Tennis elbow is pain on the outer side of the elbow, caused by repeated load on the tendons that attach the forearm muscles to the bone. The pain increases with gripping, lifting objects, turning a handle and shaking hands, and sometimes spreads along the forearm. Despite the name, most people who have it do not play tennis. It is common in people who work long hours with their hands, at a keyboard or with tools. In most cases it improves with conservative treatment within a few months. It is worth seeing an orthopedist when the pain lasts more than six weeks, when it interferes with work and sleep or when the grip weakens.
What happens in the tendon
The muscles that straighten the wrist and the fingers attach through a shared tendon to the bony bump on the outer side of the elbow. Every grip, lift or turn of the forearm puts this tendon to work. When the load repeats again and again without enough recovery time, tiny tears form in the tendon, and the tissue struggles to repair itself.
In the past it was thought to be an inflammation. It is now known that in the chronic state the main problem is a degenerative change in the tendon and not active inflammation, which is why anti-inflammatory medicines ease the pain but do not solve the problem. Effective treatment aims at gradually strengthening the tendon and reducing the load that caused the injury.
Who tends to develop tennis elbow
The condition usually appears between the ages of thirty-five and fifty-five, mainly in the dominant arm. The actions that load the tendon are shared by many occupations and hobbies:
- Long hours at a keyboard and mouse, mainly when the wrist is bent upwards.
- Work with tools such as a screwdriver, hammer, shears or paintbrush.
- Repeated lifting with the palm facing down.
- Cooking, chopping and carrying heavy pots.
- Racket sports, mainly when the technique or the grip size is not right.
- Carrying a baby or heavy bags over time.
- Strength training with a load that was increased too quickly.
Smoking and diabetes also slow tendon healing and lengthen the duration of symptoms.
How to recognise tennis elbow
The central symptom is pain and tenderness at a clear point on the outer side of the elbow, slightly below the bony bump. The pain usually begins gradually, without a particular injury, and worsens with everyday actions:
- Lifting a cup of coffee or a kettle.
- Opening a jar or turning a key and a door handle.
- Shaking hands.
- Wringing out a cloth.
- Lifting an object with the elbow straight and the palm facing down.
In the morning the elbow sometimes feels stiff, and the grip becomes weaker. The range of movement of the elbow usually stays full, and there is no obvious swelling.
Not every elbow pain is tennis elbow. Pain on the inner side of the elbow fits golfer’s elbow better. Numbness in the fingers points to pressure on a nerve, at the elbow, the wrist or the neck. An elbow that is swollen, warm or locked needs an examination, because these are not signs of tennis elbow.
What you can do at home
The first step is to reduce the load on the tendon without resting the arm completely. Total rest over time weakens the muscle and the tendon and does not shorten recovery.
- Temporarily change the actions that hurt: lift objects with the palm facing up and the elbow bent, and keep the object close to the body.
- Take short breaks during repetitive work.
- Adjust the workstation: mouse and keyboard at a height that allows a straight wrist and a supported forearm.
- Apply local cold after an activity that hurt.
- Wear a forearm strap slightly below the elbow, which spreads the load on the tendon during activity.
- Use painkillers or an anti-inflammatory gel for a short period, as advised by a doctor or pharmacist.
The exercises that really help
The treatment found most effective over time is gradual exercise of the forearm muscles, guided by a physiotherapist. The exercises load the tendon in a controlled way and encourage it to strengthen and reorganise.
The basis is an exercise in which you slowly lower a light weight using the wrist, with the forearm supported on a table and the palm facing down. The lift back up is done with the help of the other hand. Start with a light load, practise daily and increase the load gradually over weeks. Alongside this come gentle stretches of the forearm muscles and strengthening of the shoulder and shoulder blade muscles, which carry part of the load.
Mild pain during practice is acceptable. Sharp pain, or pain that lasts for hours after practice, means the load is too high. Improvement is usually felt after six to twelve weeks of consistent practice, so persistence matters more than any other treatment.
When to see an orthopedist
It is worth booking a visit with a private orthopedist in Modi’in in these situations:
- Pain that lasts more than six weeks despite reducing the load and exercising.
- Pain that wakes you from sleep or appears at rest.
- Marked weakness of grip, or objects slipping from the hand.
- Numbness or tingling in the forearm and fingers.
- Swelling, local warmth or limited straightening and bending of the elbow.
- Pain that appeared after an injury or a fall.
- Pain that returns again and again after periods of improvement.
At the examination the doctor presses on the attachment point of the tendon and checks whether the pain appears when straightening the wrist and the middle finger against resistance. The neck, the shoulder and the nerves of the arm are examined as well, to rule out another source of pain. In most cases the diagnosis is made on physical examination. An X-ray or an ultrasound is needed when the picture is not typical, when a tendon tear is suspected or when the pain does not improve.
Which treatments exist when the pain persists
When several months of orderly exercise have not brought enough improvement, the doctor presents further options and explains the advantages and limits of each:
- A steroid injection eases the pain quickly, but the relief is temporary, and the pain often returns after a few weeks. So it is not the first choice.
- Shockwave therapy suits some patients with long-lasting pain.
- An injection of platelet-rich plasma, prepared from the patient’s own blood, is considered in prolonged cases. Study findings are not uniform.
- Surgery to release the tendon and clean the damaged tissue is considered only after six months to a year of full conservative treatment that did not help. Most patients never reach this stage.
How to prevent the pain from returning
Tennis elbow tends to return when you go back to the same load in the same way. Once the pain has gone, keep up the strengthening exercises two to three times a week, and return to full activity gradually and not all at once. At work, choose tools with a thick, comfortable handle, switch hands when possible and build in short breaks. In racket sports, check technique, grip size and string tension with a coach. A short warm-up before activity, and a moderate increase of load in strength training, reduce the risk of a repeat injury. When the pain begins to return, cutting the load early and going back to daily practice usually stop it before it settles in.
At EliteMed in the Ayala 360 complex in Modi’in you can book a visit with an orthopedist without a referral, and the consultation can be held in English. If a knee is troubling you as well, read our guide to knee pain that won’t settle. The information here is general and does not replace an examination and advice from a doctor.
Frequently asked questions
How long does recovery from tennis elbow take?
In most cases the pain improves within a few months of reducing the load and orderly exercise, and in some people recovery takes up to a year. Improvement is gradual and uneven, with better and worse days. Persistence with the exercises and changing the actions that caused the load shorten the process and lower the chance of the pain returning.
Do I need to stop using the arm completely?
No. Total rest weakens the muscles and the tendon. It is better to keep using the arm, temporarily avoid the actions that provoke sharp pain, and change the way you lift and grip. Activity that does not hurt, together with gradual strengthening exercises, is part of the treatment.
Does a steroid injection solve the problem?
A steroid injection eases the pain quickly, but the effect is temporary. In a considerable share of patients the pain returns after a few weeks, and sometimes the long-term result is less good than with exercise alone. The doctor considers an injection in certain situations, for example when the pain is very strong and prevents any exercise.
Does a forearm strap help?
A strap worn slightly below the elbow spreads the load on the tendon, and for some people eases the pain during work or sport. It does not heal the tendon, so it is worth using it during loading activity, alongside the strengthening exercises and not in their place.
What is the difference between tennis elbow and golfer’s elbow?
In tennis elbow the pain is on the outer side of the elbow and is linked to the muscles that straighten the wrist. In golfer’s elbow the pain is on the inner side and is linked to the muscles that bend the wrist. The principles of treatment are similar in both: reducing the load and gradual exercise.