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Tennis Elbow

Topic Overview

What is tennis elbow?

Tennis elbow is soreness or pain on the outer part of the elbow. It happens when you damage the tendons that connect the muscles of your forearm to your elbow. The pain may spread down your arm to your wrist. If you don't treat the injury, it may hurt to do simple things like turn a key or open a door.

Your doctor may call this condition lateral epicondylitis.

What causes tennis elbow?

Most of the time tennis elbow is caused by overuse. You probably got it from doing activities where you twist your arm over and over. This can stress the tendon, causing tiny tears that in time lead to pain. A direct blow to the outer elbow can also cause tendon damage.

Tennis elbow is common in tennis players, but most people get it from other activities that work the same muscles, such as gardening, painting, or using a screwdriver. It is often the result of using equipment that is the wrong size or using it the wrong way.

Anyone can get tennis elbow, but it usually occurs in people in their 40s.

How is tennis elbow diagnosed?

To diagnose tennis elbow, a doctor will examine your elbow and ask questions about the elbow problem, your daily activities, and past injuries. You probably won't need to have an X-ray, but you might have one to help rule out other things that could be causing the pain.

If your symptoms don't get better with treatment, you might have an imaging test, such as an MRI. This can tell your doctor whether a bone problem or tissue damage is causing your symptoms.

How is it treated?

You can start treating tennis elbow at home right away.

  • Rest your arm, and avoid any activity that makes the pain worse.
  • As soon as you notice pain, use ice or cold packs for 10 to 15 minutes at a time, several times a day. Always put a thin cloth between the ice and your skin. Keep using ice as long as it relieves pain. Or use a warm, moist cloth or take hot baths if they feel good. Do what works for you.
  • Take over-the-counter pain relievers such as ibuprofen or naproxen (NSAIDs) or acetaminophen if you need them. Or try an NSAID cream that you rub over the sore area. Be safe with medicines. Read and follow all instructions on the label.
  • Wear a counterforce brace when you need to grasp or twist something. This is a strap around your forearm worn around your forearm just below the elbow. It may ease the pressure on the tendon and spread force throughout your arm.

After the pain eases, your doctor or physical therapist can teach you rehabilitation (rehab) exercises to stretch and strengthen your tendon. Doing these exercises at home can help your tendon heal and can prevent further injury.

When you feel better, you can return to your activity, but take it easy for a while. Don't start at the same level as before your injury. Build back to your previous level slowly, and stop if it hurts. To avoid damaging your tendon again:

  • Take lessons or ask a trainer or pro to check the way you are doing your activity. If the way you use a tool is the problem, try switching hands or changing your grip. Make sure you are using the right equipment for your size and strength.
  • Always take time to warm up before and stretch after you exercise.
  • After the activity, apply ice to prevent pain and swelling.

Be patient, and stay with your treatment. You will probably feel better in a few weeks, but it may take 6 to 12 months for the tendon to heal. In some cases, the pain lasts for 2 years or longer.

If your symptoms don't improve after 6 to 8 weeks of home treatment, your doctor may suggest a shot of corticosteroid. This could give you some short-term relief so you can start rehab exercises. Surgery is seldom needed for tennis elbow.

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Cause

Overuse of the forearm muscles using a repeated twisting motion is the most common cause of tennis elbow. These movements are common to various jobs, such as carpentry or plumbing, and to many daily activities, such as yard work and lifting objects. Racquet sports, swimming, and throwing sports (such as baseball) can also lead to tennis elbow.

Tennis elbow injuries can result from:

  • Overuse. Repeated movements that involve twisting of the elbow cause small tears in the tendon, weakening it. Overuse depends on how hard or how long you do something.
  • Technique, or the way you do an activity. This includes holding equipment or a tool in a awkward position while you use it.
  • Equipment. This can happen, for example, if you use a tool or sports equipment that is too heavy for you or that has a grip that is the wrong size for your hand.
  • A single accident, such as a direct hit to the side of the elbow (lateral epicondyle), or falling on an outstretched arm.

Symptoms

Tennis elbow symptoms usually begin gradually. The main symptom is pain, which may begin with a dull aching or soreness on the outer part of the elbow that goes away within 24 hours after an activity. As time goes on, it may take longer for the pain to go away. The condition may further progress to pain with any movement, even during everyday activities, such as lifting a jug of milk. Pain may spread to the hand, wrist, other parts of the arm, shoulder, or neck.

Tennis elbow pain:

  • Usually occurs in the dominant arm (your right arm if you are right-handed, or left arm if you are left-handed).
  • Affects the outside of the elbow (the side away from your body). Pain increases when that area is pressed or when you are grasping or twisting objects.
  • May increase in the evening and make sleep difficult. The elbow might be stiff in the morning.
  • Over time may occur with mild activity, such as picking up a coffee cup, turning a jar lid or doorknob or key, or shaking hands. Simply starting your car could hurt. You may even have pain when you aren't using your elbow.

Other parts of the arm, shoulder, and neck may also become sore or painful as the body tries to make up for the loss of elbow movement and strength.

Swelling rarely occurs with tennis elbow. If your elbow is swollen, you may have another type of condition, such as arthritis.

Radial tunnel syndrome is an unusual type of nerve entrapment that is sometimes confused with or can develop at the same time as tennis elbow.

What Happens

Tennis elbow pain is a symptom of tendon injury.

Overuse or stress can cause microtears in the tendon. This usually occurs because of repetitive motions of the arm or wrist. The longer you use an injured tendon, the more damaged it becomes.

The most common symptom of tennis elbow is pain on the outside of the elbow. Given enough rest, the tendon can mend on its own. But if you continue the activity, the weakened tendon may become more vulnerable to tear or rupture from a sudden accidental blow, fall, or forceful movement.

With early rest and treatment, an injured tendon is likely to heal with minimal scar tissue and maximum strength. While a recent, mild tendon injury might need a few weeks of rest to heal, a severely damaged tendon can take months to mend. Corticosteroid injections may give you short-term pain relief to allow you to start a rehabilitation (rehab) program. But they may weaken tendon tissue if given too often.

  • Mild soreness in the elbow that comes and goes may improve in 6 to 8 weeks.
  • Prolonged elbow pain and soreness may improve in 6 to 12 months. In some cases, the pain lasts for 2 years or longer.
  • Severe elbow pain or tennis elbow that doesn't improve with 6 to 12 months of tendon rest and rehab may benefit from surgery.

What Increases Your Risk

Risk factors for tennis elbow include:

  • Activities that involve repeated movements of the forearm, wrist, and fingers. This includes grasping and twisting arm movements done in jobs (such as carpentry, plumbing, or working on an assembly line), daily activities (such as lifting objects or gardening), and sports (such as racquet sports, throwing sports, or swimming).
  • Improper techniques while doing certain movements, such as gripping a handle or twisting an object.
  • Improper equipment for work, daily activities, and sports, such as using a hammer or a tennis racquet with a grip that is the wrong size for your hand.
  • Age. Tennis elbow is most common in people who are in their 40s.
  • History of tendon injuries. Some people seem susceptible to tendon injury, based on a history of various tendon injuries such as rotator cuff disorders.

If you think that your workplace activity is causing elbow pain or soreness, talk to your human resources department for information on other ways of doing your job, equipment changes, or other job assignments. For more information, see the topic Office Ergonomics.

When To Call a Doctor

Call your doctor immediately if you had an injury to your elbow and:

  • You have severe elbow pain.
  • You cannot move your elbow normally.
  • Your elbow looks deformed.
  • Your elbow begins to swell within 30 minutes of the injury.
  • You have signs of damage to the nerves or blood vessels. These include:
    • Numbness, tingling, or a "pins-and-needles" sensation below the injury.
    • Pale or bluish skin.
    • The injured arm feeling colder to the touch than the uninjured one.

Call your doctor if you have:

  • Pain when grasping, twisting, or lifting objects.
  • Work-related problems caused by your elbow pain.
  • Elbow pain after 2 weeks of home treatment or if treatment is making your elbow pain worse.

Watchful waiting

Watchful waiting is when you and your doctor watch your symptoms to see if your health improves on its own. If it does, no treatment is needed. If your symptoms don't get better or they get worse, then it's time to take the next treatment step.

Home treatment often helps mild tennis elbow pain. You may want to try resting the elbow and applying ice or heat several times a day for 1 to 2 weeks before you call your doctor.

Who to see

For evaluation, diagnosis, or treatment of tennis elbow, you may see:

You may be referred to a:

  • Physical therapist (for stretching and strengthening exercises).
  • Tennis or other sports instructor (for training in sports).
  • Specialist in job-related safety or ergonomics (for work-related activities).

Exams and Tests

Your doctor can usually determine if you have tennis elbow by talking to you about the history of your symptoms, daily activities, and past injuries. You'll have a physical exam too.

X-rays aren't usually needed for diagnosis of tennis elbow but can sometimes rule out other causes of elbow pain, such as arthritis, signs of another type of injury, or a buildup of calcium crystals in a tendon or ligament. X-rays can show unusual bone structure that might cause soft-tissue damage (such as to tendons or muscles), but they don't show soft tissues very clearly. If your elbow pain isn't severe and can't be linked to a specific injury, your doctor may recommend starting treatment without doing X-rays to see whether the problem clears up in a few weeks.

If nonsurgical treatment (such as rest, the use of ice and anti-inflammatory drugs, rehabilitation exercises, and changing or stopping certain activities) hasn't helped relieve elbow pain, or if the diagnosis is unclear, other tests may be helpful.

  • MRI can show problems in soft tissues such as tendons and muscles.
  • Arthroscopy allows the doctor to see inside the elbow and get information that can be used with what he or she knows from your X-rays or physical exam. (Doctors can surgically treat tennis elbow with arthroscopy.)
  • Bone scans are done in rare cases. They can show stress fractures in the bone or certain disease conditions, such as a tumor or infection.

If your doctor thinks you have nerve damage, electromyogram and nerve conduction tests can check how well your nerves are working.

Treatment Overview

Tennis elbow treatment is most often successful. The most important part of treatment is tendon rest. A long rest from aggravating activity allows the small tears in the tendon to heal. Depending on how severe your condition is, you may need to rest your tendon for weeks to months. Surgery is a last resort if other treatment isn't helpful.

Initial home treatment

Treatment for tennis elbow works best when it starts as soon as symptoms appear. If your condition is just starting, rest may be all you need. But in most cases, more treatment is needed to protect and heal the tendon.

You can treat your tennis elbow by:

  • Reducing pain.
    • As soon as you notice pain, use ice or cold packs for 10 to 15 minutes at a time, several times a day. Always put a thin cloth between the ice and your skin. Keep using ice as long as it relieves pain. Or use a warm, moist cloth or take hot baths if they feel good. Do what works for you.
    • You can also take nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin (such as Bayer), ibuprofen (such as Advil), or naproxen (such as Aleve). Be safe with medicines. Read and follow all instructions on the label. Do not give aspirin to anyone younger than 20 because of the risk of Reye syndrome, a serious illness. Or try an NSAID cream that you rub over the sore area. Acetaminophen (such as Tylenol) can also help with pain.
  • Stopping or changing activities that may irritate the tendon. Learn new techniques for certain movements, and use different equipment that may reduce the stress on your forearm muscles.

Wrist and elbow splints can be used in the treatment of tennis elbow. Splints are sometimes helpful for other bone, joint, and tendon problems. But splints have not been shown to help with pain or recovery for tennis elbow injuries.

Ongoing treatment

Over the first months of recovery from tennis elbow, continue your initial treatment and begin:

  • Rehabilitation (rehab). This can include exercise and other physical therapy treatments to decrease pain and increase range-of motion.
  • Wearing a special counterforce brace. This strap, worn around your forearm just below the elbow, may spread pressure throughout the arm instead of putting it all on the tendon. With a counterforce brace, you may do some grasping and twisting activities. It won't help, though, if you continue using a poor technique or the wrong equipment that originally caused your tennis elbow. You don't need a doctor's advice before trying a counterforce brace. You can find these braces in most drugstores or sporting goods stores.
  • Working with an expert to see whether you need to change how you do an activity or what equipment you use. A sports trainer can help with sports activities and equipment. An ergonomic specialist, occupational therapist, or physical therapist can help with your workplace, including what tools you use, how your workspace is set up, and how you do your job.

Treatment if the condition gets worse or does not improve

The longer you continue activity that harms the tendon after tennis elbow symptoms begin, the longer rehab will take. This ongoing activity can cause severe tendon damage and may someday require surgery. If your symptoms don't go away, your doctor may suggest:

  • Corticosteroidinjections, which can help relieve pain for a short time.footnote 1 This treatment is sometimes used when you still have pain after 6 to 8 weeks of rest and rehab. Corticosteroids may be harmful to the tendon. But this is usually only a problem after having many injections in the same year.
  • Ultrasound therapy. Ultrasound may help your tendon heal and stop pain.
  • Surgery, which is seldom used to treat tennis elbow (less than 5 out of 100 cases).footnote 2 Surgery may be a treatment option if persistent elbow pain doesn't improve after 6 to 12 months of tendon rest and rehab. Surgery usually involves cutting (releasing) the tendon, removing damaged tissue from the tendon, or both. In some cases, tendon tears can be repaired.

What to think about

Your treatment choices will depend in part on whether elbow pain affects your job or daily life. It also depends on whether you are willing or able to change habits or activities that are causing your elbow pain.

Nonsurgical treatment is usually started if the injury is:

  • A result of overuse.
  • A sudden (acute) injury that doesn't have large tears in the tendon or other severe damage in the elbow.

Most cases of tennis elbow respond to rest, ice, rehab exercises, pain medicine, and counterforce braces. This injury does take from 6 months to 12 months to heal. Patience helps.

Surgery is considered as a last resort when all other nonsurgical treatments have failed. You may be referred for surgery if:

  • The injury is from a sudden (acute) injury that left large tears in the tendon or other severe damage in the elbow.
  • The injury is from chronic overuse and more than 6 to 12 months of tendon rest and rehab haven't relieved elbow pain. (If the tendon is very weak, surgery may not improve your situation much.)
  • Pain continues despite other treatment.
  • You have had a corticosteroid shot and it hasn't helped.

In as many as 9 out of 10 people who have tennis elbow, symptoms go away and the people can return to their normal activities whether they have had surgery or not.footnote 3

Prevention

The best way to prevent tennis elbow is to stretch and strengthen your arm muscles so that they are flexible and strong enough for your activities.

Other ways to prevent tennis elbow include:

  • Staying in good overall physical shape.
  • Using the correct techniques and movements during activities.
  • Using equipment appropriate for your ability, body size, and body strength.
  • Not overusing your arm with repeated movements that can injure your tendon. For example, alternate hands during activities, if possible.
  • Strengthening the muscles of your arm, shoulder, and upper back to help take stress off of your elbow.
  • Wearing a counterforce brace during activities that require grasping or twisting arm movements. A counterforce brace is a strap worn around your forearm just below your elbow. This brace may distribute pressure from muscle use throughout the arm, easing pressure on the tendon. The brace is not usually used for prevention. But it may be recommended for someone who is at very high risk for tennis elbow. Talk to your doctor if you are thinking of using one of these braces for prevention. A counterforce brace is not a substitute for rehab exercises or an excuse to continue overuse activities.

If you feel that certain activities at your job are causing elbow pain or soreness, talk to your human resources department for information on other ways of doing your job. They can help with changes to equipment or other job assignments.

Consider taking lessons to learn the proper technique for sports, such as tennis and golf, that require grasping and twisting motions in the arm. Have a sports trainer or a person who is familiar with sports equipment check yours to make sure it suits your level of ability, body size, and body strength.

In daily routines or hobbies, look for activities that use repeated arm movements that strain your fingers, wrist, or forearm, such as in gardening, cooking, or playing musical instruments. Train yourself to use techniques that won't stress your elbow. For example, when you lift objects, lift with the palm of your hand facing upwards.

Home Treatment

If you have tennis elbow, follow these simple steps to reduce pain and start tendon healing. A rehab program such as this will prevent further injury by making your arm muscles stronger.

  • Rest your fingers, wrist, and forearm muscles to allow your tendon to heal. Stop any activity that you think may be causing your elbow pain and soreness. Depending on the severity of tendon damage, you may have to avoid this activity for weeks to months.
  • As soon as you notice pain, use ice or cold packs for 10 to 15 minutes at a time, several times a day. Always put a thin cloth between the ice and your skin. Keep using ice as long as it relieves pain. Or use a warm, moist cloth or take hot baths if they feel good. Do what works for you.
  • Wear a counterforce brace during activities that require grasping or twisting arm movements. A counterforce brace is a strap worn around your forearm just below your elbow. This brace may spread pressure throughout the arm instead of putting it all on the tendon. These braces are not a substitute for rehab exercises.
  • Try elevating your elbow to help ease pain and reduce swelling in your wrist or forearm.
  • Take nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin (such as Bayer), ibuprofen (such as Advil), or naproxen (such as Aleve) to reduce pain and inflammation. NSAIDs come in pills and in a cream that you rub over the sore area. Be safe with medicines. Read and follow all instructions on the label. Acetaminophen (such as Tylenol) can also help with pain.
  • Do simple warm-up and stretching exercises to keep your tendons from getting stiff. If you have any pain, stop the exercises.
  • When your pain is gone, start doing stretching and strengthening exercises, then gradually increase these exercises. Learn the correct techniques and which equipment is best for your activities.

Medications

Along with tendon rest, people often use medicine to treat tennis elbow. Medicine can help with pain and relieve or reduce swelling.

Medicine choices

Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin (such as Bayer), ibuprofen (such as Advil), or naproxen (such as Aleve), are the most commonly used medicines for treating tennis elbow. NSAIDs are available with or without a prescription. NSAIDs come in pills and in a cream that you rub over the sore area. Acetaminophen (such as Tylenol) can also help with pain. Be safe with medicines. Read and follow all instructions on the label.

Your doctor may suggest corticosteroid injections (shots) if you are still in pain after at least 6 to 8 weeks of tendon rest and rehab. Corticosteroids are a class of powerful anti-inflammatory medicine. Even though inflammation isn't usually present in long-term (chronic) tennis elbow, corticosteroid shots may ease elbow pain.

What to think about

Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid shots don't cure tennis elbow. But they can reduce pain and give you enough relief to start rehab.

Avoid taking NSAIDs or other pain relief medicine to control pain if you are continuing activities that can further damage your tendon. If you don't feel the pain, you won't know that your elbow is getting worse.

Surgery

Most cases of tennis elbow are treated without surgery. Less than 5 out of 100 cases require surgery.footnote 2 You and your doctor might consider surgery if several months of tendon rest and rehabilitation (rehab) haven't stopped the pain or returned the flexibility and strength to your forearm.

Consider surgery if:

  • Your elbow is still sore and painful after more than 6 to 12 months of tendon rest and rehab.
  • Your doctor has ruled out other possible causes of elbow pain, such as nerve problems, arthritis, muscle injury, or injury to another tendon.
  • Your corticosteroid shots have given good short-term pain relief, but the pain has returned.
  • You can't do normal daily activities and job tasks because of elbow pain.

During surgery, a doctor will most likely cut (release) the tendon, remove damaged tissue from the tendon, or both. In some cases, tendon tears can be repaired.

After surgery, rehab is needed to restore flexibility and strength in the forearm.

Surgery choices

Surgery for tennis elbow involves cutting (releasing) the tendon and removing damaged tissue from the tendon. In some cases, tendon tears are repairable (reattached) if the repair can be done without overtightening the tendon. These procedures can be done both arthroscopically and through a larger incision (open surgery) or with a combination of the two techniques.

What to think about

There are different approaches to surgery for tennis elbow, such as where to enter the elbow and what type of reconstruction or repair on the tendon is done. Surgical technique is determined by the type, location, and severity of the injury and by the doctor's preference and experience.

There is no strong medical research that shows that one type of surgery is better than another or that surgery is better than other treatment.footnote 4

The success of surgery depends in large part on the amount of time and effort you put into a rehab program.

Other Treatment

Other treatment for tennis elbow pain includes physical rehabilitation (rehab), acupuncture, topical nitric oxide, shock wave therapy, and transcutaneous electrical nerve stimulation (TENS).

Physical rehab is combined with tendon rest to restore flexibility and build muscle strength. Rehab is needed after surgery too.

Other treatment choices

A physical rehab program includes:

  • Relieving pain.
  • Maintaining good overall physical fitness.
  • Exercises, including warm-ups, stretching, and strengthening.
  • Learning new techniques for certain movements; using equipment that best suits your ability, body size, and strength; and limiting activities that require grasping or twisting arm movements.
  • Retraining and ergonomic changes at your work site. For more information, see the topic Office Ergonomics.

Other treatments include:

  • Acupuncture. Small studies report tennis elbow relief after acupuncture treatment. But there is not enough strong evidence to support or refute this treatment.footnote 5
  • Extracorporeal shock wave therapy. A review of shock wave therapy for tennis elbow had conflicting findings. Some studies reported that shock wave therapy improved tennis elbow recovery. But others found that it offered no therapeutic benefit when compared to placebo treatment.footnote 6
  • Topical nitric oxide. In a patch form, nitric oxide is applied to the elbow to speed recovery. This medicine has been used as a treatment for tennis elbow for a short time. One study showed positive results.footnote 7
  • Transcutaneous electrical nerve stimulation (TENS). TENS is sometimes used to treat tennis elbow, usually in a physical therapy setting.

What to think about

A physical rehab program not only helps heal injured tendons and muscles but also helps prevent further injury.

Physical rehab combined with tendon rest is the main tennis elbow treatment. Corticosteroid shots are only considered if several weeks of rest and rehab have not reduced symptoms. Surgery may be considered after 6 to 12 months of nonsurgical treatment.

If the type of work you do is causing your injury, an occupational therapist may help you change how you are working or the kind of work that you do.

References

Citations

  1. Coombes BK, et al. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. Lancet, 376(9754): 1751-1767.
  2. American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Medial and lateral epicondylitis. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 370-374. Rosemont, IL: American Academy of Orthopaedic Surgeons.
  3. Rasouli A, Gupta R (2007). Elbow, wrist, and hand injuries. In PJ McMahon, ed., Current Diagnosis and Treatment in Sports Medicine, pp. 146-159. New York: McGraw-Hill.
  4. Buchbinder R, et al. (2011). Surgery for lateral elbow pain. Cochrane Database of Systematic Reviews (3).
  5. Bissett L, et al. (2011). Tennis elbow, search date June 2009. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
  6. Buchbinder R, et al. (2005). Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews (4). Oxford: Update Software.
  7. Paoloni J, et al. (2003). Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow. American Journal of Sports Medicine, 31(6): 915-920.

Credits

ByHealthwise Staff
Primary Medical Reviewer William H. Blahd, Jr., MD, FACEP - Emergency Medicine
Kathleen Romito, MD - Family Medicine
Adam Husney, MD - Family Medicine

Current as ofNovember 29, 2017

Current as of: November 29, 2017

Author: Healthwise Staff

Medical Review: William H. Blahd, Jr., MD, FACEP - Emergency Medicine & Kathleen Romito, MD - Family Medicine & Adam Husney, MD - Family Medicine