Tennis elbow

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Tennis elbow
Other namesLateral epicondylalgia, lateral elbow tendinopathy [1]
En-elbow joint.svg
Left elbow-joint, showing posterior and radial collateral ligaments. (Lateral epicondyle visible at center.)
Specialty Orthopedics, sports medicine
Symptoms Painful and tender outer part of the elbow [1]
Usual onsetGradual [2]
DurationLess than 1 to 2 years [3]
CausesExcessive use of the muscles of the back of the forearm [2]
Risk factors Smoking, obesity [3]
Diagnostic method Based on symptoms with medical imaging used to rule out other potential causes [2]
Differential diagnosis Osteochondritis dissecans, osteoarthritis, radiculopathy [3]
TreatmentChanging activities, physical therapy, pain medication [1]
Frequencyc. 2% [3]

Tennis elbow, also known as lateral epicondylitis, is a condition in which the outer part of the elbow becomes painful and tender. [1] The pain may also extend into the back of the forearm and grip strength may be weak. [2] [1] Onset of symptoms is generally gradual. [2] Golfer's elbow is a similar condition that affects the inside of the elbow. [1]


It is due to excessive use of the muscles of the back of the forearm. [2] Typically this occurs as a result of over use during work or sports, classically racquet sports. [1] [2] The diagnosis is typically based on the symptoms with medical imaging used to rule out other potential causes. [2] It is more likely if pain increases when a subject tries to bend back the wrist when the wrist is held in a neutral position. [1] A powered screwdriver can cause this injury if overused one-handed. It is classified as a chronic tendinosis, not a tendinitis. [1]

Treatment involves decreasing activities that bring on the symptoms together with physical therapy or other treatment gradually increasing loads. [4] [1] Pain medications such as NSAIDS or acetaminophen (paracetamol) may be used. [1] A brace over the upper forearm may also be helpful. [2] If the condition does not improve corticosteroid injections or surgery may be recommended [1] although some experts recommend avoiding cortisone injections due to poor long-term results in high-quality trials. [5] [6] [7] [8] Many people get better within one month to two years. [3] [9]

About 2% of people are affected. [3] Those 30 to 50 years old are most commonly affected. [2] The condition was initially described in 1873. [3] The name "lawn tennis elbow" first came into use for the condition in 1882. [10]

Signs and symptoms

Symptoms associated with tennis elbow include, but are not limited to, radiating pain from the outside of the elbow to the forearm and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing a doorknob, and not being able to hold relatively heavy items in the hand. [12] The pain is similar to the condition known as golfer's elbow , but the latter occurs at the medial side of the elbow. [13]


The term "tennis elbow" is widely used (although informal), but the condition should be understood as not limited to tennis players. [14] [15] Historically, the medical term "lateral epicondylitis" was most commonly used for the condition. [2] [14] [15] [16]

Since histological findings reveal noninflammatory tissue, the term “lateral elbow tendinopathy," "tendinosis,” or “angio-fibroblastic tendinosis” have been suggested instead of “lateral epicondylitis”. [17] [18] Most recently, in 2019, a group of international experts agreed that "lateral elbow tendinopathy" was the most appropriate terminology. [19]


Location of tennis elbow Tennis Elbow.png
Location of tennis elbow

Tennis elbow is a type of repetitive strain injury resulting from tendon overuse and failed healing of the tendon. In addition, the extensor carpi radialis brevis muscle plays a key role. [18] [20]

Example of repetitive movement that may cause tennis elbow Tenniselbow.JPG
Example of repetitive movement that may cause tennis elbow

Early experiments suggested that tennis elbow was primarily caused by overexertion. However, studies show that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension cause more than half of these injuries. [21] Repeatedly mis-hitting a tennis ball in the early stages of learning the sport causes shock to the elbow joint and may contribute to contracting the condition. [22]

There are multiple aspects of tennis that may cause a player to develop “tennis elbow”. From a technical perspective, leading a backhand with your elbow, excessive pronation of the forearm when putting topspin on a forehand, and excessive flexion of the wrist on a serve can all greatly lead to tennis elbow. Other things that can be improved are: racquet type, grip size, string tension, type of court surface, and ball weight. [23]


Histological findings include granulation tissue, micro-rupture, degenerative changes, and there is no traditional inflammation. [18] [24] [9]

Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term “epicondylitis” is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which replaces normal tissue with a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as tendinosis or tendinopathy rather than tendinitis. [17]

Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin. [25]

The pathophysiology of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle are identified in surgical pathology specimens. [26] It is unclear if the pathology is affected by prior injection of corticosteroid.[ citation needed ]

Tennis players generally believe tennis elbow is caused by the repetitive nature of hitting thousands of tennis balls, which leads to tiny tears in the forearm tendon attachment at the elbow. [16]

The extensor digiti minimi also has a small origin site medial to the elbow that this condition can affect. The muscle involves the extension of the little finger and some extension of the wrist allowing for adaption to "snap" or flick the wrist—usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist—creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing irritation and inflammation.[ citation needed ]

At least one author questions that lateral epicondylitis is caused by repetitive microtrauma/overuse, maintaining the theory is likely overstated and lacks scientific support. [26]

Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased mental chronometry and speed and repetitive eccentric contraction of muscle (controlled lengthening of a muscle group).


Physical examination

To diagnose tennis elbow, physicians perform a battery of tests in which they place pressure on the affected area while asking the patient to move the elbow, wrist, and fingers. Diagnosis is made by clinical signs and symptoms that are discrete and characteristic. For example, when the elbow fully extended, the patient feels points of tenderness over the affected point on the elbow. The most common location of tenderness is at the origin of the extensor carpi radialis brevis muscle from the lateral epicondyle (extensor carpi radialis brevis origin), 1 cm distal and slightly anterior to the lateral epicondyle. [11] There is also pain with passive wrist flexion and resistive wrist extension (Cozen's test). [27]

Medical imaging

X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as fracture or arthritis. Rarely, calcification can be found where the extensor muscles attach to the lateral epicondyle. [11] Medical ultrasonography and magnetic resonance imaging (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost. [13] MRI screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis muscle.


Where lateral epicondylitis is caused by playing tennis, another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore, an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases. [13]

Other ways to prevent tennis elbow:

Vibration dampers (otherwise known as "gummies") are not believed to be a reliable preventative measure. Rather, proper weight distribution in the racket is thought to be a more viable option in negating shock. [30]


Evidence for the treatment of lateral epicondylitis before 2010 was poor. [31] There were clinical trials addressing many proposed treatments, but the trials were of poor quality. [32]

In some cases, severity of tennis elbow symptoms mend without any treatment, within six to 24 months. Tennis elbow left untreated can lead to chronic pain that degrades quality of daily living. [13]

Physical therapy

There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including stretches and progressive strengthening exercises to prevent re-irritation of the tendon [33] and other exercise measures. [34]

One way to help treat minor cases of tennis elbow is simply to relax the affected arm. The rest lets stress and tightness within the forearm slowly relax and eventually have the arm in working condition—in a day or two, depending on the case.

Eccentric exercise using a rubber bar is highly effective at eliminating pain and increasing strength. [35] [36] The exercise involves grasping a rubber bar, twisting it, then slowly untwisting it. [35] [37] Although it can be considered an evidence-based practice, long-term results have not yet been determined. [38]

There are differences in opinions on whether it is okay if pain occurs during these exercises. [39] Some suggest pain of less than 5/10 is okay. [39]

Moderate evidence exists demonstrating that joint manipulation directed at the elbow and wrist and spinal manipulation directed at the cervical and thoracic spinal regions results in clinical changes to pain and function. [40] [41] There is also moderate evidence for short-term and mid-term effectiveness of cervical and thoracic spine manipulation as an add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. Although not yet conclusive, the short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises, resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis. [42]

Low level laser therapy, administered at specific doses and wavelengths directly to the lateral elbow tendon insertions, may result in short-term pain relief and less disability. [43]

Extracorporeal shockwave therapy, while safe, is of unclear benefit. [44] [45]

Orthotic devices

Counterforce orthosis reduces the elongation within the musculotendinous fibers Counterforce brace YM.jpg
Counterforce orthosis reduces the elongation within the musculotendinous fibers
Wrist extensor orthosis reduces the overloading strain at the lesion area Wrist brace.jpg
Wrist extensor orthosis reduces the overloading strain at the lesion area

Orthosis is a device externally used on the limb to improve the function or reduce the pain. Orthotics may be useful in tennis elbow, however long-term effects are unknown. [46] There are two main types of orthoses prescribed for this problem: counterforce elbow orthoses and wrist extension orthoses. Counterforce orthosis has a circumferential structure surrounding the arm. This orthosis usually has a strap which applies a binding force over the origin of the wrist extensors. The applied force by orthosis reduces the elongation within the musculotendinous fibers. Wrist extensor orthosis maintains the wrist in the slight extension. This position reduces the overloading strain at the lesion area.[ citation needed ]

Studies indicated both type of orthoses improve the hand function [47] and reduce the pain [48] in people with tennis elbow.


Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit. [49] A systematic review found that topical non-steroidal anti-inflammatory drugs (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues. [50] Evidence for oral NSAIDs is mixed. [50]

Evidence is poor for long term improvement from injections of any type, whether corticosteroids, botulinum toxin, prolotherapy or other substances. [51] Corticosteroid injection may be effective in the short term [52] however are of little benefit after a year, compared to a wait-and-see approach. [53] A recent randomized control trial comparing the effect of corticosteroid injection, physiotherapy, or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year (Relative risk 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23). [54] Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site. [52] Steroid injections against appear to be more effective than shock wave therapy. [55] Botulinum toxin type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be viable. [56]


In recalcitrant cases surgery may be an option. [57] [58] [59] Surgical methods include: [60]

Surgical techniques for lateral epicondylitis can be done by open surgery, percutaneous surgery or arthroscopic surgery, with no high-quality evidence that any particular type is better or worse than another. [61] [58] Side effects include infection, damage to nerves and inability to straighten the arm. [62] A review of the evidence related to surgery found that published studies were of low quality and did not show that surgery was any more effective than other treatments. [61] A subsequent research trial showed that surgery was no more effective than sham surgery, where patients only received a skin incision, although the trial was limited by a small number of patients. [63]


Response to initial therapy is common, but so is relapse (25% to 50%) and/or prolonged, moderate discomfort (40%).[ citation needed ]

Depending upon severity and quantity of multiple tendon injuries that have built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl defines four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2.

  1. Inflammatory changes that are reversible
  2. Nonreversible pathologic changes to origin of the extensor carpi radialis brevis muscle
  3. Rupture of ECRB muscle origin
  4. Secondary changes such as fibrosis or calcification. [64]


In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling," while 42% over the age of 50 did. More women (36%) than men (24%) considered their symptoms severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a four-fold increase among men and two-fold increase among women. Tennis elbow equally affects both sexes and, although men have a marginally higher overall prevalence rate as compared to women, this is not consistent within each age group, nor is it a statistically significant difference. [65]

Playing time is a significant factor in tennis elbow occurrence, with increased incidence with increased playing time being greater for respondents under 40. Individuals over 40 who played over two hours doubled their chance of injury. Those under 40 increased it 3.5 fold compared to those who played less than two hours per day. [13]


German physician F. Runge [66] is usually credited for the first description of the condition, calling it "writer's cramp" (Schreibekrampf) in 1873. [67] Later, it was called "washer women's elbow". [68] British surgeon Henry Morris published an article in The Lancet describing "lawn tennis arm" in 1883. [69] [70] The popular term "tennis elbow" first appeared the same year in a paper by H. P. Major, described as "lawn-tennis elbow". [71] [72]

See also

Related Research Articles

Extensor carpi radialis longus muscle

The extensor carpi radialis longus is one of the five main muscles that control movements at the wrist. This muscle is quite long, starting on the lateral side of the humerus, and attaching to the base of the second metacarpal bone.

In human anatomy, extensor carpi radialis brevis is a muscle in the forearm that acts to extend and abduct the wrist. It is shorter and thicker than its namesake extensor carpi radialis longus which can be found above the proximal end of the extensor carpi radialis brevis.

In human anatomy, the extensor carpi ulnaris is a skeletal muscle located on the ulnar side of the forearm. It acts to extend and adduct at the carpus/wrist from anatomical position.

Tendinopathy Medical condition

Tendinopathy, also known as tendinitis or tendonitis, is a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder, elbow, wrist, hip, knee, or ankle.

De Quervain syndrome Medical condition

De Quervain syndrome is inflammation of two tendons that control movement of the thumb and their tendon sheath. This results in pain at the outside of the wrist. Pain is typically increased with gripping or rotating the wrist. The thumb may also be difficult to move smoothly. Onset of symptoms is gradual.

Wrist drop Medical condition

Wrist drop, is a medical condition in which the wrist and the fingers cannot extend at the metacarpophalangeal joints. The wrist remains partially flexed due to an opposing action of flexor muscles of the forearm. As a result, the extensor muscles in the posterior compartment remain paralyzed.

Prolotherapy, also called proliferation therapy is an injection-based treatment used in chronic musculoskeletal conditions. It has been characterised as an alternative medicine practice.

Flexor carpi ulnaris muscle

The flexor carpi ulnaris (FCU) is a muscle of the forearm that flexes and adducts at the wrist joint.

Lateral epicondyle of the humerus Structure of humerus

The lateral epicondyle of the humerus is a large, tuberculated eminence, curved a little forward, and giving attachment to the radial collateral ligament of the elbow joint, and to a tendon common to the origin of the supinator and some of the extensor muscles. Specifically, these extensor muscles include the anconeus muscle, the supinator, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. In birds, where the arm is somewhat rotated compared to other tetrapods, it is termed dorsal epicondyle of the humerus. In comparative anatomy, the term ectepicondyle is sometimes used.

The pronator teres is a muscle that, along with the pronator quadratus, serves to pronate the forearm. It has two attachments, to the medial humeral supracondylar ridge and the ulnar tuberosity, and inserts near the middle of the radius.

Golfers elbow Tendon inflammation disease of the elbow

Golfer's elbow, or medial epicondylitis, is tendinosis of the medial epicondyle on the inside of the elbow. It is in some ways similar to tennis elbow, which affects the outside at the lateral epicondyle.

The common extensor tendon is a tendon that attaches to the lateral epicondyle of the humerus.

Extracorporeal shockwave therapy

Extracorporeal shockwave therapy (ESWT) is a treatment mostly used to treat kidney stones and in physical therapy and orthopedics.

The posterior compartment of the forearm contains twelve muscles which are chiefly responsible for extension of the wrist and digits, and supination of the forearm. It is separated from the anterior compartment by the interosseous membrane between the radius and ulna.

Radial tunnel syndrome Medical condition

Radial tunnel syndrome (RTS) is caused by increased pressure on the radial nerve as it travels from the upper arm to the hand and wrist.

Elbow Joint between the upper and lower parts of the arm

The elbow is the visible joint between the upper and lower parts of the arm. It includes prominent landmarks such as the olecranon, the elbow pit, the lateral and medial epicondyles, and the elbow joint. The elbow joint is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm which allows the forearm and hand to be moved towards and away from the body.

Cozen's test is a physical examination performed to evaluate for lateral epicondylitis or, tennis elbow. The test is said to be positive if a resisted wrist extension triggers pain to the lateral aspect of the elbow owing to stress placed upon the tendon of the extensor carpi radialis brevis muscle. The test is performed with extended elbow. NOTE: With elbow flexed the extensor carpi radialis longus is in a shortened position as its origin is the lateral suracondylar ridge of the humerus. To rule out the ECRB, repeat the test with the elbow in full extension.

Median nerve palsy Medical condition

Injuries to the arm, forearm or wrist area can lead to various nerve disorders. One such disorder is median nerve palsy. The median nerve controls the majority of the muscles in the forearm. It controls abduction of the thumb, flexion of hand at wrist, flexion of digital phalanx of the fingers, is the sensory nerve for the first three fingers, etc. Because of this major role of the median nerve, it is also called the eye of the hand. If the median nerve is damaged, the ability to abduct and oppose the thumb may be lost due to paralysis of the thenar muscles. Various other symptoms can occur which may be repaired through surgery and tendon transfers. Tendon transfers have been very successful in restoring motor function and improving functional outcomes in patients with median nerve palsy.

Muscle imbalance Medical condition

Muscle imbalance can be described as the respective equality between the antagonist and agonist, this balance is necessary for normal muscle movement and roles. Muscular imbalance can also be explained in the scenario where the muscle performs outside of normal physiological muscle function.

Muscle strain is one of the most common injuries in tennis. When an isolated large-energy appears during the muscle contraction and at the same time, bodyweight applies huge amounts of pressure to the lengthened muscle, which can result in the occurrence of muscle strain. Inflammation and bleeding are triggered when muscle strain occur which resulted in redness, pain and swelling. Overuse is also common in tennis players from all levels. Muscle, cartilage, nerves, bursae, ligaments and tendons may be damaged from overuse. The repetitive use of a particular muscle without time for repair and recover in the most common case among the injury.


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