Tennis Elbow

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
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What is tennis elbow?

“Tennis elbow” is a term that describes soreness or pain on the outer (lateral) part of the elbow. While tennis elbow is common, playing tennis is only one of many activities that can result in this tendon injury. Also called lateral epicondylitis, tennis elbow occurs when there is tendon damage at the elbow where some of the forearm and hand muscles connect to the upper arm bone. It affects the muscles you use when extending your wrist and fingers.

See an illustration of tennis elbow .

What causes tennis elbow?

Frequent twisting movements of the hand, wrist or forearm usually cause tennis elbow. These are motions you use in everyday actions, such as using a screwdriver, digging in a garden, and playing racquet sports. A direct blow to the outer elbow can also cause tendon damage.

Tennis elbow can also result from using the wrong type of sports equipment or improper technique. A tennis racquet with a grip too large for your hand can put a lot of pressure on your tendon. Hitting the ball late in your swing can also lead to tendon damage.

Tennis elbow generally occurs in adults between the ages of 40 and 60 and is most common during the 40s.

How is tennis elbow diagnosed?

Your health professional can usually tell if tennis elbow is causing your elbow pain by learning the history of the elbow problem, your daily activities, and past injuries. You'll also have a physical exam.

It’s unlikely that you'll have an X-ray to diagnose your elbow pain. However, if your symptoms don't get better with treatment, you may have imaging tests, such as X-ray, magnetic resonance imaging (MRI), or bone scan. These tests will tell your doctor whether a bone problem or tissue damage is causing your symptoms.

How is tennis elbow treated?

Treatment for tennis elbow includes resting your arm to allow the tendon to heal and taking pain-relief medication. Surgery is seldom needed for tennis elbow.

You may wear a forearm brace or sling for a few days. Applying cold or warmth may help ease pain and stiffness.¹

Once pain eases, a rehabilitation exercise program can help your arm mend, as well as prevent injury. These ongoing exercises work to make the muscles around the injured tendon stronger and more flexible. Changing or stopping activities that may have led to your injury is vitally important in the healing process.

If your symptoms don't improve after 6 to 8 weeks of tendon rest and rehabilitation, your health professional might recommend a corticosteroid injection. This shot may give you weeks of short-term relief to allow you to start a rehabilitation program. Corticosteroids are known to weaken tendon tissue.²

Patience is a key factor in successful treatment. A typical case of tennis elbow takes 6 to 12 months to heal. Most people recover within a year.²

Frequently Asked Questions

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	Should I have surgery to treat tennis elbow?

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

See an illustration of 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.
• A single accident, such as a direct hit to the side of the elbow (lateral epicondyle), or falling on an outstretched arm.

In sports, tennis elbow can also result from using the wrong type of equipment or improper technique. For example, a tennis racquet with a grip too large or small for your hand can put a lot of pressure on your tendon. Hitting the ball late in your swing can also lead to tendon damage.

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, other parts of the arm, shoulder, or neck (referred pain).

Tennis elbow pain:

• Usually occurs in the dominant arm (your right arm if you are right-handed, 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.
• Eventually occurs with mild activity, such as picking up a coffee cup; turning a jar lid, 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.

Tennis elbow pain is a symptom of tendon injury.

See an illustration of the tendon commonly involved in tennis elbow 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. However, if the activity continues, the weakened tendon becomes 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 injection may give you short-term pain relief to allow you to start a rehabilitation program, but may weaken tendon tissue.

• 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.
• Severe elbow pain or tennis elbow that doesn't improve with 6 to 12 months of tendon rest and rehabilitation may benefit from surgery. Recovery after surgery may take 4 to 6 months.²

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, swimming, or golf).
• 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 with a grip that is too large for your hand or a tennis racquet grip that is too large or too small.
• Age. Tennis elbow usually occurs between the ages of 40 and 60 and is most common during the 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.³

If you suspect 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.

Call your health professional 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 health professional if you have:

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

Watchful Waiting

Watchful waiting is when you and your health professional watch your symptoms to see if your health improves on its own. If it does, no treatment is necessary. 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 3 times daily for 1 to 2 weeks before calling your health professional.

Who To See

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

• A primary care doctor (internist, family medicine physician, general practitioner).
• An orthopedist.
• A sports medicine specialist.
• An emergency medicine specialist.

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).

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Your health professional 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 as well.

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 health professional 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.

• Magnetic resonance imaging (MRI) can show problems in soft tissues such as tendons and muscles.
• Arthroscopy allows the health professional to see inside the elbow and get more information than is available from X-rays or a 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.
• Arthrogram (Joint X-ray) is an imaging technology that involves injecting a material into the joint to enhance its X-ray image. It shows the bones and soft tissues inside the joint, such as the cartilage. It also gives information about the soft tissues inside and outside of the joint, such as the muscles, ligaments, and tendons. Since MRI has become more available, arthrography is used less often to enhance X-rays.

If your health professional suspects nerve damage, electromyogram and nerve conduction tests can check how well your nerves are working.

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 developing, rest may be all you need. However, in most cases, more treatment is necessary to protect and heal the tendon.

You can treat your tennis elbow by:

• Reducing pain. Use ice for pain during the first 2 to 3 days after the injury. After that, apply heat. You can also take nonsteroidal anti-inflammatory drugs, including aspirin (such as Bayer), ibuprofen (such as Advil), or naproxen sodium (such as Aleve). Do not give aspirin to anyone younger than 20 because of the risk of Reye's syndrome, a serious illness. 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.
• Wearing an elbow splint if your health professional suggests it. Elbow splints hold the elbow in a bent position and don't allow the joint to move. Use splints only for a short time to allow the muscles and tendons to rest and heal.

Ongoing treatment

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

• Rehabilitation. Once tennis elbow pain is gone, you can start a rehabilitation program. This includes special exercises for flexibility and arm muscle strength, and steps to improve overall fitness. You may try:
  • Warm-up exercises for tennis elbow .
  • Stretching exercises for tennis elbow .
  • Strengthening exercises for tennis elbow .
• 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 health professional's advice before trying a counterforce brace.

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 rehabilitation will take. This ongoing activity can cause severe tendon damage and may ultimately require surgery. If your symptoms are ongoing, your health professional may suggest:

• Corticosteroid injections. This treatment is sometimes used when 6 to 8 weeks of rest and rehabilitation doesn't relieve pain. However, corticosteroids actually weaken tendon tissue.²
• Ultrasound therapy. Ultrasound may promote tendon healing and stop pain.
• Extracorporeal shock wave therapy. This treatment is sometimes used to stimulate tendon healing. Some studies conclude that this treatment works well.⁴ But some studies suggest that it doesn't improve symptoms.⁵
• Topical nitric oxide. In a "patch" form, nitric oxide is applied to the elbow to speed recovery. This medication has been used as a treatment for tennis elbow for a short time. One study showed positive results.⁶
• Surgery, which is seldom used to treat tennis elbow (less than 5% of cases).⁷ Surgery may be a treatment option if persistent elbow pain doesn't improve after 6 to 12 months of tendon rest and rehabilitation. 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 livelihood. It also depends on whether you are willing or able to change habits or activities that are causing your elbow pain.

Non-surgical 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, rehabilitation exercises, pain medication and splints. This injury does take from 6 months to 12 months to heal. Patience helps.

Surgery is considered as a last resort when:⁸

• 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 6 to 12 months of tendon rest and rehabilitation haven't relieved elbow pain. (If the tendon is very weak, surgery may not improve your situation much.)
• Pain continues despite other treatment, such as corticosteroid shots or acupuncture.

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. Try:

• Warm-up exercises for tennis elbow .
• Stretching exercises for tennis elbow .
• Strengthening exercises for tennis elbow .

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. A counterforce brace is not a substitute for rehabilitation exercises, or an excuse to continue "overuse" activities.

If you feel that certain activities at your workplace 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 your equipment 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.

If you have tennis elbow, follow these simple steps to reduce pain and start tendon healing.⁸ A rehabilitation 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.
• Ice your elbow 3 times a day for 10 minutes each time, or according to your health professional's instructions. Use an ice pack, cold pack, or even a bag of frozen peas.
• 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 relieves pressure on the tendon and distributes it throughout the arm. Wrist or elbow splints also may help reduce pain. Talk to you doctor before trying a splint. These braces are not a substitute for rehabilitation exercises.
• Try elevating your elbow to help ease pain and reduce swelling in your wrist or forearm.
• Take nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and any inflammation.
• Do simple warm-up and stretching exercises with your fingers and wrist to prevent stiffening of your tendons. If you have any pain, stop the exercises.
• When your soreness and pain are gone, begin combining stretching and strengthening exercises, then gradually increase these exercises. Learn the correct techniques and which equipment is best for your activities.

Aerobic exercise (such as walking, cycling, swimming, water aerobics, and jogging) increases blood circulation to the injured area, which helps promote healing.

Along with tendon rest, people often use medication to treat tennis elbow. Medication can decrease pain and relieve or reduce swelling.

Medication Choices

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used medications for treating tennis elbow. NSAIDs are available with or without a prescription.

Your health professional may suggest corticosteroid injections if you are still in pain after at least 6 to 8 weeks of tendon rest and rehabilitation.⁹ Corticosteroids are a class of powerful anti-inflammatory medication. Even though inflammation isn't usually present in long-term (chronic) tennis elbow, corticosteroid injections may ease elbow pain.

What To Think About

Studies suggest that corticosteroid injections may give short-term relief, but they don't have long-lasting benefit when compared to other treatments.¹⁰ One study found that although corticosteroid injection therapy gave the most relief after 6 weeks, it was linked to more relapse and pain after 52 weeks than were rehabilitation and rest.²

Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injections don't cure tennis elbow, but they can reduce pain, allowing you enough relief to start rehabilitation exercises.

Avoid taking NSAIDs or other pain relief medication 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.

Most cases of tennis elbow are treated without surgery; less than 5% require surgery.⁷ You and your health professional might consider surgery if several weeks or months of tendon rest and rehabilitation haven't stopped pain or returned the flexibility and strength to your forearm.

Consider surgery only if:

• Your elbow is still sore and painful after 6 to 12 months of tendon rest and rehabilitation.
• Your health professional 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 removes any diseased or abnormal tissue and can reattach the healthy tendon to the end of the upper arm bone (epicondyle) if necessary.

After surgery, rehabilitation is necessary to restore flexibility and strength in the forearm.

Should I have surgery to treat tennis elbow?

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 are available both arthroscopically and through a larger incision (open surgery), or with a combination of the two techniques.

What To Think About

In general, among people who are identified as needing surgical tennis elbow repair, surgery successfully relieves elbow pain, and people report being happy with the results.¹¹

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.

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

Other treatment for tennis elbow pain includes physical rehabilitation, acupuncture, and transcutaneous electrical nerve stimulation (TENS).

Physical rehabilitation is combined with tendon rest to restore flexibility and build muscle strength. Rehabilitation is also necessary after surgery.

Other Treatment Choices

A physical rehabilitation program includes:

• Relieving pain.
• Maintaining good overall physical fitness.
• Exercising and physical therapy.
• 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.

Complementary or alternative medicine treatments

Complementary or alternative treatments are sometimes used along with traditional therapy to treat tennis elbow. Although there is no solid scientific evidence that these therapies relieve pain and restore elbow flexibility and strength, some people report them as helpful.^{10, 12}

• Acupuncture. While small studies report significant tennis elbow relief after acupuncture treatment, a review of studies concludes that there is not yet enough evidence to support or refute this treatment.¹²
• Transcutaneous electrical nerve stimulation (TENS) and ultrasound therapy are sometimes used to treat tennis elbow, usually in a physical therapy setting.
• A review of shock wave therapy for tennis elbow found two trials with conflicting findings. While one study reported that shock wave therapy improved tennis elbow recovery, a similar study found that it offered no therapeutic benefit when compared to placebo treatment.¹³

What To Think About

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

Physical rehabilitation combined with tendon rest is the main tennis elbow treatment. Corticosteroid injections or surgery is only considered if several weeks of rest and rehabilitation haven't improved symptoms.

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.

Organizations

• Bursitis
• Office Ergonomics
• Tendon Injury (Tendinopathy)

Citations

1. Nirschl RP, et al. (2003). Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. American Journal of Sports Medicine, 31(2): 189–195.

2. Smidt N, et al. (2002). Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: A randomised controlled trial. Lancet, 359(9307): 657–662.

3. Gabel GT, Morrey BF (1998). Tennis elbow. AAOS Instructional Course Lectures, 47: 165–172.

4. Rompe JD, et al. (2004). Repetitive low-energy shock wave treatment for chronic lateral epicondylitis in tennis players. American Journal of Sports Medicine, 32(3): 734–743.

5. Haake M, et al. (2002). Extracorporeal shock wave therapy in the treatment of lateral epicondylitis. Journal of Bone and Joint Surgery, 84-A(11):1982–1991.

6. 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.

7. Kraushaar BS, Nirschl RP (1999). Tendinosis of the elbow (tennis elbow). Journal of Bone and Joint Surgery, 81-A(2): 259–278.

8. Brigham and Women's Hospital (2003). Upper extremity musculoskeletal disorders. A guide to prevention, diagnosis, and treatment. Boston: Brigham and Women's Hospital. Also available online: http://www.guideline.gov/summary/summary.aspx?doc_id=3694&nbr=2920&string=upper+AND+extremity.

9. Putnam MD, Cohen M (1999). Painful conditions around the elbow. Orthopedic Clinics of North America, 30(4): 109–118.

10. Boyer MI, Hastings H II (1999). Lateral tennis elbow: "Is there any science out there?" Journal of Shoulder and Elbow Surgery, 8(5): 481–491.

11. Ciccotti MG (1999). Epicondylitis in the athlete. AAOS Instructional Course Lectures, 48: 375–381.

12. Green S, et al. (2002). Acupuncture for lateral elbow pain. Cochrane Database of Systematic Reviews (3). Oxford: Update Software.

13. Buchbinder R, et al. (2002). Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews (4). Oxford: Update Software.

Other Works Consulted

• Johnson TR, Wirth MA, eds. (2001). Epicondylitis and radial tunnel syndrome. In WB Greene, ed., Essentials of Musculoskeletal Care, pp. 176–181. Rosemont, IL: American Academy of Orthopaedic Surgeons.

Author:	Nancy Bateman	Last Updated March 4, 2005
Medical Review:	William M. Green, MD - Emergency Medicine Patrick J. McMahon, MD - Orthopedics
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