Acute and chronic tennis elbow

Tennis Elbow, medically known as lateral epicondylitis, refers to the inflammation of the 

epicondyles, which are bony protuberances at the distal end of the humerus bone. The elbow joint is made of the humerus articulated with the radius and ulna, responsible for flexion and extension of the forearm. The muscles attached to the epicondyles (lateral and medial) allow the movement of the wrist, hand, and middle finger, for example, grasping and twisting. However, the repetitive use of these muscles can eventually lead to microtears in the tendons, resulting in pain. Therefore, these conditions are known as enthesopathies, i.e. attachment point diseases. As a result, such conditions are recently recommended to be referred to as tendinosis or epicondylalgia. Activities that involve repetitive gripping or lifting, like handheld tools or even drawing, can contribute to the development of these conditions. Moreover, playing sports like tennis and golf is commonly associated with lateral and medial epicondylitis, respectively.¹

This article emphasises the lateral epicondylitis as it is the more common of the two types (lateral and medial epicondylitis) and usually affects patients between 35 and 55 years of age.²

As the name suggests, the pain is on the lateral or outer part of the elbow, typically on the dominant hand. It is generally worsened by the extension of the wrists or fingers, as the muscles responsible for these movements are attached to the lateral epicondyle, collectively known as the extensor tendons. In particular, the extensor carpi radialis brevis or longus is commonly affected in this condition.³ There is typically worsening of the pain with wrist extension against resistance when the elbow is extended, known as Cozen’s test.⁴

The diagnosis is largely clinical, as no specific test or imaging is required to make the diagnosis. However, imaging like X-rays may be done to rule out the Arthritis of the elbow. Even MRI or ultrasound can be done to directly visualise the tendon and assess injury, looking for signs such as thickening of the tendon sheath. Most of the cases would be self-limiting within 3 years and are mostly treated conservatively. Initially, with rest and icing, and over-the-counter (OTC) analgesia (Paracetamol, ibuprofen) alongside stretching and physiotherapy. Counterforce straps can reduce symptoms by relieving tension over the affected area, but this is controversial, as some patients have reported an increase in symptoms with their use. In some cases, steroid injections are used in the short term, but these have not been shown to improve long-term relief. Surgery is used in 10% cases, mostly in those who have not responded after 6-12 months of conservative treatments. In general, it includes the deprivation or release of the extensor carpi ulnaris at the lateral epicondyle. 

Tennis elbow can be classified into two categories: acute and chronic 

Acute tennis elbow usually refers to the recent onset of symptoms, lasting not more than 3 months. Chronic tennis elbow is a long-lasting condition with persistent symptoms lasting more than 6 months.⁵

Acute tennis elbow is often caused by a sudden injury or overexertion. Symptoms may include:

• Sudden onset of pain on the lateral aspect of the elbow
• Pain exacerbated by wrist extension or finger movements
• Limited mobility or stiffness in the elbow or wrist

On the other hand, chronic tennis elbow is often caused by repetitive strain or overuse. The symptoms may include:

• Persistent pain on the lateral aspect of the elbow
• Weakness in the affected arm

As can be seen from the above, the key difference between acute and chronic tennis elbow lies in the onset and duration of symptoms. However, the treatment options can vary depending on the type of tennis elbow a patient may have.

Treatment for acute tennis elbow involves conservative measures such as:

• Rest and ice to reduce inflammation
• OTC analgesia
• Stretching and physiotherapy to help improve flexibility

Treatment for chronic tennis elbow involves more aggressive measures, such as:

• Physical therapy: Targeted strengthening of forearm muscles and improved tendon resilience 
• Counterforce straps or orthotics to reduce tension on the affected area
• Steroid injections
• Surgery to release the affected tendon or repair damaged tissue

Preventing tennis elbow requires a combination of proper techniques, regular exercise, and ergonomic adjustments. Individuals can reduce their risk by using proper grip and technique when engaging in activities that involve gripping, twisting, or lifting, and by taking regular breaks to rest and stretch the forearm, wrist, and hand. Regular strengthening exercises, such as wrist extensions, wrist curls, and shoulder rotations, can also help to build resilience in the muscles and tendons. Furthermore, using ergonomic equipment and tools, maintaining a healthy weight, and engaging in regular cardiovascular exercise can also help to reduce overall muscle fatigue. By taking these preventive measures, individuals can reduce their risk of developing tennis elbow. If symptoms do occur, management strategies such as applying ice, using over-the-counter pain relievers, and engaging in gentle stretching and strengthening exercises can help to promote healing and improve flexibility.

Summary: differences between acute and chronic tennis elbow

Tennis elbow (lateral epicondylitis) is a painful condition caused by overuse of the forearm muscles attached to the lateral epicondyle, commonly affecting adults aged 35–55. It presents as pain on the outer elbow, worsened by wrist or finger extension. Diagnosis is clinical, with imaging used only to rule out other conditions.

• Acute tennis elbow: Recent onset (<3 months), often due to sudden injury or overexertion. Symptoms include sharp pain, stiffness, and limited mobility. Treatment: rest, ice, OTC pain relief, and physiotherapy
• Chronic tennis elbow: Persistent pain (>6 months), usually from repetitive strain. Symptoms include ongoing pain and weakness. Treatment: targeted physiotherapy, straps/orthotics, steroid injections, or surgery in resistant cases

Prevention includes proper technique, ergonomic adjustments, strengthening exercises, and regular rest breaks. Most cases are self-limiting, but management strategies focus on reducing pain, improving flexibility, and restoring tendon strength