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Lateral Epicondylitis (Tennis Elbow)

Most common tendinopathy of the upper limb, affecting the wrist extensor insertion on the lateral epicondyle, mainly the extensor carpi radialis brevis (ECRB). Prevalence of 1-3%. Eccentric strengthening (Tyler protocol) and shockwave therapy are the reference treatments.

Characteristics

Lateral epicondylitis, commonly known as tennis elbow, is the most common tendinopathy of the upper limb with a prevalence of 1 to 3% of the general population [1]. It affects the insertion of the wrist extensor muscles on the lateral epicondyle of the humerus, mainly the extensor carpi radialis brevis (ECRB). Despite its name, it affects manual workers (repetitive gripping, vibrations) more than tennis players. Peak incidence is between 35 and 50 years, with no significant sex predominance.

Current pathophysiology has abandoned the inflammation concept in favor of angiofibroblastic degeneration of the tendon (Nirschl): anarchic neovascularization, collagen fiber degeneration, absence of inflammatory cells [2]. Natural history is favorable in 80-90% of cases within 12-18 months.

Evidence-based therapeutic options include eccentric exercises (Tyler protocol with FlexBar®, evidence level A), extracorporeal radial shockwave therapy (level B), and PRP injections (Platelet-Rich Plasma, promising medium-term results). Corticosteroid injections are effective short-term (< 6 weeks) but detrimental long-term with recurrence rates higher than placebo at 12 months, and should be reserved for hyperalgesic forms failing conservative treatment [3].

  • Pain on the lateral aspect of the elbow, at the lateral epicondyle, radiating toward the dorsal forearm. Aggravated by resisted wrist extension, gripping (handshaking, turning a door handle), carrying heavy objects with arm extended (chair test).
  • Clinical tests: Cozen's test (resisted wrist extension, elbow in full extension), Mill's test (passive extensor stretching: pronation + wrist flexion + elbow extension), chair test (lifting a chair by its back), Maudsley's test (resisted middle finger extension – isolating ECRB).
  • Prevalence of 1-3% in the general population, peak between 35 and 50 years. Risk factors: repetitive gripping movements (grip force), mechanical vibrations, smoking, obesity, tennis (poor backhand technique, thin grip, tight strings).
  • Favorable natural history in 80-90% of cases within 12-18 months. Corticosteroid injections provide short-term relief (< 6 weeks) but worsen long-term prognosis (higher recurrence rate than placebo at 12 months). Refractory forms (5-10%) may require surgical treatment (arthroscopic or open debridement).

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  1. Stage 1 – Reversible acute inflammation

    Acute peritendinous inflammation without structural tendon damage. Pain only during activity, resolving at rest. Histology: inflammation with edema without tissue degeneration. Fully reversible with rest and conservative treatment. Symptom duration generally less than 2 weeks.

  2. Stage 2 – Angiofibroblastic degeneration

    Angiofibroblastic tendon degeneration: invasion of immature fibroblasts and anarchic neovascularization with collagen fiber disorganization. Pain during activity and sometimes at rest. Reversible with prolonged conservative treatment (eccentric, shockwave). Most frequently diagnosed stage.

  3. Stage 3 – Partial tear

    Partial tendon tear with macroscopic structural changes: longitudinal or transverse tendon fissuring, grayish friable tissue on imaging (MRI) or during surgical exploration. Pain at rest and during activity. Incomplete response to conservative treatment, potential indication for PRP or surgery.

  4. Stage 4 – Fibrosis and complete tear

    Terminal stage with extensive fibrosis, intratendinous calcifications and complete tendon rupture. Non-functional scar tissue replacing the degenerated tendon. Chronic disabling pain. Surgical treatment generally necessary: debridement of pathological tissue and tendon reinsertion or reconstruction.

Medical and Surgical Management

  • PRP injections (Platelet-Rich Plasma): superior results to corticosteroids at medium and long term (6-12 months). 1-3 injections spaced 2-4 weeks apart. Mechanism: stimulation of tendon healing cascade through platelet growth factors.
  • Corticosteroid injection: short-term efficacy only (< 6 weeks), with risk of recurrence and long-term worsening. Reserve for hyperalgesic forms failing conservative treatment. Maximum 2-3 injections per year. Relative rest after injection.
  • Surgery (5-10% of refractory cases): debridement of angiofibroblastic tissue via open or arthroscopic approach. Resection of degenerative ECRB tissue with underlying bone decortication. Epicondyle decortication to stimulate neovascularization. Success rate of 80-90%.

Physiotherapy treatment

  • Eccentric wrist extensor strengthening: Tyler protocol with FlexBar® (flexible rubber bar). 3 sets of 15 repetitions, twice daily, for 6-8 weeks. Efficacy demonstrated by randomized controlled trials (evidence level A). Progressive resistance.
  • Extracorporeal radial shockwave therapy (RSWT): 3-5 sessions one week apart. 2000-3000 impulses at 8-12 Hz, pressure of 1.5-3 bars. Mechanism: stimulation of neovascularization and tendon healing. Success rate of 60-80% in controlled studies.
  • Ergonomics and activity modification: identification and correction of pathogenic gestures (power gripping, repetitive movements, vibrations). Epicondylar brace (counterforce orthosis) worn during at-risk activities. Workstation adaptation (ergonomic mouse, keyboard, desk height).
  • Comprehensive rehabilitation program: wrist extensor stretches (3×30 sec, 3 times/day), radial nerve neural mobilization, Cyriax deep transverse massage on ECRB, complete muscle chain strengthening (shoulder, elbow, wrist). Progressive return to sports at 8-12 weeks.

After the session

You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.

Questions About Elbow Rehabilitation

When should I start physiotherapy after elbow surgery?

Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.

What are the goals of elbow rehabilitation?

Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.

Is elbow rehabilitation painful?

The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.

Scientific sources

Average duration

6 to 12 weeks of active rehabilitation, favorable natural history within 12-18 months

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