Tennis Elbow (and Pickleball Elbow)

Symptoms

• Pain on the outside of the elbow that may spread down the forearm
• Pain when gripping, lifting a cup, or shaking hands
• Weak grip
• Pain with backhands or with repetitive paddle or racquet strokes

Causes and who gets it

Repeated gripping and wrist extension overload the common extensor tendon. Risk factors include a sudden increase in play, poor technique, an equipment change (grip size, paddle weight), and repetitive work tasks. It is most common between ages 35 and 55.

How it is diagnosed

Diagnosis is clinical: tenderness at the outer elbow bone and pain with resisted wrist or middle-finger extension. Ultrasound can show tendon thickening, tears, or calcification if the diagnosis is uncertain or symptoms persist.

Treatment

• Modify the activities that provoke pain, and check grip size, paddle or racquet weight, and technique
• A progressive tendon-loading program (isometric, then slow strengthening) is the core treatment
• A counterforce strap may reduce pain during activity
• Corticosteroid injections can help short term but are associated with worse outcomes and more recurrence at one year
• Persistent cases may be considered for procedures such as ultrasound-guided needle tenotomy or orthobiologic injection

Recovery time

Most cases improve within 6 to 12 months with activity changes and a loading program. Some take longer. Steady, gradual loading works better than complete rest.

When to see a doctor

• Pain after a fall or a sudden pop
• Numbness or tingling in the hand or fingers
• Elbow swelling, locking, or loss of motion
• Pain that has not improved after several months of rehab

Clinical pearls

• Provocative tests: resisted wrist extension (Cozen), passive wrist flexion with elbow extended (Mill), and resisted middle-finger extension (Maudsley)
• Consider radial tunnel syndrome when pain is maximal several centimeters distal to the epicondyle
• Also consider posterolateral rotatory instability, radiocapitellar pathology, and cervical radiculopathy
• Corticosteroid injection offers short-term relief but poorer intermediate and long-term outcomes than wait-and-see or physiotherapy
• Ultrasound-guided percutaneous needle tenotomy is an option for refractory tendinopathy