Tennis elbow is chronic degeneration of a tendon — not inflammation, not an acute injury. It is a tough problem that often hangs around for months despite your best efforts. Dr. Graham's approach: throw the kitchen sink at it. Cortisone, formal therapy, PRP, and surgery when needed — with the goal of providing as much relief as possible for as long as possible.
You don't have to play tennis to get tennis elbow. Most patients are manual workers, office workers, or recreational athletes who have never held a racket.
Understanding the Condition
Tennis elbow — lateral epicondylitis — is chronic degeneration of the extensor carpi radialis brevis (ECRB) tendon at its origin on the lateral epicondyle of the humerus. Despite the name "epicondylitis," this is not primarily an inflammatory condition. Biopsy studies show degenerative changes in the tendon tissue — angiofibroblastic dysplasia — rather than the inflammatory cells you would expect with true "-itis." The tendon is wearing down, not inflaming.
This distinction matters for understanding treatment. Anti-inflammatory medications and cortisone injections may reduce pain in the short term, but they are not addressing the underlying degenerative process. The tendon has to heal on its own — and degenerated tendon tissue is not efficient at doing that. This is why tennis elbow can linger for months, sometimes longer, despite treatment.
The ECRB tendon is loaded every time the wrist is extended against resistance — which happens constantly during gripping, lifting, turning, and carrying. Its origin on the lateral epicondyle is a high-stress mechanical junction. Repetitive loading over years — from work, sport, or daily activity — causes microscopic tears that accumulate faster than the tendon can repair them. The result is a degenerative tendon that hurts with use and is slow to recover.
In Dr. Graham's experience, the single most reassuring thing he can tell patients is also the most accurate: this condition almost always gets better eventually. The goal of treatment is to accelerate that process and reduce pain along the way — not to find a magic cure that none of the treatments offer.
The ECRB (extensor carpi radialis brevis) originates at the lateral epicondyle. The degenerative zone (red circle) sits just at this origin — the highest-stress point where the tendon transitions from bone to soft tissue. This is where the microscopic tears accumulate and where pain is generated.
Tenderness is typically maximal just anterior and inferior to the lateral epicondyle — the anatomic footprint of the ECRB origin. Pressing on this spot reproduces the patient's pain precisely.
If you've looked up tennis elbow treatment, you found a long list: cortisone, physical therapy, dry needling, ultrasound, massage, bracing, PRP, laser, acupuncture, shockwave therapy, surgery — and more. This is not reassuring information when you think about it carefully. All those treatments exist because not one of them works reliably every time. Lateral epicondylitis is a genuinely difficult condition to resolve. Dr. Graham will be honest with you about that from the first visit — and his response to that difficulty is to offer as many reasonable options as possible, in a logical sequence, until you find relief.
Dr. Graham's Treatment Philosophy
The goal is maximum relief for as long as possible. That means not relying on any single treatment — it means offering everything reasonable in a logical order and letting the patient guide how far to go.
First-Line Treatment
A corticosteroid injection at the ECRB origin is the most consistently helpful single intervention Dr. Graham offers for lateral epicondylitis. The injection is performed in the office under local anesthesia — a precise injection directly to the point of maximal tenderness at the lateral epicondyle. Relief often begins within days to a week.
The cortisone does not repair the degenerated tendon. What it does is reduce the pain signal sufficiently to allow the patient to participate in formal physical therapy without being limited by discomfort. Therapy alone can be difficult to perform when the elbow hurts enough that any loaded wrist extension provokes pain — the injection creates the window for therapy to work.
Repeat cortisone injections are a conversation that depends on how much relief was achieved, how long it lasted, and whether formal therapy was completed. In most cases, Dr. Graham prefers to use cortisone strategically rather than repeatedly — if multiple injections have not provided durable relief, PRP or surgery becomes a more appropriate next step.
Platelet-rich plasma (PRP) is processed from the patient's own blood — concentrated growth factors and platelets that, when injected into the degenerative tendon, can stimulate the repair process that the tendon has failed to complete on its own. For chronic tendinopathy specifically, PRP has a reasonable evidence base and a compelling biological rationale.
Dr. Graham does not bring up PRP in every consultation — but he is enthusiastic about it as an option, particularly for two groups of patients: those who want to exhaust biologic options before considering surgery, and those who have had some but incomplete relief from cortisone and therapy and are looking for the next step. PRP is also appropriate for patients who are specifically interested in biologic treatment and have done their research.
The PRP injection for tennis elbow is performed in the office. The patient's blood is drawn, processed in a centrifuge to concentrate the platelets, and injected precisely at the ECRB origin under ultrasound or fluoroscopic guidance. Unlike cortisone — which is a one-directional pain reducer — PRP aims to biologically stimulate the healing response in the tendon itself.
For patients interested in PRP, Dr. Graham's full PRP page has detailed information on the procedure, preparation, and what to expect.
When Conservative Treatment Isn't Enough
Surgery for lateral epicondylitis is offered after a genuine and committed trial of conservative treatment — cortisone, formal therapy, and in many cases additional modalities including PRP — has not resolved the pain to the patient's satisfaction. There is no hard rule about how long to wait; the conversation is about whether the patient has done enough to give conservative treatment a fair chance, and whether they are ready to move forward.
Dr. Graham does not discourage surgery for patients who want it after a reasonable trial of conservative care. His experience is that the vast majority of patients who proceed to surgery achieve meaningful, durable pain relief — and when a patient has been dealing with this problem for months or more than a year, that outcome is well worth pursuing.
The surgical procedure removes the degenerative portion of the ECRB tendon, detaches the tendon from the lateral epicondyle, and reattaches it using suture anchors. Dr. Graham uses the Nirschl scratch test intraoperatively to identify the degenerative tissue precisely — this is the gold standard for confirming which tissue needs to be removed. The tendon is then secured with the latest suture anchors from Arthrex, which provide robust fixation to the bone.
Operative Technique
The surgical technique for lateral epicondylitis involves three essential steps: detaching the ECRB from its origin on the lateral epicondyle, removing the degenerative portion of the tendon, and reattaching the healthy tendon to bone with suture anchors. The goal is to excise the pathologic tissue while preserving the healthy ECRB and restoring its anatomic origin.
Dr. Graham uses the Nirschl scratch test as an intraoperative tool to identify the degenerative tendon. During the procedure, the degenerative tissue has a characteristic grayish, friable appearance and texture — different from healthy white tendon. The scratch test confirms which tissue should be removed and which healthy tendon should be preserved. Removing too little leaves pathologic tissue behind; removing too much sacrifices healthy tendon. The scratch test threads that needle.
After debridement, the ECRB is reattached to the lateral epicondyle using the latest generation of suture anchors from Arthrex — providing robust, secure fixation that allows the tendon to heal to bone reliably. The construct is strong enough to begin hand therapy at 2 weeks post-operatively. Most patients are back to full activity by 3 months.
Named after the pioneer of tennis elbow surgery, the Nirschl scratch test identifies degenerative tendon tissue intraoperatively. Degenerative ECRB has a characteristic grayish, fish-flesh appearance distinct from the white, glistening healthy tendon. Dr. Graham uses this tactile and visual assessment to guide the boundaries of debridement precisely — removing the pathologic tissue while preserving everything healthy.
Regional block — axillary or more proximal. Outpatient procedure at Baptist Beaches Hospital or Horizon Surgery Center. No general anesthesia required in most cases.
Small incision centered over the lateral epicondyle. The common extensor origin is identified and the ECRB is separated from the extensor digitorum communis and isolated for inspection.
The ECRB is detached from the lateral epicondyle to expose the degenerative tissue at its origin. The Nirschl scratch test is used to identify and delineate the degenerative zone — distinguishing pathologic gray tissue from healthy white tendon.
The degenerative portion of the ECRB is excised. Healthy tendon is preserved. The lateral epicondyle is lightly decorticated to promote bleeding and enhance the biological healing environment for reattachment.
The ECRB is reattached to the lateral epicondyle using the latest Arthrex suture anchors — providing robust, secure fixation. The construct is confirmed to be stable and anatomic before closure.
Post-operative splint for 2 weeks. Custom-made orthosis for an additional 4 weeks. Hand therapy begins at 2 weeks. Full recovery: approximately 3 months.
Recovery After Surgery
The recovery from tennis elbow surgery is structured and predictable — and significantly faster than the months or years of conservative treatment that preceded it.
Splint in place protecting the repair. Swelling management. Fingers and wrist are rested but grip is not prohibited. Wound check at 2 weeks.
Custom-made elbow and wrist orthosis. Hand therapy begins — gentle range of motion, tendon gliding, progressive loading. Orthosis worn during activity for protection.
Orthosis discontinued. Strengthening program advances. Eccentric loading, grip strengthening, functional activities. Gradual return to work and sport activities.
Most patients return to full activity — including manual labor and sport — by 3 months. Some demanding activities may take slightly longer based on individual progress.
"I had tennis elbow for over a year. Tried everything. Dr. Graham was the first doctor who was honest with me that this is just a hard problem — and then actually gave me a plan that worked. Surgery was my last resort and it was the right call. Three months later I was back to work with no elbow pain."
Common Questions
Questions from patients who have been dealing with this problem for months and are trying to figure out what to do next.