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Introduction Tennis elbow is inflammation in the area around the bony bump on the outer side of the elbow. This bony lump is called the lateral epicondyle, and the medical name for tennis elbow is lateral epicondylitis. Similar symptoms can occur on the inner side of the elbow, which is sometimes called 'golfer's elbow' (epicondylitis). Tendons controlling the muscles of the forearm are located around the lateral epicondyle. When this area is inflamed, it can be painful to carry out movements using the forearm. Twisting movements such as turning a door handle may be particularly painful. The elbow joint is surrounded by muscles that move your elbow, wrist and fingers. Tendons in the elbow join the bones and muscles together, and tennis elbow happens when one or more of these tendons become inflamed. The pain you feel is at the point where the tendons from the forearm muscle attach to the bone. This is the result of small injuries to the tendon that cause it to become inflamed.
Symptoms Tennis elbow is characterised by pain and tenderness in the elbow and in the back of the forearm. This is made worse by using the elbow, particularly for twisting movements. Symptoms 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 such as a pen; pain on twisting the forearm, for example, when turning a door handle; and difficulty extending the forearm fully. The pain caused by tennis elbow normally lasts for 6 to 12 weeks. Some people have pain for as little as 3 weeks, while others may experience discomfort in the elbow joint for several years. Pain 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 builds up. 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, the shoulder, or neck.
Causes Excessive or repeated use of the muscles that straighten the wrist can cause injury to the tendons, leading to tennis elbow. These injuries consist of tiny tears in parts of the tendons and muscle coverings. If these injuries are not allowed to heal fully, they can tear again, which leads to the formation of rough tissue. A protein called collagen leaks out from around the injured areas, causing inflammation. The inflamed tendon can cut off blood flow and pinch the radial nerve, one of the major nerves controlling muscles in the arm and hand, which causes pain when the arm is used. The tendons of the elbow can be injured by overuse of the forearm muscles in repeated actions such as: using scissors or shears; gardening; sports that involve lots of throwing; swimming; golf (golfers also get golfers' elbow, which affects the inside of the arm); manual occupations that involve repetitive turning or lifting the wrist, such as plumbing or bricklaying; typing; and racquet sports (particularly if you play very regularly after not playing for a long time, if you use a lot of backhand, or if your backhand technique is not very good). Tennis elbow happens most commonly when you suddenly use your forearm muscles a lot without having used them much before. Even if you are used to this type of work, you can still overdo it.
Diagnosis To diagnose tennis elbow, your GP with examine the affected arm and discuss the symptoms with you. Your GP will also check for pain in the area around the elbow by pressing on it, as well as bending the hand upwards against pressure to see if this causes pain. Tennis elbow itself cannot be seen on an X-ray. However, in some cases it may be necessary to take an X-ray in order to rule out a possible injury inside the elbow joint. Your GP will also want to make sure pain is not being caused by pressure on a nerve. For severe tennis elbow that has failed to heal, you might need to have an MRI scan. This gives an image of the soft tissues, including muscles and tendons, inside the arm.
Treatment Some cases of tennis elbow clear up with plenty of rest and support, and by avoiding activities that put more stress on the tendons. Over the counter painkillers can be taken to treat any mild pain. Allowing symptoms to get better without further treatment can take several weeks or months; tendons are slow to heal. If tennis elbow is particularly painful and making movement difficult, other treatment may be necessary. Steroid injections (usually of cortisone) are commonly given to reduce inflammation. They are delivered into the tender spot in the elbow using a fine needle, and are usually combined with an anaesthetic so that it is not painful. Most people find that the pain is significantly better, or gone completely, within four weeks of the treatment. Sometimes two or three steroid injections are needed over a few weeks, especially if the first does not work. Some people find that pain returns after steroid injections, which can be a result of putting too much strain on the arm too quickly. As with any injury, you should gently build up to normal activities to prevent the problem coming back. Your GP may prescribe anti-inflammatory painkillers to ease pain and inflammation. These are often available in creams or gel form, which can be rubbed over the affected joint. Some anti-inflammatory painkillers can be bought over the counter; ask your pharmacist for advice. In some cases, referral to a physiotherapist or to a specialist may be advised if symptoms persist. Physiotherapy treatment will include exercises to stretch and strengthen the forearm muscles, along with the use of supports to encourage the tendons to heal. A small number of people require surgery to relieve symptoms. If the inflammation resulted from playing sport, professional advice on technique may be necessary.
Prevention The best way to avoid tennis elbow is to avoid putting too much stress on the tendons in the elbow. The following measures may help: Stop the activity that is causing you pain or find a different way of doing it. If you use your wrist and elbow more than the rest of the arm, try to spread the load so that the larger muscles of the shoulder and upper arm work too. 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. Warm up and gently stretch the muscles before playing sport. Enlarging the grip size on racquets or tools and decreasing their weight can also help to prevent you putting excess strain on the tendons. Wearing a 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 for advice about the best type of splint 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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