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Tennis elbow

Introduction

Tennis elbow is a condition that results in pain around the outer side of the elbow.

It often occurs after strenuous overuse of the muscles and tendons of the forearm, near the elbow joint.

As its name suggests, tennis elbow is sometimes caused by playing tennis. However, it is usually caused by a number of other physical activities. See Tennis elbow - causes for more information.

The medical name for tennis elbow is lateral epicondylitis. This is because the pain usually occurs on the bony lump on the outside of the elbow which is called the lateral epicondyle.

Similar symptoms can occur on the inner side of the elbow, which is sometimes called golfer's elbow.

The elbow joint

The elbow joint is surrounded by muscles that move the elbow, wrist and fingers.  Tendons in your elbow join the bones and muscles together and control the muscles of the forearm around the lateral epicondyle.

When a person gets tennis elbow, one or more of the tendons in their elbow becomes painful. The pain occurs at the point where the tendons of the forearm muscle attach to the bone.  Twisting movements, such as turning a door handle or opening the lid of a jar, may be particularly painful.

In around three quarters of cases of tennis elbow, the dominant hand (the one that is used the most) is affected.

How common is tennis elbow?

Tennis elbow is fairly uncommon. Approximately five in every 1,000 adults in the UK are affected by the condition each year.

Tennis elbow usually occurs in adults. Men and woman are affected equally. The condition tends to affect people who are around 40 years old.

Outlook

Tennis elbow is a self-limiting condition. This means that in most cases the symptoms eventually improve and clear up without treatment.

Anti-inflammatory painkillers can often reduce mild pain that is caused by tennis elbow. However, if your pain is severe or prolonged, a corticosteroid injection may be recommended.

Occasionally, surgery may be used to treat very severe and persistent cases of tennis elbow.

Most cases of tennis elbow last between six months and two years. However, in around 9 out of 10 cases, a full recovery is made within one year.

See Tennis elbow - treatment for more information.

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Symptoms

The main symptom of tennis elbow is pain and tenderness on the outside of the elbow.  You may also feel pain travelling down the back of the forearm.

This pain is often made worse by using the arm and elbow, particularly for twisting movements. Repetitive wrist movements, such as wrist extension and repeated gripping, can also make the pain worse.

Tennis elbow can vary in severity, but usually include most of the following:

  • recurring pain on the outside of the upper forearm, just below the bend of the elbow. Sometimes, pain may be felt down the arm towards the wrist
  • pain caused by lifting or bending the arm
  • pain when writing or when gripping even small objects.  This can make it difficult to hold small items, such as a pen
  • pain on twisting the forearm - for example, when turning a door handle or opening a jar
  • difficulty extending the forearm fully.

On average, a typical episode of tennis elbow lasts between six months and two years. Most people (90%) make a full recovery within a year.

Pain of tennis elbow ranges from a mild discomfort when the elbow is used, to severe pain that can be felt even when the elbow is still, or when sleeping. You may have stiffness in your arm, which gets progressively worse as tendon damage increases.

As the body tries to compensate for the weakness in the elbow, you may also get pain or stiffness in other parts of the affected arm or in the shoulder or neck.

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Causes

Tennis elbow is caused by small tears in the muscles of the forearm due to overuse of the muscles or minor injury. It can also occur as the result of a single, forceful injury.

Excessive or repeated use of the muscles that straighten the wrist can cause injury to the tendons in your arm and elbow, leading to tiny tears which causes the formation of rough tissue to form near the bony lump on the outside of your elbow.  

Tennis elbow often occurs after you do an activity that uses your forearm muscles when you have not used them much in the past. However, even if you use your forearm muscles frequently, it is still possible to injure them and develop tennis elbow.

Activities that can cause tennis elbow 

The tendons of the elbow can be injured by overusing the forearm muscles in repeated actions such as: 

  • moved gardening - e.g. using shears
  • moved playing racquet sports, such as tennis or squash 
  • sports that involve throwing, such as the javelin or discus
  • swimming

Tennis elbow can also develop in the workplace through carrying out repetitive tasks and actions, such as:

  • manual work that involves repetitive turning or lifting of the wrist, such as plumbing or bricklaying
  • repetitive, fine movements of the hand and wrist, such as typing or using scissors

Your risk of developing tennis elbow increases if you regularly play racquet sports, such as tennis or squash, or if you play a racquet sport for the first time in a long time. However, despite its name, only 5 out of 100 people develop tennis elbow through playing racquet sports such as tennis.

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Diagnosis

You should visit your GP if the symptoms of tennis elbow do not improve after you have avoided or modified the activity that is causing the problem, or if ordinary painkillers such as paracetamol are not effective.

To diagnose tennis elbow, your GP can make a diagnosis based on your symptoms and by examining the affected arm. Your GP will also check for pain in the area around the elbow.  They may also ask you several questions to help confirm a diagnosis. For example, they may ask you about your job and any leisure or sports activities that you do.

Further investigations

Further investigations are not usually needed to diagnose tennis elbow. This is because the condition can usually be confirmed after your GP examines your arm.

However, if your GP suspects that your pain is caused by nerve damage in your arm, they may want to refer you for a more detailed examination. The two types of investigations that may be used are:

  • magnetic resonance imaging (MRI) scan
  • ultrasound scan

MRI scan

A MRI scan uses a strong magnetic field and radio waves to produce a detailed image of the inside of your body. The scan will also show if any pressure is being placed on your nerve and is causing your pain.

See the Health topic about Magnetic resonance imaging scan for more information.

Ultrasound scan

An ultrasound scan uses high-frequency sound waves to create an image of part of the inside of your body.

See the Health topic about Ultrasound scan for more information.

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Treatment

The pain caused by tennis elbow can last for some time. As tendons are slow to heal, the symptoms often last for a number of weeks or months. In severe cases, tennis elbow can persist for more than a year.

However, tennis elbow is a self-limiting condition, which means it will eventually get better with or without treatment.

There are non-surgical and surgical treatment options for tennis elbow. Before surgery is considered, managing the symptoms using non-surgical treatment is recommended. Surgery will only be recommended as a treatment of last resort, after non-surgical methods have not worked.

Non-surgical treatments

If you have tennis elbow, you should rest the affected arm as much as possible and avoid doing any activities that put more stress on the tendons (see below).

Painkillers

Taking painkillers, such as paracetamol and ibuprofen, may help to reduce mild pain that is caused by tennis elbow. Children under 16 years old should not take aspirin.

Non-steroidal anti-inflammatory drugs (NSAIDs)

As well as tablets, anti-inflammatory painkillers are also available in creams or gel form.  These are known as topical NSAIDs, which can be rubbed over the affected joint, such as your forearm or elbow.

Some anti-inflammatory painkillers can be bought over the counter.  Others are only available on prescription.  Your pharmacist or GP can advise you about which NSAID is most suitable for you.

Examples of topical NSAIDs include:

  • ibuprofen
  • ketoprofen
  • piroxicam

These have been proven to provide some pain relief for musculoskeletal conditions (those that affect the muscles or bones), such as tennis elbow.
 
NSAID creams or gels should be gently rubbed into the area that is causing pain and discomfort. Make sure that you read the patient information leaflet that comes with your cream or gel to check how often the treatment should be applied.

Anti-inflammatory creams and gels are often recommended for tennis elbow rather than anti-inflammatory tablets. This is because gels and creams provide effective pain relief and reduce inflammation without causing side effects, such as nausea and diarrhoea.
 
However, photosensitivity reactions can sometimes occur while using ketoprofen. Therefore, avoid exposing the affected area to sunlight while using ketoprofen and for two weeks after the treatment has finished.
 
Avoid using topical NSAIDs during pregnancy and breastfeeding. Many topical NSAIDs are also unsuitable for children. Ask your GP or pharmacist for advice if you are not sure about whether a topical NSAID is suitable for you or your child.

Corticosteroid injections

A corticosteroid injection may be recommended if you have particularly painful tennis elbow that is making movement difficult. Corticosteroids are a medication that contain steroids (a type of hormone). A corticosteroid injection will reduce the pain in your arm.

The injection will be made directly into the painful area around your elbow. Before you have the injection, you may be given a local anaesthetic to numb the area so you do not feel any further pain while the injection is being given.

Most people who have a corticosteroid injection find that their pain initially improves significantly. However, a study of 198 people has shown that corticosteroid injection treatment is only effective in the short-term (around six weeks), and its long-term effectiveness is poor.

Research has shown that when compared to physiotherapy and a ‘wait and see’ approach to see if symptoms disappear naturally, corticosteroid injections were not as effective at 52 weeks. They were effective in the short term, at six weeks after the treatment. High recurrence rates have also been reported in people who have corticosteroid injections.

The recommended time in between corticosteroid injections is six weeks.

Potential side effects of corticosteroid injections include:

  • pain in the affected area after having the injection
  • skin depigmentation – the loss of colour (pigment) around the injection site
  • wasting away of the surrounding subcutaneous tissue (the layer of tissue beneath the surface of the skin)

Before you decide to have corticosteroid injections to treat tennis elbow, discuss the effectiveness and potential side effects with your GP. This will enable you to make a well-informed decision about this type of treatment.

After having a steroid injection (or injections) take care to rest your arm. Avoid putting too much strain on the arm too quickly. As with any injury, you should gently build up to normal activitie levels to prevent the problem coming back.

Physiotherapy

In some cases, referral to a physiotherapist or to a specialist may be advised if symptoms are particularly severe or persist. A physiotherapist is a healthcare professional who is trained to use physical methods, such as massage and manipulation, to promote healing.

A physiotherapist will be able to show you exercises to help stretch and strengthen the forearm muscles.  They may also recommend that you wear a splint (an elasticated band that is positioned just below the elbow joint) to help support the elbow and encourage the tendons to heal.

Shock wave therapy

Shock wave therapy is where high-energy sound waves are passed through the skin of the affected area to help relieve the pain of tennis elbow and improve mobility (movement).

Depending on the severity of your pain, shock wave therapy may be given once or it may be repeated. You may have a local anaesthetic during the procedure to prevent you feeling any pain while the shock waves are being passed through your skin.

Following shock wave therapy, potential side effects include:

  • bruising
  • red skin
  • inflammation (swelling) of the skin
  • skin damage around the area being treated

Research has shown that shock wave therapy is safe. However, NICE states that there is a lack of evidence of its effectiveness in treating tennis elbow, and more research is required.

Your GP may recommend shock wave therapy if other non-surgical treatments have proved to be ineffective in relieving your symptoms of tennis elbow. Discuss the potential risks, benefits and side effects with your GP.

Acupuncture

Acupuncture is a type of complementary treatment where fine needles are inserted into the skin around the affected area. In some cases, this may reduce pain and improve movement. However, there is a lack of evidence that it relieves the symptoms of tennis elbow.

Surgery

Surgery may be recommended as a last resort treatment option in rare cases of severe or persistent tennis elbow. Surgery aims to relieve the painful symptoms by removing the damaged part of the tendon.

Modifying activities

If you have tennis elbow, modifying the activities that cause pain can be an effective way of reducing your painful symptoms. Examples of ways that you can modify activities include:

  • avoid lifting, gripping or rotating the affected arm
    if you need to lift a heavy object, making sure that your palms are facing upwards to reduce the strain on your wrist muscles
  • take regular breaks when you are at work
  • discuss with your employer altering any strenuous activities that could cause you pain and aggravate your affected arm
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Prevention

It is often difficult to prevent tennis elbow.  Avoiding putting too much stress on the tendons in the elbow will help you to avoid the condition or to prevent your symptoms from getting worse.

Self-care advice

The following measures may help prevent tennis elbow developing or prevent it reoccurring:

  • If you have tennis elbow, stop doing the activity that is causing you pain or find a different way of doing it that does not place stress on your tendons.
  • Rather than using your wrist and elbow more than the rest of the arm, try to spread the load to the larger muscles of the shoulder and upper arm.
  • If you play a sport that uses repetitive movements, such as tennis, try to get some professional advice about your technique so that you do not strain your elbow.
  • Before playing a sport that involves repetitive arm movements, such as tennis or squash, warm up and gently stretch the arm muscles to help you avoid injury.
  • Enlarging the grip size on racquets or tools and using lightweight can also help to prevent you putting excess strain on the tendons. 
  • Wear a tennis elbow splint when you are using your arm, and taking it off when you are sleeping or resting can help prevent further damage to the tendons. Ask your GP or physiotherapist for advice about the best type of splint or brace for you to use. 
  • Increasing the strength of your forearm muscles can help to prevent tennis elbow occurring. A physiotherapist will be able to advise you about suitable exercises to build up your forearm muscles.
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