Tennis Elbow: Causes, Symptoms, and Treatment

Tennis elbow is a painful irritation of tendons that attach to the outside of the elbow. The main trigger is considered to be a permanent overstrain of the forearm muscles caused by monotonous movements without adequate relief. Via the respective tendons, the forearm muscles attach to the elbow or upper arm, which are mainly responsible for the extension of the wrist and fingers. Most tennis elbows heal with the right therapy; only rarely, the limitation is chronic.

Important facts about the causes, treatment options, and exercises, as well as the course and prognosis of tennis elbow, are discussed in more detail below.

Tennis player with tennis elbow

How is tennis elbow treated?

The treatment of tennis elbow can be divided into conservative and operative treatments.

As a rule, the conservative therapy is started with the conservative treatment, which includes not only protection and, if necessary, immobilization of the elbow joint, but also natural cooling. Painkiller or cortisone ointments (bandages), bandages or cuffs, physiotherapeutic treatment (strengthening training, stretching exercises, massages, etc.) and acupuncture are also part of the conservative treatment measures.

Local injections can also be made in the area of the elbow, which contains a mixture of local anesthetic and cortisone.

Painkillers can also be taken in tablet form, preference being given to non-steroidal anti-inflammatory drugs (NSAIDs, e.g., diclofenac, ibuprofen), which have an anti-inflammatory effect in addition to their analgesic properties.

If conservative therapy is unsuccessful, the step can then be taken to surgical therapy, whereby there are various procedures for relieving tennis elbow.

Another therapy attempt for chronic complaints is the injection of botulinum toxin (also known as Botox) into the muscle to “paralyze” it for 2-3 months so that it can recover.

Check our article about Elbow Dislocation: Causes, Symptoms, and Treatment

Brace

One possibility of conservative therapy of tennis elbow is the application and wearing of a tennis elbow bandage or tennis elbow brace.

Therapy with a bandage or brace plays a very important role in the acute phase, while both aids become less efficient in the chronic phase.

In the case of still existing tennis elbow together with cooling, protection, painkillers, physiotherapy, and stretching exercises, this can help to relieve the affected muscles and to heal. However, it can also prevent a recurrence after successful therapy and still existing, heavy strain on the forearm muscles.

A bandage/clip does not restrict the freedom of movement as consistently as a plaster cast, for example, but rather guarantees a free range of motion.

The purpose of such a bandage/clip is to exert targeted pressure, concentrated on the point of attachment of the tendons at the elbow, which relieves the muscles of the forearm and relieves pain.

Such cuffs can be purchased over the counter in various sports shops and medical supply stores, but advice should be sought from the doctor treating the patient as to which type of bandage/brace is most suitable. Care should also be taken to ensure the correct size and fit, as otherwise even more unpleasant complaints can be caused by a too tight, constricting bandage.

Your doctor can easily tell you whether you benefit more from a bandage or brace.

The wearing time of the bandage, brace, or cuff depends on various factors.

As a rule, the aids should only be worn during exercise (during sports, at the PC) to relieve the tendon. Where the elbow is not exposed to any strain, no bandages or similar should be worn, as this interferes with the healing process through compression.

Read more about Elbow bandage for tennis elbow

Tapering

Tapering in the context of tennis elbow can also be regarded as a supportive therapy measure and can support conservative treatment, i.e., non-operative treatment.

Taping can be done with elastic tapes (e.g., Kinesio tapes) as well as with inelastic tapes (e.g., Leukoplast).

Elastic Kinesio-tapes are used to support the healing process. Non-elastic tapes help athletes to be less painful during sports.

The type of tape to be used depends on what exactly is to be achieved with the tape: inelastic tapes have a more “splinting” function – similar to bandages or fixed traction bandages – they restrict the range of movement in the elbow somewhat and support immobility.

Elastic tapes (Kinesio-tapes), on the other hand, restrict movement less or not at all, at most support the movements and promote or activate the blood circulation, the misused muscles, and the lymph drainage, so that pain relief, swelling and inflammation control can be achieved.

The tapes should always be applied or glued by a specialist, as incorrectly or too tightly glued tapes can also lead to other complaints, such as circulatory problems.

More about Taping a tennis elbow

Stretching exercises

Stretching exercises can be carried out during an acute tennis elbow and help to heal. Still, they can also be used regularly in everyday life after tennis elbow has been overcome to prevent recurrence.

For example, the following exercise can be performed 2-3 times a day: The arm is stretched straight forwards at a 90° angle away from the body, the elbow should not be bent. With the palm facing upwards, the hand in the wrist is now bent downwards and held in this position for approx. 30 seconds with the help of the other hand.

Exercises

To support the healing process, various exercises can be performed, which are often used in the context of physiotherapy.

These include strengthening exercises for the forearm and hand muscles as well as stretching exercises to prevent incorrect strain and muscle shortening.

Stretching exercises should already be carried out to accompany pain therapy, whereas strengthening exercises should only be carried out in the pain-free stage or after complete healing to prevent a recurrence of tennis elbow.

Important: The exercises must not cause any pain. In treatment, exercises are measures that support healing and are rather harmful in the acute phase of tennis elbow!

Want to know more about Elbow bursitis: Causes, Symptoms, and Treatment?

Cortisone injection

Another therapeutic option is the administration of an injection into the area of the inflamed elbow joint, whereby this injection consists of a mixture of local anesthetic and cortisone.

The cortisone has an anti-inflammatory effect, and the anesthetic quickly and temporarily relieves the pain.

A cortisone injection is an efficient way to end the disease, especially in the initial phase of a tennis elbow. In phases of chronic tennis elbow, an isolated cortisone injection cannot help.

The side effects of a locally given cortisone injection are usually manageable and are often overestimated by those affected. As a practitioner of thousands of tennis elbow injuries, I cannot confirm a torn tendon – as often described elsewhere – when used correctly. Nevertheless, even the use of the cortisone injection is not a procedure of first choice.

Shockwave therapy

Shock wave therapy, like radiation, is a non-invasive therapy option for tennis elbow, i.e., a treatment that does not penetrate, i.e., does not open up the body surface, as would be the case with surgery.

This procedure is used by various orthopedic surgeons to treat severe, protracted, chronic tendon insertion inflammation.

Strictly speaking, shock waves are electromagnetically generated acoustic waves that are directed to the affected part of the body, where they exert pressure through the impulse and energy transfer. This pressure is intended to irritate the respective tissue, as well as to stimulate blood circulation and cell metabolism and to promote complex healing processes.

The pain symptoms can also be reduced by the application of shock waves, but the exact mechanism of action in all its details has not yet been deciphered.

Shockwave therapy is an efficient reserve procedure when other therapy methods have failed, or the symptoms persist for more than six months.

As with all therapeutic procedures, the success of shock wave therapy depends mainly on the experience of the user.

Read more about this topic in our article: Shock wave therapy for tennis elbow.

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Surgery

Surgery for tennis elbow is usually only considered if the success of an exhausted conservative therapy fails to materialize, and there is no improvement of the symptoms after a good six months of conservative treatment.

The operation can be performed on an outpatient or inpatient basis, whereby the former is the actual standard procedure. Besides, the surgery can be performed under local anesthesia, so that only the arm is anesthetized, but general anesthesia can also be used if desired or under certain circumstances.

Stretching exercises after the operation

During an operation on tennis elbow, the affected tendon and muscle attachments are usually separated from the bony protrusion.

After immobilization for 1-2 weeks, the arm should be moved through again.

Careful stretching exercises are also part of the physiotherapeutic follow-up treatment after an operation of a tennis elbow. These can prevent the tendon from re-growing at the elbow and thus a recurrence of the tennis elbow.

The intensity of the exercises can be determined together with the treating physiotherapists and can also be carried out independently at home.

Irradiation

Irradiation in the context of tennis elbow is the so-called X-ray stimulation radiation.

As the name suggests, it involves the use of X-rays that are explicitly directed at the area of the elbow and is a long-established procedure for treating inflammation of tendon attachments. Like surgery, the irradiation of a tennis elbow is only a reserve therapy, which can be used after at least six months of unsuccessful conservative treatment.

Usually, six applications are carried out, 2 of them in one week. Often the symptoms initially worsen during the treatment, but this is not serious, but rather stands for the excellent response to the treatment. The final result, i.e., the relief of the symptoms, often occurs 3-4 months after the last radiation.

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Physiotherapy

The implementation of physiotherapy has a very high priority in the treatment of tennis elbow, both for the regeneration and for the prevention of tennis elbow recurrence.

Physiotherapy includes targeted strengthening exercises to strengthen the muscles of the forearm, stretching exercises, and massages.

In the very acute stage of the disease, i.e., when the inflammation is still most pronounced, physiotherapy should not be performed, especially with no stretching exercises and massages, as these can sometimes promote and aggravate the inflammation.

Also, physiotherapy is used to determine the triggering circumstances, i.e., the patient is also examined for incorrect posture, and posture corrections (e.g., in the spine or at the workplace) are carried out.

Osteopathy

An osteopath can also be consulted, who will manually diagnose the functional disorders causing the problem and will not only focus on the overstrained forearm muscles but will also pay holistic attention to the cervical/chest spine, shoulder and ribs.

However, osteopathy plays only a minor role in the treatment of tennis elbow.

Ointment

The use of ointments can be part of the therapy and can certainly be tried.

As a rule, the ointments to be applied and rubbed in contain certain active substances, which are mainly used to combat the pain symptoms or even have an anti-inflammatory effect.

Well-known are ointments such as Voltaren Emulgel®, which contain the active ingredient diclofenac, which is a painkiller from the group of non-steroidal anti-inflammatory drugs (NSAIDs).

Ointments containing cortisone can also be used, which also has an anti-inflammatory effect.

You may also want to read about Golfer’s elbow: Causes, Symptoms, and Treatment

Does heat or cold affect tennis elbow?

Because tennis elbow is an inflammatory process, the application of cold is the method of choice in this case.

Cold relieves the inflammatory symptoms such as pain, swelling, redness, and overheating.

If heat is applied to an inflammation, the pain and inflammation may even worsen, which is caused by the increased blood flow (heat causes the blood vessels to dilate, allowing more blood to flow in).

Cooling compresses or ice can be used, but the too long or intensive application should be avoided to prevent skin damage.

Plaster

About a consistent immobilization of the elbow joint for the therapy of tennis elbow, and upper arm cast can be used. Still, immobilization by independent sparing, bandages, tapes, etc. should be preferred.

It is, therefore, neither the method of choice nor a permanent therapy option, but the cast should only immobilize for a short time, if at all.

Immobilization with an upper arm cast that includes the elbow causes the muscles to regress very quickly. If the subsequent training for reconstruction is carried out incorrectly, a new incorrect/overstrained load can easily occur, which can lead to renewed tennis elbow.

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Duration of a tennis elbow

How long the symptoms of tennis elbow persist cannot always be said in general terms, this depends on several factors that influence the course of the disease.

In addition to the correct, accompanying therapy, the consistent immobilization of the elbow, and the protection of the elbow are significantly responsible for healing.

Nevertheless, tennis elbow is often a persistent complaint that can last for several weeks despite therapy. These should then be treated symptomatically with cooling, painkillers, and an injection of cortisone and local anesthetic if necessary.

The immobilization can either be carried out independently or with a bandage, tape, or even a plaster cast.

If the symptoms persist for more than six months, the condition is called chronic tennis elbow, and under certain circumstances, a surgical therapy procedure may be considered.

Unfortunately, it is not possible to quantify the exact duration of the tennis elbow. A tennis elbow that exists for a few weeks can usually be healed in 2 weeks.

Chronic tennis elbow can take months to heal and be painless and fully resilient again.

Accordingly, the duration of sick leave is also challenging to predict. Someone who works in an office usually benefits from a week’s relief. For craftsmen, a sick note can last several weeks.

The same applies to an operation. For an office worker, the ability to work with minimally invasive technology is achieved in 14 days. Someone who has to lift heavily every working day can be absent for many weeks in an open surgery.

Check our article about Elbow Dislocation: Causes, Symptoms, and Treatment

Healing of a chronic tennis elbow

The healing of a chronic tennis elbow is much more complicated than that of an acute tennis elbow.

In general, the treatment measures are inevitably more invasive and radical. Often, at this stage, the only way to help is surgery, in which the affected tendon is severed (tenotomy), and the symptoms are resolved.

A further measure, in addition to surgery, is the injection of botulinum toxin into the affected muscle. This drug, also known as “Botox,” switches off the nerve innervation of the muscle so that it is paralyzed, allowing it to recover and regenerate at rest.

Symptomatically accompanying warmth should be applied in the chronic stage, in contrast to the acute inflammatory stage, in which only cold relieves the symptoms.

The typical symptoms of tennis elbow are:

  • Pain on the outer side of the elbow
  • Pain when grabbing the elbow
  • Pain when lifting the wrist
  • Pain when stretching the fingers

In addition to the typical pulling, burning pain on the outside of the elbow, which may be caused by pressure or even at rest, there are other characteristic symptoms associated with tennis elbow.

Pain can occur particularly when the elbow is stretched, as well as when the forearm is rotated (e.g., when screwing) and when lifting heavy loads.

In addition to the pain, sensitivity disorders can also occur in some cases. Sensitivity disorders are numbness, which is often limited to the area of the elbow, but in some cases, it can also affect the forearm.

In cases of severe inflammation, external signs of inflammation can rarely be observed, such as redness, swelling, and overheating of the elbow joint.

However, this is less frequently the case with tennis elbow; instead, such symptoms indicate an inflammation of the joints (arthritis) or the bursa (bursitis).

Pain

Typical for tennis elbow or tennis elbow is, on the one hand, the pain that can be triggered by pressure on the outside of the elbow – where the tendons of the forearm muscles are located – and on the other hand the pain that is only intensified by the movement of the affected forearm muscles. The pressure pain is caused by the local inflammation, which irritates the tissue and skin in the area of the elbow.

The pain of movement is provoked mainly by stretching the fingers and wrist (especially against resistance).

Sometimes even the closing of the fist or turning of the forearm can cause pain.

Specific localized symptoms of tennis elbow

Symptoms in the forearm

With tennis elbow, the accompanying symptoms are mainly located in the area of the forearm. The pain is primarily concentrated on the outside of the elbow, which can be triggered by pressure. Also, pain is caused by stretching movements of the fingers and wrist, often also by fist closure and rotation of the forearm.

Initially, the pain is often only felt in the tendon attachment area of the elbow, but as the disease progresses or the muscles are subjected to additional strain, it can then radiate clearly into the forearm.

Symptoms in the upper arm

Depending on how pronounced the inflammation is in tennis elbow, the pain can also spread beyond the elbow. In severe cases, the pain can also radiate into the upper arm under stress, certain movements, or sometimes even at rest.

More often, however, pain radiates to the upper arm and forearm at the golfer’s elbow, where it is not the tendon attachments on the outer elbow that are inflamed, but those on the inside.

Symptoms in the shoulder

If, in addition to the pain in the elbow, there is also pain or painful movement restrictions in the shoulder, this can sometimes be an indication of incorrect weight-bearing, incorrect posture, or inaccurate movements in the area of the upper body.

In some cases, a severely inflamed tennis elbow can even lead to pain radiating into the shoulder. On the other hand, a painful shoulder can also lead to poor posture and incorrect strain on the muscles of the forearm, which in turn can cause tennis elbow when overstrained.

More about Taping a tennis elbow

General symptoms of tennis elbow

Numbness

As a rule, the tennis elbow or tennis elbow is not accompanied by numbness or so-called sensitivity disorders (e.g., tingling sensations). Only when the disease is very pronounced can it spread to slight numbness of the skin in the area of the outer side of the elbow or on the outer forearm down to the wrist.

It is assumed that the inflammatory process at the elbow causes simultaneous irritation of the skin nerves running along it. If, on the other hand, a complete numbness of the hand or individual fingers with possibly a tingling sensation occurs, other, potentially more serious diseases should be considered (e.g., slipped disc, carpal tunnel syndrome, sulcus-ulnaris syndrome, etc.).

Tremor

If a tremor occurs for the first time in the context of tennis elbow and if the tremor is also limited to the side affected by the inflammation, there is initially no cause for concern, as the tremor, in this case, is most likely due to the tennis elbow.

Due to the overstrained musculature and the straining pain, especially the muscles of the forearm, are quickly tired and more easily overstrained. This muscular exhaustion can then cause trembling in the hand, arm, or fingers. This is comparable to a tremor after strong muscle strain due to training, e.g., strength training.

Which doctor treats tennis elbow?

If symptoms of tennis elbow occur, the first thing to do is to consult your family doctor, who can make an initial suspected diagnosis based on a conversation and examination of the elbow.

Often the family doctor will then initiate the appropriate therapy so that no further doctor needs to be consulted at first.

If the therapy does not work satisfactorily, and the symptoms persist, the tennis elbow becomes chronic. Even if the general practitioner cannot make the diagnosis with absolute certainty, a referral to an orthopedic specialist is often necessary. The orthopedic surgeon repeats the examination, possibly supplementing it with imaging, and can offer further methods of therapy.

Causes of tennis elbow

The main cause of tennis elbow is the overuse of the forearm muscles, which are responsible for stretching the fingers and wrist.

Overstrain can be caused by various factors. On the one hand, permanent and constant incorrect strain in everyday life, work (e.g., screwing, grinding) and leisure time (e.g., sport) can lead to overstrain, as can one-sided strain on the upper body (e.g., when using the mouse/keyboard at work, when climbing, etc.).

Incorrect techniques in stroke sports such as tennis or golf can also lead to increased strain on the forearm muscles, as can certain arm positions during sleep (lying on your side, with your head on your elbow).

Painful tendon attachment points on the elbow in the context of other diseases such as fibromyalgia are to be distinguished.

Fibromyalgia is a chronic, incurable disease, in which pain can occur in changing muscles, joints, and tendon attachments in relapses.

Read more about Elbow bandage for tennis elbow

Diagnosis of tennis elbow

To be able to make a diagnosis of tennis elbow, the attending physician first begins with a medical history, i.e., the collection of a medical history, whereby the emphasis is placed on the characteristic pain symptoms.

Afterward, the elbow is examined, whereby often a pressure pain on the outside, as well as redness, swelling, overheating, or even a relieving posture, can be noticed.

Often the diagnosis can be made, but if doubts persist, further clinical tests can follow: on the one hand the stool test, in which the patient has to lift a chair with an extended arm and forearm turned inwards; on the other hand, the Thomson test, in which the hand is closed to the fist, and the wrist is bent backward against resistance (further tests: Bowden test, Mill test, Cozen test).

Also, blood tests can confirm signs of inflammation (CRP, blood sedimentation rate, leukocyte elevation). Finally, various imaging procedures can be used to eliminate uncertainties in the diagnosis: ultrasound examination of the elbow, X-ray of the arm, or magnetic resonance imaging (MRI) can be applied.

MRI for tennis elbow

As a rule, a tennis elbow can only be provided by the medical history, i.e., by the conversation between doctor and patient, and the subsequent physical examination, i.e., the examination of the elbow by the attending doctor.

If the results of the examination are not entirely clear, the doctor can use imaging to help. In addition to X-rays and ultrasound, magnetic resonance imaging (MRI elbow) is also used. MRI of the elbow can be used to visualize soft structures particularly well, including the tendons and muscles of the affected elbow. The extent of inflammation can then be determined, and possible complications such as muscle/tendon tears can be ruled out.

Forecast

In most cases, a tennis elbow has a good prognosis. Many patients can be treated conservatively, i.e., an operation is not necessary in most cases. However, it is possible that the disease occurs over a long period and may only be healed with surgery. In rare cases, even an operation cannot provide lasting relief from the pain.

The prognosis of tennis elbow is mainly influenced by the inflammation of the common extensor tendon (i.e., “extensor vision”).

It is prognostically unfavorable if there is a tear of the common extensor tendon (at the tennis elbow). In principle, however, torn tendons can also heal under optimal follow-up treatment.

How can I prevent a recurrence after surviving a tennis elbow?

To prevent or avoid the recurrence of tennis elbow, a few rules of conduct should be observed in everyday life.

On the one hand, care should be taken to avoid one-sided arm strain, as well as excessive, monotonous movements of the forearm muscles. It is important to train the arm and forearm muscles in a balanced way, so that incorrect loads, incorrect posture, and overstraining are avoided. Training that strengthens the hand and forearm muscles can be useful to avoid tiring too quickly and overloading.

Sufficient warming up of the muscles is essential, as are regular stretching exercises, which should be done two or three times a day.

Since it is precisely in every day (working) life that one finds triggering arm movements, care should be taken in every area to ensure that preventive measures are taken. In essence, the right tools should be used by craftsmen at home or work, strenuous screw driving by hand can be carried out by a cordless screwdriver, for example, and grinding work by a grinding machine.

At the workplace with a PC, the correct sitting and arm position should also be observed.

Want to know more about Elbow bursitis: Causes, Symptoms, and Treatment?

Summary

Tennis elbow is a localized inflammation in the extensor muscles of the forearm and hand.

From a medical point of view, it is a so-called epicondylitis (humeri radialis).

Tennis elbow belongs on the one hand to the insertion tendinopathies (= disease of the tendons, tendon sheaths, and ligaments), on the other hand, also to the myotendinoses. Consequently, epicondylitis (humeri radialis) is a disease of the tendons and ligaments, involving the adjacent muscles.

Tendinopathies (tendon inflammations) can under certain circumstances cause painful changes in tendons in the area of a muscle origin, muscle, ligament, or capsule attachment. Tendinopathy can, therefore, occur almost throughout the entire body.

In tennis elbow/tennis elbow, characteristic pain occurs as a result of overstraining the muscles, which can severely restrict the usability of the affected arm. Tennis elbow occurs equally in men and women, most frequently in middle age.

Tennis elbow can be treated both conservatively and surgically.

Due to the now excellent conservative treatment options, operations on tennis elbow are hardly ever necessary.

As a rule, one tries to treat the clinical picture of the tennis elbow conservatively. This includes treatment methods such as:

  • Immobilization (this method is increasingly being abandoned)
  • Electromechanical stimulation
  • Cortisone injections
  • Ointment dressings
  • Shockwave therapy

If the conservative measures do not work, surgery may be necessary. In this case, the muscles required for stretching the arm (“forearm extensor”) are loosened by notching or even completely cutting the tendon attachment.

Please check other articles about Elbow conditions: Types and Information

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