Background

Lateral epicondylitis or lateral epicondylalgia, better known as tennis elbow, is a condition where the outer part of the elbow becomes sore and tender.  It is also called shooter’s elbow, archer’s elbow or simply lateral elbow pain.

Since the pathogenesis of this condition is still unknown, there is no single agreed name.  While the common name ‘tennis elbow’ suggests a strong link to racquet sports, this condition can also be caused by sports such as swimming and climbing, the work of manual workers and waiters, as well as activities of daily living (ADL).

Tennis elbow is an overuse injury occurring in the lateral side of the elbow region, but more specifically it occurs at the common extensor tendon that originates from the lateral epicondyle of the humerous.  Acute pain is experienced as the arm is extended.  Overuse injury can also affect the back (posterior) part of the elbow as well.

• Tennis elbow: pain in the outer (lateral) part of the elbow; and
• Golfer’s elbow: pain in the inner (medial) part of the elbow.

In one study, data was collected from 113 patients who had tennis elbow and the main factor common to them all was overexertion.  Sportspersons as well as those who used the same repetitive motion for many years, especially in their profession, suffered from tennis elbow.  It was also common in individuals who performed motions they were unaccustomed to.  The data also mentioned that the majority of patients suffered tennis elbow in their right arms.

The Elbow Joint

The elbow joint is surrounded by muscles that move the elbow, wrist and fingers.  The tendons at your elbow join the muscles of the forearm to the bones and along with the muscles, control movement of the wrist and hand.

When a person gets tennis elbow, one or more of the tendons on the lateral aspect of the elbow becomes painful.  The pain occurs at the point where the tendons attach to the bone.  Twisting movements, such as turning a door handle or opening the lid of a jar, are 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 5 in every 1,000 adults in the UK are affected by the condition each year.  Tennis elbow usually occurs in adults and men and woman are affected equally.  The condition tends to affect people who are around 40 years old.

Symptoms: Tennis Elbow

The main symptom of tennis elbow is pain and tenderness on the outside of your elbow.  You may also feel pain travelling down your forearm.  It can vary in severity, but you will usually have the symptoms listed below:

• Recurring pain on the outside of your upper forearm, just below the bend of your elbow. Sometimes, you may also feel pain down your forearm towards your wrist;
• Pain caused by lifting or bending your arm;
• Pain when writing or when gripping small objects. This can make it difficult to hold small items, such as a pen;
• Pain when twisting your forearm. For example, when turning a door handle or opening a jar; and/or
• Difficulty fully extending your forearm.

The pain of tennis elbow can range from mild discomfort when using your elbow to severe pain that can be felt even when your elbow is still or when you are asleep.  You may have stiffness in your arm that gets progressively worse as the damage to your tendon increases.

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

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.

How is Golfer’s Elbow Different

Golfer’s elbow (medial epicondylitis) causes pain and inflammation at the point where the flexor tendons of the forearm are attached to the upper arm.  The pain centres on the bony bump on the inside of your elbow and may radiate into the forearm.  It can usually be treated effectively with rest.

Golfer’s elbow is usually caused by overuse of the muscles in the forearm that allow you to rotate your arm and flex your wrist.  Repetitive flexing, gripping or swinging can cause pulls or tiny tears in the tendons close to where they are attached to the bone.

Both tennis elbow and golfer’s elbow are forms of elbow tendinitis.  The difference is that tennis elbow stems from damage to the extensor tendons on the outside of the elbow, while golfer’s elbow is caused by flexor tendons on the inside.

Symptoms: Golfer’s Elbow

The primary symptom of golfer’s elbow is pain that is centred near the bony knob on the inside of the elbow.  Sometimes it extends all along the inner forearm.  You are most likely to feel it when you bend your arm inwards or flex your wrist towards the body.  In most cases, the pain becomes gradually worse.

Causes & Risk Factors of Elbow Tendonitis

Elbow tendonitis 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 your wrist can injure the tendons in your arm and elbow and lead to tiny tears, which cause rough tissue to form near the bony lump on the outside of your elbow.

Elbow tendonitis 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 elbow tendonitis.  You are more at risk of developing elbow tendonitis if the tendons in your elbow can be injured by overusing your forearm muscles in repeated actions, such as:

• Gardening, e.g. using shears;
• Playing racquet sports, such as tennis or squash;
• Sports that involve throwing, such as the javelin or discus; and/or
• Swimming.

Elbow tendonitis 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; and/or
• 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.

Diagnosis

You should visit your medical professional if the symptoms 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.

Your medical professional can make a diagnosis based on your symptoms and by examining your arm; checking for pain in the area around your elbow.  Your medical professional 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.  Remember, your work and sport activities are not mutually exclusive when it comes to placing stress on your muscles and joints.  For example, it could be:

1. Your sport activity led to the injury and your work activity exacerbates it; or
2. Your work activity led to the injury and your sport activity exacerbates it;

Further Investigations

Further investigations are not usually needed to diagnose either tennis elbow or golfer’s elbow.  This is because these conditions can usually be confirmed after your medical professional examines your arm (i.e. a clinical diagnosis).  However, if your medical professional 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: 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; or
• Ultrasound scan: An ultrasound scan uses high-frequency sound waves to create an image of part of the inside of your body.

However, since there are many other conditions that can cause pain around the elbow, it is important that you seek medical advice so the correct diagnosis can be made.  Then your medical professional can prescribe the appropriate treatment.

Treatment Options and Outlook

Both conditions are self-limiting and this means that in the majority of cases the symptoms eventually improve and clear up without treatment.  Most cases last between six months and two years, this is because tendons are slow to heal.  However, in around 9 out of 10 cases, a full recovery is made within one year.

There are medical (non-surgical) and surgical treatment options for tennis and golfer’s elbow.  Medical treatments are tried first and in general surgery will only be recommended as a treatment of last resort, after failure to improve with medical treatments.

The type of treatment recommended will depend on several factors including age, type of other medications being taken, overall health, medical history and severity of pain.  The goals of treatment are to reduce pain or inflammation, promote healing and to decrease stress and abuse of the injured elbow, in order to return to normal elbow function.

Medical (Non-surgical) Treatments

If you have elbow tendonitis, the most important method of management is rest.  You should rest the affected arm as much as possible and avoid doing any activities that put more stress on the tendons.

Taking painkillers, such as paracetamol and ibuprofen (NSAIDs[1]), may help to reduce mild pain that is caused by elbow tendonitis.  Children under 16 years old should not take aspirin.  Ibuprofen also has anti-inflammatory properties, so helps reduce associated inflammation and swelling.

NSAIDs are also available as creams and gels, known as topical NSAIDs.  These are applied directly to a specific area of your body, such as your forearm or elbow.  Some NSAIDs are available over the counter at a pharmacy while others are only available on prescription.  Your pharmacist or medical professional can advise you about which NSAID is most suitable for you.  Examples of topical NSAIDs include:

• Ibuprofen;
• Diclofenac;
• Ketoprofen; and
• Piroxicam.

These have been proven to provide some pain relief and reduce inflammation for musculoskeletal conditions (those that affect the muscles or bones).  There is strong evidence from research that topical NSAIDs are effective in improving pain, stiffness and function, in particular, in osteoarthritis of the knee (Bookman et al., 2004; NICE, 2008).

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, irritation of the stomach lining and diarrhoea.

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.

Avoid using topical NSAIDs during pregnancy and breastfeeding.  Many topical NSAIDs are also unsuitable for children.  Ask your pharmacist or medical professional 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: your symptoms are prolonged; your pain is severe; your elbow function is grossly limited; or NSAIDs have been ineffective.  Corticosteroids are a medication that contains steroids (a type of hormone) that helps to reduce inflammation.

The injection will be made directly into the painful area around your elbow.  You may be given a local anaesthetic to numb the area to reduce pain while the injection is being given.  But steroids are often injected along with a local anaesthetic to provide immediate pain relief while the steroids takes time to work.

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.  However, 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 and the potential side effects of corticosteroid injections include:

• Pain in the affected area after having the injection;
• Skin de-pigmentation – the loss of colour (pigment) around the injection site; and
• 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 elbow tendonitis, discuss the effectiveness and potential side effects with your medical professional.  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 it too quickly.  As with any injury, you should gradually build up to your normal activity levels to help prevent the problem reoccurring.

Physiotherapy

If your elbow tendonitis symptoms are particularly severe or persistent despite rest and use of NSAIDs, your medical professional may refer you to a physiotherapist.  A physiotherapost 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 your 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 your elbow and encourage the tendons to heal.

Shock Wave Therapy

Shock wave therapy is where high-energy sound waves, like ultrasound, are passed through the skin of the affected area to help relieve the pain of elbow tendonitis and improve mobility (movement), this is normally performed by physiotherapists.  The theory is that the shock waves stimulate blood flow to the tendons thus aiding healing.

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; and/or
• Skin damage around the area being treated.

Research has shown that shock wave therapy is safe.  However, NICE[2] (2009) states that there is a lack of evidence of its effectiveness in treating tennis elbow, and more research is required.

Your medical professional or physiotherapist 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 medical professional or physiotherapist.

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 elbow tendonitis.  Surgery aims to relieve the painful symptoms by removing the damaged part of the tendon.

Prevention

It is often difficult to prevent elbow tendonitis.  However, avoiding putting too much stress on the tendons of your elbow will help you to avoid the condition or to prevent your symptoms from getting worse.

Self-care Advice

There are a number of measures that you can take to help prevent elbow tendonitis developing or prevent it reoccurring:

• If you have elbow tendonitis, stop doing the activity that is causing pain, or find an alternative way of doing it that does not place stress on your tendons;
• Rather than using your wrist and elbow more than the rest of your arm, try spreading the load to the larger muscles of your shoulder and upper arm;
• If you play a sport that uses repetitive movements, such as tennis, you could get 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 beforehand and gently stretch your arm muscles to help you avoid injury;
• Use lightweight tools or racquets, and enlarge their grip size, to help you avoid putting excess strain on your tendons;
• Wear a tennis elbow splint when you are using your arm, and take it off while you are resting or sleeping to help prevent further damage to your tendons.  Ask your medical professional or physiotherapist for advice about the best type of brace or splint for you to use; and/or
• Increasing the strength of your forearm muscles can help prevent tennis elbow.  A physiotherapist can advise you about suitable exercises to build up the muscles of your forearm.