Tennis Elbow: Causes, Symptoms, Treatment and How to Get Back to Sports

Kathy Ryan-Ceisel, PT MHS | Algonquin Sports PT

Overhead Throwing Expert-Athletic Edge and Wellness

Tennis elbow is not just a tennis injury. It can affect tennis players, baseball players, golfers, weightlifters, manual workers, mechanics, musicians, and anyone who repeatedly loads the muscles and tendons on the outside of the elbow.

The medical term for tennis elbow is lateral elbow tendinopathy (LET). Despite the common name "lateral epicondylitis," the condition is generally better understood as a tendon overload and degenerative process rather than simply inflammation.

At Edge 360 Wellness, treatment focuses on identifying why the tendon became overloaded, restoring mobility and strength, gradually rebuilding tendon capacity, and then progressing the athlete back to the activities that caused the problem.

📢What Is Tennis Elbow?

Tennis elbow involves the common extensor tendon origin on the outside of the

elbow, particularly the extensor carpi radialis brevis (ECRB). The tendon helps stabilize the wrist and hand during gripping and resisted wrist and forearm movements. When the demands placed on the tendon repeatedly exceed its capacity to recover, the tendon can become painful and develop changes in its structure. This is why simply "resting the elbow" may decrease symptoms temporarily but does not always solve the underlying problem.

The goal is not simply to make the tendon hurt less.

The goal is to make the tendon stronger and more capable of handling the demands of the sport or activity.

Current evidence supports exercise-based rehabilitation as an important component of treatment for lateral elbow tendinopathy.

⚠️What Causes Tennis Elbow?

Tennis elbow usually develops because of repetitive loading, rather than one specific traumatic event.

Common contributors include:

• Repetitive gripping

• Repetitive wrist extension

• Repeated forearm rotation

• Increasing tennis volume too quickly

• Changing racquets, strings, grip size, or technique

• Increased baseball throwing or hitting volume

• Weightlifting, especially gripping-heavy exercises

• Repetitive occupational activities

• Heavy tools or equipment

• Poor wrist or forearm strength

• Shoulder or scapular weakness

• Limited mobility elsewhere in the kinetic chain

• Inadequate recovery between activities

• Returning to sport too quickly after a period of inactivity

For athletes, the problem is often not one particular exercise or practice.

It is the relationship between load and tissue capacity.

A common scenario

A tennis player takes several weeks off and then returns to playing four or five times per week.

The cardiovascular system may tolerate the workload.

The tendon may not.

The tendon needs time to adapt to increased loading.

💪Tennis Elbow Symptoms

The most common symptom is pain over the outside of the elbow.

Pain may occur during:

• Gripping

• Opening a jar

• Shaking hands

• Carrying a bag

• Lifting a coffee cup

• Typing or using a mouse

• Resisted wrist extension

• Tennis strokes

• Baseball hitting

• Weightlifting

• Using tools

Some people experience:

• Localized tenderness over the lateral elbow

• Weak grip

• Pain with lifting

• Pain with wrist extension

• Pain after activity rather than during it

• Morning stiffness

• Pain that persists after exercise

• Difficulty returning to previous activity levels

A particularly important symptom in athletes is loss of performance.

An athlete may say:

"I can still play, but my forearm gets tired and my grip doesn't feel the same."

That can be an early indication that the tendon is not tolerating the current workload.

🩻How Is Tennis Elbow Diagnosed?

Tennis elbow is primarily a clinical diagnosis.

A physical therapist or physician will evaluate:

• Location of pain

• Grip strength

• Wrist strength

• Forearm strength

• Pain with resisted wrist extension

• Pain with resisted middle-finger extension

• Elbow range of motion

• Shoulder and scapular function

• Cervical spine

• Neural tension

• Sport-specific mechanics

• Training volume and recent changes in workload

Imaging is not always necessary.

When might imaging be useful?

Ultrasound or MRI may be considered when:

• Symptoms are severe or persistent

• The diagnosis is uncertain

• There has been significant trauma

• A tendon tear is suspected

• There is concern for another condition

• Symptoms fail to improve with appropriate rehabilitation

Other conditions can mimic tennis elbow, including radial tunnel syndrome, cervical radiculopathy, elbow joint pathology and referred pain. A good examination is therefore essential.

⚕️Tennis Elbow Treatment

Treatment should be individualized based on the severity and duration of symptoms. The best treatment is usually not one intervention.

Instead, successful rehabilitation combines load management with progressive exercise.

1. Activity Modification

The first step is determining which activities are aggravating the tendon.

This does not necessarily mean complete rest.

It is rest from abuse not from activity.

Instead, modify:

• Volume

• Intensity

• Frequency

• Grip demands

• Repetitions

• Equipment

• Technique

The goal is to keep the athlete active while temporarily reducing the amount of stress placed on the tendon.

2. Physical Therapy

Physical therapy is one of the most important components of tennis elbow treatment. A rehabilitation program may include:

➡️Isometric strengthening

Isometric wrist extension exercises can initially help improve tolerance to loading while limiting movement.

➡️Progressive resistance training

As symptoms improve, resistance is gradually increased.

Exercises may include:

• Wrist extension

• Wrist flexion

• Forearm pronation/supination

• Grip strengthening

• Radial deviation

• Eccentric wrist extension

• Combined forearm strengthening

The emphasis should eventually shift from simply performing exercises to building capacity.

➡️Proximal strengthening

The elbow does not work independently.

Depending on the athlete, rehabilitation may also address:

• Rotator cuff strength

• Scapular control

• Shoulder strength

• Thoracic mobility

• Trunk control

For throwing athletes, the entire kinetic chain should be evaluated.

3. Manual Therapy

Manual therapy can sometimes be useful as an adjunct to exercise.

Treatment may include:

• Soft tissue techniques

• Joint mobilization

• Mobilization with movement

• Forearm mobility techniques

• Cervical or thoracic interventions when indicated

The important distinction is that manual therapy should generally support an active rehabilitation program rather than replace it. Recent research continues to investigate combinations of manual therapy and exercise for lateral elbow tendinopathy.

4. Bracing

A counterforce elbow strap may decrease symptoms during activity by altering the load placed on the tendon. A wrist splint may also be useful in selected cases because limiting excessive wrist extension can reduce extensor tendon demand.

Bracing is best viewed as a symptom-management tool, not a cure. The athlete still needs to restore tendon capacity.

5. Ice and Heat

Ice may temporarily decrease pain after activity. Heat may help some people with stiffness before exercise. Neither treatment addresses the underlying tendon capacity problem. Use them as tools for symptom management rather than the primary treatment.

6. Medications

Over-the-counter medications may sometimes help with pain.

These include:

• Acetaminophen

• NSAIDs such as ibuprofen or naproxen

• Topical NSAIDs such as diclofenac

Because medications have contraindications and potential side effects, athletes should discuss their use with their physician or pharmacist, particularly if they have kidney disease, gastrointestinal problems, cardiovascular disease, take blood thinners, or use other medications. Importantly, reducing pain does not necessarily mean the tendon is ready for increased loading.

7. Corticosteroid Injections

Corticosteroid injections can provide short-term pain relief.

However, they are not generally considered a definitive treatment for chronic tendon pathology. Research comparing corticosteroid injections with physical therapy suggests that steroid injections may perform well in the short term, while exercise-based rehabilitation tends to have better intermediate- and long-term results and lower recurrence.

This is an important distinction for athletes:

Feeling better is not the same as being ready to return to full sport.

8. PRP and Other Injections

Platelet-rich plasma (PRP) and autologous blood injections have been studied extensively for chronic lateral elbow tendinopathy. Some systematic reviews suggest potential longer-term benefits, but results across studies remain inconsistent and treatment protocols vary.

A 2023 umbrella review found evidence supporting several conservative approaches, including exercise, while suggesting that PRP and autologous blood may have longer-term benefits than corticosteroid injections. A 2024 network meta-analysis, however, found that evidence remains limited and that no treatment demonstrated a clear, consistently superior effect over placebo in the short term.

In other words:

PRP may be reasonable for selected patients, but it should not replace progressive rehabilitation.

9. Shockwave Therapy

Extracorporeal shockwave therapy has also been investigated. The evidence is mixed, and results vary depending on the protocol and patient population. Current research does not support treating shockwave therapy as a universal solution. If used, it should generally be considered an adjunct to a broader rehabilitation program.

10. Surgery for Tennis Elbow

Fortunately, most people do not need surgery.

Surgery may be considered when:

• Symptoms persist for many months

• Appropriate conservative treatment has failed

• Pain significantly limits daily activities or sport

• Significant tendon pathology is present

• Other diagnoses have been excluded

Surgical procedures generally involve removing diseased tendon tissue and/or repairing or reattaching the tendon. Both open and arthroscopic techniques may be used. Surgery is not the beginning of rehabilitation. It is usually considered after a well-designed nonoperative program has failed.

🎾Returning to Tennis

Returning to tennis should be based on capacity rather than simply time.

Before returning to unrestricted play, an athlete should ideally demonstrate:

• Minimal or no resting pain

• Normal elbow motion

• Symmetrical grip strength

• Improved wrist and forearm strength

• Ability to perform sport-specific exercises without significant symptom increase

• Ability to tolerate progressive hitting volume

A smart progression

Step 1: Shadow swings and controlled strengthening

Step 2: Short-duration hitting

Step 3: Groundstrokes at reduced intensity

Step 4: Gradually increase duration

Step 5: Add higher-intensity shots

Step 6: Add serving

Step 7: Return to full practice

Step 8: Return to competition

Do not increase volume and intensity simultaneously whenever possible.

⚾Returning to Baseball

Tennis elbow can also occur in baseball players, particularly with repetitive gripping, hitting and throwing.

For baseball athletes, rehabilitation should consider:

• Throwing volume

• Batting volume

• Grip strength

• Forearm strength

• Shoulder strength

• Scapular control

• Thoracic mobility

• Throwing mechanics

• Recovery between throwing sessions

A pitcher with lateral elbow pain should not automatically be assumed to have "tennis elbow." Pain on the outside of the elbow in a throwing athlete can have several possible causes and should be evaluated carefully.

Five Tips to Help Tennis Elbow

1. Don't completely stop using your arm.

Modify the irritating activity rather than automatically eliminating everything.

2. Reduce the workload before reducing everything else.

If symptoms started after a sudden increase in tennis, lifting, throwing or work volume, that increase matters.

3. Start strengthening.

Tendons adapt to progressive loading.

4. Don't use pain relief as your return-to-sport test.

Pain can improve before tissue capacity has recovered.

5. Treat the athlete—not just the elbow.

Shoulder, scapular, thoracic and kinetic-chain deficits may contribute to how the elbow is being loaded.

The Bottom Line

Tennis elbow is best understood as a load-capacity problem involving the extensor tendon. The most successful long-term strategy is usually not simply rest, medication, an injection or a brace.

It is a combination of:

Load management + progressive strengthening + movement optimization + gradual return to sport.

If your elbow pain is interfering with tennis, baseball, golf, lifting, work or everyday activities, an individualized physical therapy evaluation can help determine what is actually driving the problem and how to safely rebuild your capacity. Call our office today at ☎️224-505-3343 to start your treatment today.