Tennis Elbow & Golfer's Elbow

Two names, one problem

Tennis elbow is pain at the outside of the elbow, where the tendons that extend your wrist and fingers anchor to the bone. Golfer's elbow is the same problem on the inside of the elbow, at the anchor point of the tendons that flex your wrist and grip. The medical names — lateral and medial epicondylitis — are older than our understanding of the condition, and they contain a mistake.

The "-itis" suffix means inflammation. But when researchers actually looked at these tendons under a microscope, they found very little inflammation. What they found was degeneration: disorganized collagen, failed healing attempts, tissue that has been asked to do more than it can repair. That is why the modern term is tendinopathy, and why treatments aimed at inflammation — rest, ice, anti-inflammatories, cortisone — so often disappoint.

Most people who get tennis elbow have never held a racquet. It shows up in carpenters, climbers, new parents lifting a growing baby, desk workers who spent a weekend painting a fence. The common thread is gripping and wrist work that ramped up faster than the tendon could adapt.

What it feels like

Lateral epicondylitis produces pain at the bony bump on the outside of the elbow, often radiating down the forearm. It hurts to grip — shaking hands, turning a doorknob, lifting a coffee cup with the palm facing down, opening a jar. The grip itself may feel weak, though that is usually pain inhibition rather than true weakness.

Medial epicondylitis mirrors this on the inside: pain with gripping, wrist flexion, and pulling movements. Climbers, golfers, and anyone doing heavy pulling work know this one.

Both tend to start as an ache after activity, then pain during activity, then pain with everyday tasks. The earlier in that sequence you address it, the shorter the road back.

What else it could be

Elbow pain is usually the tendon, but not always, and the exam is what sorts this out.

Radial tunnel syndrome — compression of a branch of the radial nerve — causes lateral elbow and forearm pain that can coexist with or masquerade as tennis elbow. The tenderness sits a few centimeters further down the forearm, and it does not improve with tendon-directed treatment.

Cervical radiculopathy from the neck can refer pain to the lateral elbow. If there is numbness, tingling, or neck pain in the picture, the elbow may not be the source at all.

Ulnar nerve irritation runs right behind the medial epicondyle. Medial elbow pain with tingling into the ring and small fingers points at the nerve, not the tendon.

Joint pathology — arthritis, loose bodies, ligament injury — behaves differently on exam and matters for throwers especially.

This is a place where a careful physical exam plus in-office ultrasound earns its keep. Ultrasound shows the tendon directly: thickening, tears, calcification, and the neovascularity that marks a tendon stuck in failed healing.

Why rest alone doesn't fix it

Complete rest makes a degenerated tendon weaker, not healthier. Tendons adapt to load; remove the load and they lose capacity, so the pain returns as soon as you do. Cortisone injections follow a similar pattern that is now well documented: good short-term relief, but at one year, tendons injected with steroid do worse than tendons treated with a wait-and-see approach or with exercise. Cortisone can quiet a flare that is blocking progress, but it is not a cure, and repeated injections weaken the tendon.

What actually rebuilds a tendon is progressive loading — asking it to do slightly more than it is comfortable with, letting it adapt, and repeating. That process takes weeks to months, which is unwelcome news but honest news.

How we approach it

Confirm the diagnosis. Exam plus ultrasound. If the story doesn't fit, we look at the nerve and the neck before treating the tendon.

Address the whole chain. A stiff shoulder, a thoracic spine that doesn't rotate, or a wrist that doesn't extend well all shift load to the elbow. Osteopathic treatment of those restrictions changes what the tendon has to absorb every day.

Progressive loading. A structured program of tendon loading — typically starting with isometrics for pain relief, progressing to slow heavy resistance work. This is the intervention with the strongest evidence, and it is the backbone of the plan. We make it specific: what exercise, what weight, what progression, what to do when it flares.

Shockwave therapy for tendons that have stalled. Extracorporeal shockwave stimulates a healing response in degenerated tendon and has reasonable evidence in both lateral and medial epicondylitis, usually as a series of three to five sessions layered on top of the loading program, not instead of it.

PRP for stubborn cases. For chronic tennis elbow that has failed months of good conservative care, platelet-rich plasma has some of its better evidence — trials against cortisone consistently favor PRP at six months and beyond. It is an escalation, not a first move.

What we mostly avoid: repeated cortisone. If we use it at all, it is once, with a clear reason, and with the loading program already in place.

What you can do right now

Keep using the arm, but modify the load: lift with the palm up rather than palm down, use two hands where one is aggravating, and shrink the heavy gripping temporarily rather than eliminating it. A counterforce brace — the strap that sits a few centimeters below the elbow — helps some people stay functional while the tendon rebuilds.

Start isometrics: press the back of your hand against resistance (for tennis elbow) and hold 30 to 45 seconds, a few times per day, at an intensity that is noticeable but tolerable. This is both treatment and pain relief.

Be patient with the timeline. Tendon rehab is measured in months. Most cases of tennis elbow resolve within a year even without treatment; good treatment shortens that arc and drops the recurrence rate, but nothing makes it a two-week problem.

When to come in

Come in if elbow pain has lasted more than a few weeks despite sensible modification, if it involves numbness or tingling into the hand, if it followed a distinct pop or injury, or if you have already tried rest and a cortisone shot and are back where you started. That last story is the most common one we hear, and it is very fixable — it just needs a plan aimed at what the problem actually is.