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Injuries Musculoskeletal

Tennis elbow

Last revised in October 2025

Tennis elbow or lateral epicondylitis describes a tendinosis that affects the common attachment of the common extensor origin.

Tennis elbow: Summary

  • Tennis elbow or lateral epicondylitis describes tendinosis (chronic symptomatic degeneration of the tendon) affecting the common attachment of the tendons of the extensor muscles of the forearm to the lateral epicondyle of the humerus.
    • It is characterized by pain localized to the lateral elbow, often a few millimetres distal to the epicondyle.
    • The person may describe difficulty with a range of common activities such as raising a cup, shaking hands, shaving, or lifting bags with an extended elbow.
    • It is exacerbated by resisted wrist extension, gripping activities, and forearm pronation.
    • It is also known as lateral elbow pain, 'rowing elbow', tendonitis of the common extensor origin, and peri-tendinitis of the elbow.
  • Tennis elbow is typically associated with repetitive overuse of the forearm extensor muscles, commonly seen in occupations involving manual labour, repetitive wrist movements, or sports such as tennis, squash, and badminton
  • Women and men are affected equally, and peak incidence occurs between 35 and 54 years of age.
  • Tennis elbow is generally a self-limiting condition, and spontaneously improves in about 80–90% of people within 12 to 24 months.
  • On examination, there may be:
    • Localized point tenderness on palpation over and/or distal to the lateral epicondyle and along the common extensor tendon.
    • Pain on resisted middle finger extension.
    • Pain on resisted wrist extension.
    • Reduced grip strength due to pain.
    • Preserved full range of active and passive movement at the elbow and wrist joints.
  • Initial management of suspected tennis elbow includes:
    • Advising the person to apply heat or ice to help relieve pain.
    • Advising the person to rest the arm and avoid any aggravating sport or manual work activities for 6 weeks, while maintaining activity where possible.
    • Advising the person to consider using an orthosis.
    • Offering analgesia for symptom relief, such as paracetamol, or a topical or oral nonsteroidal anti-inflammatory drug, if needed.
    • Providing information and advice.
  • If symptoms persist, options include:
    • Reassessing the person and considering alternative diagnoses.
    • Arranging referral to physiotherapy.
  • Referral to an orthopaedic surgeon should be arranged if:
    • The diagnosis is uncertain.
    • There is refractory pain or severe functional impairment.
    • Symptoms persist despite 12–24 weeks of optimal management in primary care.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the management of tennis elbow in primary care.

This CKS topic does not cover detailed information on physiotherapy interventions, injection techniques, or surgical management of tennis elbow.

There are separate CKS topics on Carpal tunnel syndrome, Gout, Osteoarthritis, Rheumatoid arthritis, and Shoulder pain.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

October 2025 — reviewed. A literature search was conducted in August 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

Previous changes

November 2020 — reviewed. A literature search was conducted in November 2020 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been minor structural changes, and a recommendation not to use corticosteroids routinely for treating tennis elbow has been added to this topic.

July 2020 — minor update. Change made to patient sources of information to reflect that Arthritis Research UK has been rebranded as Versus Arthritis, and the link to Versus Arthritis patient leaflet updated.

November 2017 — reviewed. A literature search was conducted in November 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has undergone minor restructuring. A node on Differential diagnosis has been created in the Diagnosis section. The recommendations on the diagnosis and management of tennis elbow have been amended in line with current evidence.

April 2015 — minor update. A link to the CKS topic on Analgesia - mild-to-moderate pain has been added.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

October 2012 — revised. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes to clinical recommendations have been made.

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

September 2010 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that topical ketoprofen is associated with a risk of photosensitivity reactions. 

July 2010 — minor update. In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line nonsteroidal anti-inflammatory drugs (NSAIDs). 

June 2009 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has advised prescribers of the risk of photosensitivity reactions for people using topical ketoprofen. 

February 2009 — minor update. Addition to text in the Background information section and to the text on advice in the section on Treatment. 

September to December 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2025.

Systematic reviews and meta-analyses

No new systematic reviews since 1 August 2025.

Primary evidence

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion published since 1 August 2025.

New policies

No new national policies or guidelines since 1 August 2025.

New safety alerts

No new safety alerts since 1 August 2025.

Changes in product availability

No changes in product availability since 1 August 2025.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of tennis elbow.
  • Offer appropriate self-management advice and treatment in primary care.
  • Arrange referral to secondary care or other specialist services, if needed.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Tennis elbow, also referred to as lateral epicondylitis, describes tendinosis (chronic symptomatic degradation of the tendon) involving the common attachment of the tendons of the extensor muscles at the lateral epicondyle of the humerus  [Ahmad, 2013; Hegmann, 2013; Tosti, 2013; Sims, 2014].
    • The extensor carpi radialis brevis is the most commonly affected muscle, although other muscles such as the extensor digitorum, extensor carpi ulnaris, and extensor carpi radialis longus may also be involved.
    • Clinical features include:
      • Pain localized to the lateral elbow, often a few millimetres distal to the epicondyle.
      • Pain exacerbated by resisted wrist extension, gripping activities, and forearm pronation.
      • Reduced grip strength and functional impairment in activities involving wrist and hand use. 
    • The condition is typically associated with repetitive overuse of the forearm extensor muscles, commonly seen in occupations involving manual labour, repetitive wrist movements, or sports such as tennis, squash, and badminton [Schwarzman, 2017].
    • The dominant arm is involved in 75% of people [Schwarzman, 2017].
    • It is also known as lateral elbow pain, 'rowing elbow', tendonitis of the common extensor origin, and peri-tendinitis of the elbow [Bisset, 2011]. For the purposes of this topic, the term tennis elbow will be used.

What causes it?

  • Tennis elbow is a musculoskeletal condition characterized by pain over the lateral aspect of the elbow, which may radiate down the forearm. It results from a disruption in normal tendon homeostasis, often due to repetitive strain or overuse of the extensor muscles of the forearm [Singh, 2023].
    • Repetitive overuse causes micro-tears near the origin of the common extensor tendon at the lateral epicondyle of the humerus, which initiates a degenerative process [Tosti, 2013]. Adaptation of the tendon to multiple micro-tears can lead to the formation of granulation tissue, fibrosis, and eventual tendinosis [Taylor, 2012; Ahmad, 2013; Childress, 2013].
  • Activities associated with tennis elbow include those with repetitive movements of flexion–extension and prone–supination of the elbow, lifting of heavy loads, and frequent extensions of the wrist against resistance [Di Filippo, 2022].
    • Despite its name, racquet sports are the cause in fewer than 10% of people with tennis elbow [Tosti, 2013].

How common is it?

  • Tennis elbow is common, with a population prevalence estimated at 1–3% and an incidence of 4–7 per 1000 people a year [Descatha, 2016; Lapner, 2021].
    • It is the most common cause of persistent elbow pain, accounting for two-thirds of cases in general practice [Descatha, 2016].
    • It is seven times more common than golfer's elbow (medial epicondylitis) [Cutts, 2019]. 
  • Women and men are affected equally, and peak incidence occurs between 35–54 years of age [Bisset, 2011; Taylor, 2012; Ahmad, 2013].

What is the prognosis?

  • Tennis elbow is generally a self-limiting condition, with most cases resolving spontaneously over time. Recent evidence suggests that approximately 80–90% of individuals experience significant improvement within 12 to 24 months, even without formal intervention [Konarski, 2023; Wolf, 2023].
  • A US retrospective population-based cohort study (n = 576; study performed between 2000 and 2012) found the recurrence rate of tennis elbow within 2 years was 8.5% [Sanders, 2015].
  • Pain relief typically occurs within 6–12 months of initiating conservative treatment, particularly when patients adhere to a structured management plan. 
  • Factors associated with a worse outcome for pain at 12 months include: 
    • High baseline pain intensity.
    • Longer duration of symptoms prior to treatment initiation.
    • Coexisting neck or shoulder pain.
    • Female gender.
    • Older age.
    • Recurrent episodes.
    • Involvement of the dominant arm.
    • Occupations involving manual work or repetitive strain.
    • Low levels of social support.
    • Lifestyle factors such as smoking and heavy alcohol consumption, which have been shown to increase the likelihood of treatment failure and need for surgical intervention [Zhang, 2024].

[Lai, 2018; Holmedal, 2019; Keijsers, 2019]

What are the complications?

  • The complication rate for surgical intervention is low, but includes: 
    • Infection — occurs in fewer than 1% of cases.
    • Scar formation — may result in localized discomfort or cosmetic concerns.
    • Reduced grip strength — a decrease of up to 10–15% may be observed postoperatively, though it often improves with rehabilitation.
    • Decreased range of motion — uncommon, but may occur due to postoperative stiffness or adhesions.
    • Neurovascular injury — rare, but includes potential damage to the radial or ulnar nerve during surgical dissection.
  • Possible complications with corticosteroid injections include: 
    • Tendon weakening or rupture — particularly with repeated injections, due to collagen degradation and impaired tendon healing.
    • Post-injection pain flare — temporary increase in pain may occur within 24–48 hours.
    • Skin changes — includes fat atrophy and hypopigmentation at the injection site.
    • Ulnar nerve injury or paralysis — may result from incorrect injection technique.
    • Symptom recurrence — up to 50% of patients may experience recurrence, often with worsened symptoms.
    • Systemic effects — facial flushing, transient hyperglycaemia in diabetic patients, and rare infections have been reported.

[Keijsers, 2019; Karbowiak, 2023; Kholinne, 2024]

Diagnosis of tennis elbow

How should I make a diagnosis of tennis elbow?

Diagnosis of tennis elbow is usually based on history and clinical findings. 

  • Take a history and ask about:
    • Red flags such as a history of trauma, joint swelling, or systemic symptoms, which may suggest an alternative diagnosis.
    • The severity, onset, duration, and exacerbating features of the pain.
      • Symptoms are often of insidious onset, without any clear precipitating event, but may follow an injury or increased levels of activity.
      • Pain (or a burning sensation) is typically present in the dominant arm in the region of the lateral epicondyle with radiation down the extensor aspect of the forearm, and occasionally proximally into the upper arm. Symptoms are usually exacerbated by repetitive wrist movements (particularly wrist extension and repetitive power gripping palm-down). 
      • Occupational and recreational activities that may provoke symptoms and may have precipitated the problem, such as construction work, assembly line work, use of vibratory tools, typing, playing the piano, playing tennis, or kayaking.
    • Grip weakness. 
    • The impact on daily functioning, such as difficulty with raising a cup, shaking hands, shaving, or lifting bags with an extended elbow. 
    • Any associated disturbed sleep, anxiety and/or depression.
    • Any previous history of elbow pain and treatments tried.
  • Examine the person:
    • Assess for red flag features such as a swollen, red, tender joint, which may suggest an alternative diagnosis.
    • Look for typical features:
      • Localized point tenderness on palpation over and/or distal to the lateral epicondyle and along the common extensor tendon. 
      • Resisted middle finger extension may be painful (Maudsley's test).
      • Dorsiflex the wrist against resistance with the elbow flexed at 90° — extending the elbow increases pain further. 
      • Grip strength may be reduced. 
      • A full range of active and passive movement at the elbow and wrist joints is usually preserved. 
      • Normal sensation. 
    • Check for Tinel's sign — tap lightly on the medial elbow over the ulnar nerve. It is positive if testing generates paraesthesia without pain. 
      • A negative Tinel's signs can help rule out cubital tunnel or other neurological conditions.
    • Assess the neck and shoulder to exclude an alternative diagnosis, such as referred pain.
  • Investigations are not usually needed in primary care.

Basis for recommendation

These recommendations are based on expert opinion in narrative reviews Tennis elbow [Keijsers, 2019], Management of later epicondylitis: a narrative literature review [Ma, 2020], Lateral epicondylitis: current concepts [Johns, 2020], Chronic lateral epicondylitis: challenges and solutions [Lai, 2018], Evaluation and management of elbow tendinopathy [Taylor, 2012], Elbow pain: a guide to assessment and management in primary care [Javed, 2015], and Progressive elbow pain [Descatha, 2016].

What else might it be?

  • Other conditions that may present similarly to tennis elbow include:
    • Rheumatoid arthritis or septic arthritis — may be suggested by a hot, tender, or swollen joint. See the CKS topic on Rheumatoid arthritis for more information.
    • Cervical radiculopathy (referred pain from the cervical spine) may cause neck pain and numbness or muscle weakness affecting the C6–8 distribution. See the CKS topic on Neck pain - cervical radiculopathy for more information.
    • Elbow arthropathy (most commonly osteoarthritis) — elbow osteoarthritis most commonly affects the radiocapitellar joint, and typically presents with joint stiffness, loss of flexion and extension with end-range pain. See the CKS topic on Osteoarthritis for more information.
    • Osteochondritis dissecans of the capitellum — this may present with joint effusion. This is more common in young people, especially following repetitive overhead throwing activities.
    • Radial tunnel syndrome (compression of the posterior interosseous nerve) — maximal tenderness is localized to the area distal to the radial head, and pain is often worse at night. Resisted wrist extension may not be painful; however, resisted thumb and index finger extension may cause pain.
      • Note: this condition may co-exist with tennis elbow in 5% of cases.
    • Trauma and intra-articular loose bodies — elbow stiffness, deformity, swelling, or soft tissue damage may suggest an old or new traumatic injury. Clicking or limitation of range of movement may suggest loose bodies.
    • Malignancy (rare) — may be suggested by bone pain, an increasing mass or swelling. See the CKS topic on Bone and soft tissue sarcoma - recognition and referral for more information.
    • Posterior interosseous nerve entrapment syndrome.
    • Posterolateral elbow instability.
    • Synovitis.
    • Synovial fold syndrome.
    • Frozen shoulder.

Basis for recommendation

This information is based on expert opinion in narrative reviews Tennis elbow [Keijsers, 2019], Management of later epicondylitis: a narrative literature review [Ma, 2020], Tennis elbow: a clinical review article [Cutts, 2019], Ultrasound-guided interventions in lateral epicondylitis [Shergill, 2019], Lateral epicondylitis of the elbow [Vaquero-Picado, 2016], Evaluation and management of elbow tendinopathy [Taylor, 2012], Elbow pain: a guide to assessment and management in primary care [Javed, 2015], Progressive elbow pain [Descatha, 2016], and Lateral epicondylitis: a review of pathology and management [Ahmad, 2013]; and the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2025].

Management

Scenario: Management of tennis elbow

From age 16 years onwards.

How should I manage a person with tennis elbow?

  • The aim of management is to provide pain relief and restore physical function.
  • Advise the person to:
    • Apply heat or ice to help relieve pain.  
    • Rest the arm and avoid (or reduce instances of) any aggravating sport or manual work activities for 6 weeks, while maintaining activity where possible:
      • Avoid tasks that involve high force, hand-gripping or pinching, or the use of high-amplitude vibrating handheld tools.  
    • Consider using an orthosis (for example, a forearm strap, or a wrist or elbow brace). Inform the person that the evidence for benefit is limited.
  • Offer analgesia for symptom relief, such as paracetamol or a topical nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen gel, first-line. 
    • Advise people using topical ibuprofen gel to avoid smoking and other naked flames, as there is a risk of severe burns — fabrics that have been in contact with gel burn more easily and are a serious fire hazard. Washing clothing and bedding may reduce product buildup, but not totally remove it.
      • Topical NSAIDs may be preferred over oral NSAIDs due to lower risk of gastrointestinal side effects. 
      • Consider prescribing an oral NSAID if symptoms persist.
      • See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for more information on cautions, contraindications, adverse effects, and potential drug interactions.
  • Provide appropriate information and advice.
  • Reassure the person that tennis elbow is a self-limiting condition, with most people improving within 3–6 months.

If there is no response to initial treatment after 6 weeks:

  • Reassess the person and consider alternative diagnoses. 
  • Consider arranging referral to physiotherapy as it has strong evidence for short-term benefit.
    • Interventions include stretching and strengthening exercises for the wrist and forearm extensors, eccentric muscle training, massage, and ultrasound therapy.
  • Do not offer corticosteroid injection. It may provide short-term relief but is associated with worse outcomes at 6 months.
    • If corticosteroid injection is offered, discuss the possible adverse effects and long-term implications.

If there is no response to treatment 6–12 months after initial presentation, consider referral to an orthopaedic surgeon for evaluation. 

  • Inform the person that current evidence does not support surgery as more effective than placebo. The only placebo-controlled trial showed no clear benefit, and methodological limitations prevent firm conclusions. Surgery may be considered in selected cases, but expectations should be managed.

Basis for recommendation

These recommendations are largely based on the British Elbow and Shoulder Society (BESS) article BESS patient care pathway: Tennis Elbow [Singh, 2023] and the systematic reviews Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults [Pattanittum, 2013], Tennis elbow [Bisset, 2011], Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials  [Sims, 2014], Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review [Hoogvliet, 2013], Treatment of lateral epicondylitis with autologous blood, platelet-rich plasma or corticosteroid injections [Houck, 2019], Injection therapies for lateral epicondylagia: a systematic review and Bayesian network meta-analysis [Dong, 2016], Platelet-rich plasma vs corticosteroids for elbow epicondylitis: a systematic review and meta-analysis [Li, 2019], and Efficacy of nonoperative treatments for lateral epicondylitis: a systematic review and meta-analysis [Kim, 2020]; expert opinion in narrative reviews Tennis elbow [Keijsers, 2019], Management of later epicondylitis: a narrative literature review [Ma, 2020], Tennis elbow: a clinical review article [Cutts, 2019], Ultrasound-guided interventions in lateral epicondylitis [Shergill, 2019], Management of chronic tendon injuries [Kane, 2019], Chronic lateral epicondylitis: challenges and solutions [Lai, 2018], Lateral epicondylitis of the elbow [Vaquero-Picado, 2016], Evaluation and management of elbow tendinopathy [Taylor, 2012], Elbow pain: a guide to assessment and management in primary care [Javed, 2015], and Progressive elbow pain [Descatha, 2016]; the American College of Occupational and Environmental Medicine (ACOEM) guideline Elbow disorders [Hegmann, 2013].

Analgesics
  • There is limited evidence to support the use of topical or oral analgesics in people with tennis elbow. The recommendations on the use of analgesia are based on conflicting evidence in the literature and expert opinion in narrative reviews.
    • A Cochrane systematic review of 15 controlled clinical trials or randomized controlled trials (RCTs) of oral (n = 437) and topical NSAIDs (n = 301) with different comparators found [Pattanittum, 2013]:
      • Low-quality evidence that topical NSAIDs were significantly more effective than placebo in improving pain scores in the short term up to 4 weeks.
      • Low-quality and conflicting evidence that oral NSAIDs produced a greater improvement in pain scores than placebo, however, this finding was not supported in a second trial.
      • Overall, limitations included small sample sizes, short follow-up times, and few of the included studies used intention-to-treat analysis.
    • An earlier systematic review of multiple interventions for tennis elbow found moderate-quality evidence that topical NSAIDs are likely to be beneficial in the short term (4 weeks) compared with placebo, but concluded that oral NSAIDs are of unknown effectiveness for symptom relief [Bisset, 2011].
    • The recommendation to offer a topical NSAID (or an oral NSAID if required) is supported by the ACOEM practice guideline that cites moderate-quality evidence for the use of topical and oral NSAIDs as a treatment option for tennis elbow [Hegmann, 2013].
    • Experts in narrative reviews agree that while there is a limited evidence to support the use of NSAIDs, short-term use may be beneficial in the acute stages of tennis elbow [Descatha, 2016; Cutts, 2019; Keijsers, 2019; Shergill, 2019; Johns, 2020].
  • The recommendation to use paracetamol for the management of tennis elbow is pragmatic, based on what CKS considers to be good clinical practice.
    • ACOEM advises that while there is no evidence for the efficacy of paracetamol it is a reasonable alternative and may be the first option for patients with contraindications to NSAIDs [Hegmann, 2013]. 
Orthoses 
  • There is limited, conflicting evidence on the benefits of orthoses in the literature.
  • Bracing (forearm straps and wrist extension splints) may provide symptom relief by offloading and decreasing stress on the diseased common extensor tendon and reducing extensor muscle activity [Taylor, 2012; Javed, 2015; Lai, 2018; Ma, 2020].
    • Orthoses are recommended in the ACOEM practice guideline, which cites moderate-quality evidence for the use of elbow straps [Hegmann, 2013].
    • A systematic review of multiple interventions for tennis elbow found very low-quality evidence that orthoses are less effective than combination physical therapies at providing pain relief at 6 weeks, but low-quality evidence that orthoses may be more effective at improving the ability to perform daily activities than physiotherapy at 6 weeks follow up [Bisset, 2011].
    • Another systematic review concluded that orthoses provide little or no additional benefit when combined with physiotherapy [Sims, 2014].
  • CKS notes that the expert opinion of previous external reviewers of this CKS topic was divided as to the benefits of different orthotic devices for tennis elbow, but some felt that forearm bands may be of benefit in the short term, especially if used in combination with physiotherapy. The recommendation to advise people to consider using an orthosis is pragmatic. 
Corticosteroid injections
  • The recommendation that corticosteroid injections should not be offered routinely for people with tennis elbow is based on evidence that while there are short-term clinical benefits, the long-term outcomes may be less favourable and there may be higher recurrence rates than with physiotherapy or no treatment [Singh, 2023].
Physiotherapy 
  • The recommendation to arrange physiotherapy referral is based on the fact that exercises are simple, with minimal potential to cause harm [Childress, 2013], however, CKS notes there is limited, conflicting evidence on the benefits of physiotherapy in the literature.
    • The ACOEM guidelines state that strengthening exercises are most helpful in the management of chronic elbow pain rather than stretching exercises, particularly if joint movement is preserved, and also cites evidence of modest efficacy for ultrasound treatment for tennis elbow [Hegmann, 2013].
    • A systematic review of multiple interventions for tennis elbow concluded that combination physical therapies, exercise, orthoses, and ultrasound therapy are of unknown clinical effectiveness, as there was insufficient good-quality evidence to draw conclusions [Bisset, 2011].
      • In the short term, physiotherapy interventions (exercise and mobilization) may be less effective than corticosteroid injections in terms of pain scores and global improvement scores, but physiotherapy shows superior outcomes after 6 weeks.
    • A systematic review of one clinical review and 12 RCTs found moderate-quality evidence for the short-term effectiveness of stretching plus strengthening exercises compared with ultrasound and massage treatment. It noted, however, that statistical pooling of the trial results was not possible due to heterogeneity of the studies included [Hoogvliet, 2013].
    • A randomized, placebo-controlled trial (n = 165) found a short-term benefit of physiotherapy alone compared with no physiotherapy in terms of improved rates of complete recovery or symptom improvement at 4 weeks, however, physiotherapy did not result in any significant differences in outcome at 1 year follow up [Coombes, 2013].
    • A recent systematic review and meta-analysis of 58 RCTs that assessed the outcomes of non-surgical treatments for tennis elbow found that electrophysiotherapy and physical therapy reported statistically and clinically improved scores in pain and function compared to placebo [Kim, 2020]. 
Orthopaedic specialist referral
  • The recommendation to consider referring people with tennis elbow to an orthopaedic surgeon if there is no response to treatment 6–12 months after initial presentation is based on expert opinion in narrative reviews [Javed, 2015; Descatha, 2016; Cutts, 2019; Kane, 2019], and what CKS considers good clinical practice. The advice that there is no clear evidence that surgical intervention has better benefits over placebo is from the narrative review [Singh, 2023].

When should I refer a person with tennis elbow?

  • Arrange referral to an orthopaedic surgeon if:
    • The diagnosis is uncertain.
      • Imaging techniques (such as ultrasonography or Magnetic Resonance Imaging [MRI]) may be considered to rule out other conditions, but should only be used where diagnostic uncertainty persists. There is no evidence that imaging improves outcomes.
    • There is refractory pain or severe functional impairment.
    • Symptoms persist despite 12–24 weeks of optimal management in primary care.
    • Surgical treatments such as open or arthroscopic debridement may be considered after 3–6 months of failed non-surgical treatment. Inform the person that current evidence does not support surgery as more effective than a placebo. The only placebo-controlled trial showed no clear benefit, and methodological limitations prevent firm conclusions. Surgery may be considered in selected cases, but expectations should be managed.

Basis for recommendation

These recommendations are based on the  British Elbow and Shoulder Society (BESS) article BESS patient care pathway: Tennis Elbow [Singh, 2023] and expert opinion in narrative reviews Elbow pain: a guide to assessment and management in primary care [Javed, 2015], Progressive elbow pain [Descatha, 2016], Tennis elbow: a clinical review article [Cutts, 2019], and Management of chronic tendon injuries [Kane, 2019]; and what CKS considers good clinical practice.

What information and advice should I provide?

  • Advise the person:
    • On sources of information and advice on tennis elbow, such as:
    • To discuss with their employer or Occupational Health department if work-related activities are exacerbating symptoms.
      • Options may include to mix work patterns, increase the number of rest breaks, to change the way objects are handled (if appropriate), and to make modifications to the work environment.

Basis for recommendation

These recommendations are pragmatic and what CKS considers good clinical practice. 

Supporting evidence

This CKS topic is largely based on the British Elbow and Should Society (BESS) article BESS patient care pathway: Tennis elbow [Singh, 2023], and on systematic reviews, including Tennis elbow [Bisset, 2011], Non-surgical treatment of lateral epicondylitis: a systematic review of randomized controlled trials [Sims, 2014], Treatment of lateral epicondylitis with autologous blood, platelet-rich plasma or corticosteroid injections [Houck, 2019], and Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis [Dong, 2016]; expert opinion in narrative reviews including Tennis elbow [Keijsers, 2019], Tennis elbow: a clinical review article [Cutts, 2019], Chronic lateral epicondylitis: challenges and solutions [Lai, 2018], Evaluation and management of elbow tendinopathy [Taylor, 2012], Elbow pain: a guide to assessment and management in primary care [Javed, 2015], and Progressive elbow pain [Descatha, 2016]. The rationale for the individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of tennis elbow.

Search dates

November 2020 - August 2025

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Elbow tendinopathy/, tennis elbow.tw, rowing elbow.tw, rowers elbow.tw., 
  • (lateral near/5 (epicondyle or epidcondylitis or epicondylosis or epicondylalgia)) or LET.tw.
  • ((elbow* or lateral or common extensor or epicondyl*) near/5 (tendonitis or tendinitis or peritendonitis or peritendinitis or tendinopath* or tendinosis)).tw
  • (elbow near/2 pain*).tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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