blind injections (performed only by palpation), there is always a possibility that the medication will go outside the tendon, into fatty tissue, or between muscles.

As an Interventional Radiologist, our greatest advantage is that we treat by “seeing.” The ultrasound device shows us every layer beneath the skin in real time. We watch with millimetric precision on the screen as the needle enters through the skin, passes through the muscles, and enters the degenerated, discolored portion of the tendon.

The advantages of imaging guidance are as follows:

• Maximum treatment efficacy
• Prevention of nerve and vessel injury risk
• Accurate diagnosis and treatment confirmation
• Prevention of medication leakage outside the target

This precision is a factor that directly affects the success of treatment. Especially biological agents such as prolotherapy and PRP must be delivered to the bone–tendon junction. In procedures performed under ultrasound guidance, patient comfort is higher and the safety of the procedure is at the maximum level.

When Is Surgery Necessary and What Are the Alternatives?

More than 90% of tennis elbow cases heal with non-surgical methods. Surgical treatment is considered only for a small group of patients whose pain does not subside despite very long-term (usually 6 months to 1 year) conservative and interventional treatments and whose daily life is completely restricted. The procedure performed during surgery involves excising the damaged tissue in that area and reattaching the tendon to the bone.

However, surgery is always an option that carries risks, may involve a long and painful recovery process, and can lead to loss of work capacity. This is where Interventional Radiology applications serve as the most important bridge filling the large gap between “drug therapy” and “surgery.” These methods, which aim to repair tissue naturally without exposing the patient to surgical risks, have significantly reduced the number of patients progressing to surgery today. If your elbow pain is reducing your quality of life, evaluating these imaging-guided regenerative treatment options before going under the knife will be the most correct step you can take for your health. With patience and the right treatment, there is no tendon that cannot heal.

Frequently Asked Questions

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez is one of Türkiye’s leading interventional radiology and neuroradiology specialists, focusing on minimally invasive endovascular treatments. His primary areas of expertise include aneurysm and stroke treatments, embolization procedures, non-surgical treatments of thyroid and parathyroid diseases, interventional oncology, and peripheral vascular interventions. He currently serves as the Head of the Interventional Radiology and Neuroradiology Department at Istanbul Memorial Göztepe Hospital.
Graduating from Istanbul University Cerrahpaşa Faculty of Medicine in 1997, Prof. Dr. Kılıçkesmez received advanced training in interventional radiology and oncology as a Clinical Fellow at London Guy’s & St Thomas’ and King’s College Hospital between 2012 and 2013. He earned the title of Professor in 2020 and, in the same year, became the Founding Interventional Radiologist at SBÜ Çam and Sakura City Hospital. He also holds the EBIR (European Board of Interventional Radiology) certification.
Prof. Dr. Kılıçkesmez has 94 international and 40 national publications and over 2500 citations. He serves as a reviewer for prestigious journals such as the American Journal of Roentgenology (AJR) and Diagnostic & Interventional Radiology. With his clinical and academic expertise, he is a nationally and internationally recognized authority in stroke treatment, brain aneurysm, embolization, tumor ablation, and minimally invasive treatments of thyroid/parathyroid diseases.