Is tennis elbow inflammation? Will icing and anti-inflammatory drugs fix it?

Research in recent years shows tennis elbow is usually not true inflammation but rather tendon degeneration and collagen disorganization, so anti-inflammatory treatment alone often does not last. In the acute phase, icing or short-term anti-inflammatory medication can ease symptoms, but over the long term relative rest and rehabilitation exercise are usually still needed.

Who is more likely to get tennis elbow?

It is common in people aged 40 to 60, and about 75% of cases occur in the dominant arm. Smoking, obesity, alcohol, an ill-fitting racket grip or string tension, poor backhand technique, and playing more than 2 hours a day or repetitive forearm rotation for more than 4 hours a day are associated with higher risk.

Does tennis elbow always require a corticosteroid or PRP injection?

Not necessarily. Corticosteroid injection is effective for short-term relief, but there is less evidence of long-term benefit, and repeated injections may affect tendon integrity. In some studies, PRP performed better for function and pain improvement at 6 months and beyond, and shockwave may also ease symptoms, but all of these depend on your condition and a physician's assessment.

Will tennis elbow heal on its own? How long does recovery take?

Tennis elbow may be a self-limiting condition, and most patients improve markedly with conservative treatment, but full recovery often takes several months. The management approach should be assessed according to the severity of symptoms.

When should surgery be considered for tennis elbow?

According to this article, most people do not need surgery; it is usually considered only when non-surgical treatment has been tried for about 6 months without success. Options may include debriding damaged tissue or tendon release, and outcomes after surgery are generally favorable.

Myth Buster: Tennis Elbow May Not Be Inflammation, and Traditional Anti-Inflammatory Treatment Doesn't Last

Tennis elbow, or lateral epicondylitis, is an injury caused by overuse of the forearm and wrist extensors that produces pain on the outside of the elbow. It is also described as a common extensor tendinopathy. Research over recent years suggests that the pathology of tennis elbow is not true inflammation but rather angiofibroblastic degeneration and collagen disorganization, and that there are relatively few blood vessels in the tendon near its attachment. This inadequate blood supply may make the tendon prone to hypoxic tendon degeneration.

Epidemiology

The incidence is about 1.3% of the general population; it is estimated that only about half of symptomatic patients seek medical evaluation.
It accounts for about 20% of tennis injuries.
About 90% of lateral epicondylitis cases arise from tennis, badminton, work, and other activities that require repetitive wrist extension, radial deviation, and forearm pronation; 75% of cases occur in the dominant arm.

Risk factors

Age between 40 and 60.
Smoking, obesity, alcohol.
Improper equipment (for example, an ill-fitting grip size, excessive racket string tension, inappropriate racket weight).
Poor technique (for example, a backhand with excessive wrist extension).
Recreational tennis players.
Playing tennis or performing repetitive movements for more than 2 hours a day.
Associated with forearm rotation for more than 4 hours a day.

History

Pain pattern: patients usually report that the pain onset is chronic, typically with overuse and no specific trauma. Pain can range from mild (for example, appearing only during vigorous activity such as tennis or repetitive tool use) to severe (for example, triggered simply by lifting a coffee cup).
Numbness or tingling: radiating symptoms suggest possible nerve entrapment or nerve compression.
Backhand style: tennis elbow is more common among players who use a one-handed backhand.
Poor technique: hitting the backhand too late, striking at the wrong position, or insufficient follow-through.
Associated with improper equipment, playing surface, and frequency: old or wet tennis balls, an overly tight or heavy racket, and courts with fast rebound surfaces are all relevant; there is not enough evidence that shock-absorbing equipment reduces risk.
Poor conditioning: general deconditioning leads to fatigue of the core and shoulder muscles, which places excessive reliance on the forearm extensor muscles.

Physical examination

Pain located on the lateral elbow.
Accompanied by wrist and forearm movement.
Pain when gripping objects such as a coffee cup (the “coffee cup sign”) and pain on shaking hands.
Localized tenderness on palpation about 1 to 2 cm over and just anterior-inferior to the lateral epicondyle, which is the origin of the wrist extensor tendon.
Pain on resisted wrist extension (Thomsen test), resisted middle-finger extension, and resisted forearm pronation.
Reduced internal rotation of the same-side shoulder, leading to excessive compensatory wrist flexion.
Scapular dyskinesis.
Some authors believe that about 30% of tennis elbow cases actually involve PIN nerve entrapment (radial tunnel syndrome); although the figure is hard to measure precisely, these two conditions are clinically difficult to clearly distinguish.

Differential diagnosis

Posterior interosseous nerve entrapment
Radial tunnel syndrome
Osteoarthritis
C7 radiculopathy
Musculocutaneous nerve entrapment
Chronic compartment syndrome of the anconeus muscle
Radiocapitellar osteochondritis dissecans (radiocapitellum OCCD)
Lateral collateral ligament sprain
Stress fracture

Diagnostic tools

X-ray:
Elbow X-ray (anteroposterior and lateral views) is performed when other underlying injuries are suspected (such as fracture, tumor, or degenerative joint disease).
Up to 25% of cases have calcification within the extensor tendon, but the presence of these deposits does not affect initial treatment.
Ultrasound may show:
Tendon thickening, calcification, hypoechoic changes, and neovascularization within the tendon.
It is a powerful diagnostic tool, uses no radiation, and can be combined with guided injection treatment.
Magnetic resonance imaging (MRI):
Partial internal tears and tendinopathy.
Used to assess other possible causes of lateral elbow pain, such as osteochondral lesions and stress fractures.

Initial treatment

Icing after excessive activity or relative rest, avoiding activities that provoke pain.
Anti-inflammatory medication: consider nonsteroidal anti-inflammatory drugs (NSAIDs), applied topically or taken orally.
Braces and elbow supports: may be helpful during acute symptoms; compared with a brace, other treatments including physical therapy may be more beneficial.
Injection treatment: corticosteroid injection can be used short-term but with caution; it is effective for relieving symptoms but may work poorly for chronic tendinopathy. Corticosteroid injection carries some side effects, which are mild and resolve within six months after treatment. These side effects include persistent pain after injection, skin pigment loss (5%), and tissue atrophy at the injection site (4%); corticosteroid use may also cause short-term high blood sugar, especially in patients with diabetes.
Although corticosteroid injection is effective in the short term, there is less evidence for its long-term benefit. Repeated injections may also negatively affect soft-tissue structures and tendon integrity. Providers should carefully monitor the corticosteroid burden and pay attention to injection frequency to avoid causing harm.
Phonophoresis or iontophoresis may help athletes return to activity sooner but has not shown long-term benefit.

Further management

If symptoms have not eased after 4 to 6 weeks, referral to physical therapy, manual therapy, or acupuncture may be considered, which can help reduce pain and improve function; the evidence base for these is relatively low and not clearly settled.
PRP injection, prolotherapy, botulinum toxin injection, and similar treatments have shown positive effects in some small studies. PRP has been studied as a single injection, and some protocols use two injections two to four weeks apart; there is growing evidence supporting PRP injection to treat elbow tendinopathy. A recent meta-analysis concluded that, although corticosteroid injection provided better relief in the short term (under 2 months), PRP injection performed better for function improvement and pain relief in the long term (over 6 months).
Shockwave: may provide symptom relief; the evidence for long-term effectiveness is still uncertain. Compared with placebo, it can reduce pain levels and improve grip strength.
Surgery: surgery may be considered when non-surgical treatment has failed for 6 months. Surgical approaches may include removing damaged tissue or tendon release.

Prognosis

Most patients can improve markedly with conservative treatment, but full recovery may take several months.
Among the very few patients who require surgery, outcomes after surgery are generally favorable.
Tennis elbow may be a self-limiting condition, and society guidelines differ across countries on whether treatment is needed: the Canadian Shoulder and Elbow Society suggests observation, while the relevant Japanese society recommends active treatment; in principle, management should be assessed according to the patient’s symptoms.

References

J Orthop. 2020 Jan-Feb; 17: 203–207. Published online 2019 Aug 10. doi: 10.1016/j.jor.2019.08.005
BMJ. 2023 May 18:381:e072574. doi: 10. 1136/bmj-2022-072574. Management of lateral epicondylitis (tennis elbow)
N Engl J Med. 2023 Jun 22;388(25):2371-2377. doi: 10.1056/NEJMcp2216734
https://blogs.bmj.com/bjsm/2024/12/23/the-msk-playbook-tennis-elbow/