A note on this column: This article is general medical information, not a description of a service offered at this practice. Dr. Ishiguro's surgical practice is focused on hip and knee conditions — he does not treat or perform surgery for tennis elbow or golfer's elbow. This column is written to help readers understand two very common elbow tendon conditions and know when and how to seek the right specialist, typically an orthopaedic surgeon or hand/elbow specialist, or a physiotherapist as a first step.
What these conditions actually are
"Tennis elbow" and "golfer's elbow" are common names for two mirror-image conditions affecting the tendons that attach forearm muscles to the elbow. Lateral epicondylitis ("tennis elbow") affects the extensor tendons — chiefly the extensor carpi radialis brevis — where they attach to the bony bump on the outer side of the elbow (the lateral epicondyle). Medial epicondylitis ("golfer's elbow") affects the flexor-pronator tendons attaching to the bony bump on the inner side of the elbow (the medial epicondyle). Lateral epicondylitis is considerably more common than medial epicondylitis, by a ratio of roughly 4 to 1 in most series.
Despite the "-itis" suffix, which implies inflammation, tissue studies of chronically symptomatic tendons typically show little to no inflammatory cells. Instead, they show disorganised collagen, small blood vessel ingrowth, and immature repair tissue — a pattern called angiofibroblastic degeneration. For this reason, many specialists now prefer the term tendinopathy (lateral or medial elbow tendinopathy) over "epicondylitis," though both terms remain in common use and refer to the same underlying condition.
Who gets it, and why
Despite the sport-specific names, the large majority of cases are not related to tennis or golf at all. The underlying mechanism is repetitive or forceful gripping, twisting, and wrist extension (for lateral) or wrist flexion (for medial) — activities like typing and mouse use, manual trades, cooking, childcare (lifting a child repeatedly), and racquet or club sports where technique places excess load on the tendon. It typically develops gradually from cumulative overload rather than a single injury, most often in the dominant arm, and peaks in the 35–55 age range.
Established risk factors (lateral epicondylitis)
- Repetitive forceful gripping or wrist extension — the dominant mechanical driver, whether occupational or recreational
- Female sex — associated with meaningfully higher odds across pooled studies
- Smoking history — current or past tobacco use is independently associated with increased risk
- Manual labour — occupations involving heavy, repetitive forearm use show a strong association
- Hypercholesterolemia — identified as a significant metabolic risk factor in pooled data
A 2024 meta-analysis pooling multiple case-control and cohort studies found that female sex, smoking history, manual labour, and hypercholesterolemia were each significantly associated with increased risk of lateral epicondylitis, with statin use also flagged as a possible associated factor requiring further study (Chen et al., Journal of Hand Therapy, 2024). This is a useful reminder that tendinopathy is not purely a mechanical, "overuse" problem — metabolic and vascular factors appear to play a role in why some people develop symptomatic tendon degeneration and others with similar activity levels do not.
Symptoms
The hallmark symptom is pain centred directly over the bony bump on the affected side of the elbow, which typically radiates a short distance down the forearm along the affected tendon. Pain is provoked by specific movements: for tennis elbow, gripping, lifting with the palm down, or extending the wrist against resistance (a firm handshake or lifting a kettle is a classic trigger); for golfer's elbow, gripping combined with wrist flexion or forearm rotation, such as throwing or swinging a golf club. Morning stiffness, a weakened grip, and tenderness that can be reproduced by pressing directly on the epicondyle are typical findings. Unlike a nerve problem, numbness and tingling are not expected — their presence should prompt consideration of an alternative or coexisting diagnosis.
How the diagnosis is made
In the great majority of cases, the diagnosis is made clinically — a focused history plus a physical exam that reproduces pain with resisted wrist extension (lateral) or resisted wrist flexion and forearm pronation (medial), combined with point tenderness directly over the epicondyle. Imaging is not routinely required to start treatment. It becomes useful when the diagnosis is unclear, symptoms fail to improve after several months of appropriate conservative care, or a surgeon is considering intervention and wants to characterise the extent of tendon damage.
| Method | Role |
|---|---|
| X-ray | Usually normal; used to rule out other causes such as loose bodies, arthritis, or calcific deposits, not to diagnose tendinopathy itself |
| Ultrasound | Can show tendon thickening, hypoechoic (degenerative) areas, and small tears; convenient, low-cost, and can be done in the clinic |
| MRI | Detailed view of tendon signal change, partial tears, and surrounding structures; typically reserved for atypical, refractory, or pre-surgical cases |
A careful exam also matters because several other conditions can mimic or coexist with epicondylitis and change the treatment plan: cervical radiculopathy (a pinched nerve in the neck), radial tunnel syndrome (compression of a nerve branch running near the lateral epicondyle, which causes pain but without the same point tenderness pattern), elbow joint arthritis, and — for medial-sided pain — ulnar nerve irritation at the elbow (cubital tunnel syndrome), which can produce ring- and little-finger numbness alongside inner elbow pain. When symptoms don't fit the typical pattern, or don't respond to standard treatment, these alternatives are worth ruling out.
What the evidence says about treatment
The reassuring headline is that both conditions are self-limiting in most people — a large majority improve within 6 to 24 months with conservative management alone, and only a small minority ever require surgery. The evidence base is largest for lateral epicondylitis specifically, since it is far more common and more studied; management principles for golfer's elbow are generally extrapolated from the same evidence, adjusted for the different tendon group.
Commonly used treatment options
- Activity modification — temporarily reducing the specific gripping or repetitive motion that provokes symptoms, without full immobilisation
- Physiotherapy and eccentric/isometric exercise — a structured, progressive loading programme is the most consistently evidence-supported first-line treatment
- Counterforce bracing — a strap worn below the elbow to offload the tendon during activity
- NSAIDs (oral or topical) — used for short-term pain control
- Corticosteroid injection — can relieve pain in the first few weeks, but evidence suggests it should not be used as a default or repeated treatment (see below)
- Platelet-rich plasma (PRP), extracorporeal shock wave therapy (ESWT) — second-line options for cases that don't respond to initial conservative care; evidence for clear superiority over placebo is mixed
- Surgery (open or arthroscopic tendon debridement/repair) — reserved for the small minority with persistent, significant symptoms after 6–12 months of genuine conservative treatment
What the evidence shows — corticosteroid injections: A landmark Australian randomised controlled trial compared corticosteroid injection, physiotherapy, both combined, or neither ("wait-and-see") in 165 patients with lateral epicondylalgia. At 1 year, the corticosteroid injection group had significantly worse outcomes and higher recurrence rates than the wait-and-see group, despite better pain relief in the first few weeks. Physiotherapy improved outcomes in the short term and reduced the negative long-term effect of corticosteroid injection when the two were combined (Coombes et al., JAMA, 2013). This trial is a major reason many specialists now caution against corticosteroid injection as a first- or only-line treatment — it can help quickly, but may worsen the tendon's long-run trajectory.
What the evidence shows — injections compared: A 2025 randomised controlled trial comparing PRP, corticosteroid, hyaluronic acid, and saline placebo injections in 60 patients with lateral elbow tendinopathy found that all four groups improved substantially over 52 weeks of follow-up, with corticosteroid providing a modest short-term (1–4 week) advantage but no clear long-term advantage over the other injections — including placebo (Reichert et al., Journal of Clinical Medicine, 2025). This aligns with a broader pattern in the tendinopathy literature: injections tend to speed up short-term pain relief more reliably than they change the long-term outcome, and the natural healing trajectory of the tendon accounts for much of the improvement seen across all groups.
What the evidence shows — shock wave therapy: A 2024 systematic review and meta-analysis of randomised trials comparing extracorporeal shock wave therapy (ESWT) with local corticosteroid injection for chronic lateral epicondylitis found that ESWT was less effective in the short term (around 1 month) but produced better outcomes at 3 and 6 months compared with corticosteroid injection (Zhang et al., Orthopaedic Surgery, 2024). This mirrors the injection findings above: corticosteroid tends to win early, non-corticosteroid or activity-based approaches tend to hold up better over time.
Taken together, the current evidence favours starting with activity modification and a structured, physiotherapist-guided loading programme, reserving corticosteroid injection for short-term flare control rather than as a default first step, and considering PRP, ESWT, or other second-line options for the subset of patients whose symptoms persist beyond several months of appropriate conservative treatment. Surgery is uncommon and generally considered only after 6–12 months of genuine, well-executed conservative care has failed.
When to see a specialist
Most mild-to-moderate elbow pain consistent with tennis elbow or golfer's elbow can reasonably start with rest from the provoking activity, a period of self-directed exercise, and over-the-counter pain relief. A specialist evaluation is worthwhile if pain is severe or worsening, if there is numbness or tingling in the hand (suggesting a nerve rather than tendon problem), if symptoms haven't improved after 4–6 weeks of activity modification, or if the pain followed a specific injury rather than developing gradually. An orthopaedic surgeon, hand and upper-limb specialist, or sports medicine physician can confirm the diagnosis, rule out the mimics described above, and guide a structured treatment plan.
References (PubMed / Journal)
Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. 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
Chen Q, Shen P, Zhang B, Chen Y, Zheng C. A meta-analysis of the risk factors for lateral epicondylitis. J Hand Ther. 2024;37(1):44-52. DOI: 10.1016/j.jht.2023.05.013
Zhang L, Zhang X, Pang L, Wang Z, Jiang J. Extracorporeal Shock Wave Therapy Versus Local Corticosteroid Injection for Chronic Lateral Epicondylitis: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Orthop Surg. 2024;16(11):2598-2607. DOI: 10.1111/os.14212
Reichert P, et al. Comparative Efficacy of Platelet-Rich Plasma, Corticosteroid, Hyaluronic Acid, and Placebo (Saline) Injections in Patients with Lateral Elbow Tendinopathy: A Randomized Controlled Trial. J Clin Med. 2025;14(2):472. DOI: 10.3390/jcm14020472