Tennis and golfer's elbow

What they are

The muscles that bend the wrist back and straighten the fingers all attach by a shared tendon to the bony point on the outside of the elbow. Trouble in that tendon is tennis elbow (lateral epicondylitis). The muscles that bend the wrist forwards and grip attach to the bony point on the inside; trouble there is golfer's elbow (medial epicondylitis).

The cause is not fully understood. The usual explanation is that the tendon has been loaded beyond what it can recover from, leading to a change in its structure known as tendinopathy. There is little true inflammation, which is why anti-inflammatory treatments give only limited or temporary relief.

Despite the names, sport is rarely responsible: tennis accounts for only about 1 in 20 cases of tennis elbow.¹ Both conditions are most common between the ages of 35 and 54.² They are seen more often in people whose work involves heavy lifting, forceful gripping or repetitive movements of the arm,³ but that is an association, and the evidence that such work actually causes them is limited.⁴ Many people can identify no trigger at all.

Symptoms

• Pain and tenderness over the bony point on the outside (tennis) or inside (golfer's) of the elbow, sometimes spreading into the forearm.
• Pain on gripping, lifting with the palm down, shaking hands, wringing a cloth or turning a door handle.
• A weaker grip, because it hurts.

The elbow itself should still bend and straighten fully. Tingling in the ring and little fingers alongside golfer's elbow suggests the nearby ulnar nerve is also irritated; see the guide to cubital tunnel syndrome.

How it is diagnosed

The diagnosis is made from your account and an examination. Scans are not usually needed. An ultrasound or MRI is sometimes arranged if the symptoms are unusual, if they have not settled as expected, or before considering surgery.

How it behaves over time

Both conditions get better by themselves in most people, but slowly. Around 80 to 90 in every 100 people recover within one to two years.² In a trial in which people with tennis elbow were simply given advice and followed up, about 8 in 10 had recovered by a year.¹

Knowing this matters. The aim of treatment is to keep you comfortable and working while the tendon recovers, not to rescue an elbow that is deteriorating.

What helps

Adjust what aggravates it, but keep using the arm

Work out which tasks bring on the pain and alter them: lift with the palm up and the elbow bent, use two hands, take a larger grip on tools, break up repetitive jobs. Complete rest is not helpful.

Exercises

Progressive strengthening and stretching of the forearm muscles, guided by a physiotherapist, helps the tendon adapt. Expect this to take weeks to months, and some discomfort during the exercises is acceptable.

Pain relief

Simple painkillers, or an anti-inflammatory gel rubbed over the sore area, can take the edge off. Some people find a strap worn just below the elbow makes gripping more comfortable.

Injections

Steroid

A steroid injection often gives good relief for a few weeks, but the benefit does not last and the problem is more likely to come back. In a trial of 165 people with tennis elbow, 83 in 100 of those given a steroid injection were recovered or much improved at one year, compared with 96 in 100 given a dummy injection; the condition recurred in 54 in 100 after steroid and 12 in 100 after the dummy injection.⁵ For this reason steroid injections are no longer routinely recommended.

Platelet-rich plasma and blood injections

These use a preparation of your own blood. They are widely offered, but a Cochrane review of the trials concluded that they probably give little or no meaningful benefit over a dummy injection.⁶

Shockwave therapy

Shockwave therapy passes pulses of sound energy through the skin to the sore area. It is often offered when symptoms persist. A Cochrane review of nine trials in over 1,000 people, each comparing it with a sham treatment, found that it gives little or no benefit for pain or function in tennis elbow.⁷

Surgery

An operation to release or remove the affected part of the tendon is sometimes offered when symptoms have lasted more than a year. Most people who have it do improve. The difficulty is knowing whether the operation is the reason.

• No robust trial has shown surgery to be better than non-operative treatment. A systematic review of the randomised trials concluded that it was no more effective than non-surgical or sham treatment.⁸
• In the one trial to compare the standard operation with a placebo, in which the skin was opened but the tendon left alone, both groups improved and there was no difference between them. The trial was small, with 26 patients.⁹

Improvement after surgery may therefore reflect the natural recovery of the condition, or a placebo effect, as much as the operation itself. For these reasons Mr Wright very rarely recommends surgery for tennis or golfer's elbow. Like any operation it carries risks, including infection, a tender scar, stiffness, nerve irritation and persisting pain, and recovery takes about three months.

When to seek further advice