Family doctor

What is it?

Tennis elbow is a painful condition affecting the outside part of the elbow. Its medical term is lateral epicondylitis (the lateral epicondyle being the bony prominence at the outer part of base of the humerus or upper arm bone), and it was first described as long ago as 1873. A similar condition affects the 'medial epicondyle' (the bony prominence at the inner part of the base of the humerus) and is termed 'golfer's elbow'.

What causes tennis and golfer's elbow?

The epicondyles are where the muscles that cause extension and flexion of the forearm originate (as musculotendinous attachments on the bone). The pain of tennis and golfer's elbow is thought to result from tiny (and not-so-tiny) tears of the muscle origins at the junction between muscle and bone, which occur with repetitive overuse of the elbow. There is then only slow healing, which is further delayed by continued use of the forearm. In fact, symptoms are probably related to the poor healing process than to any original injury.

Who gets tennis and golfer's elbow?

These conditions are both related to repetitive overuse of the elbow. Tennis elbow occurs where a strong grip of the extended wrist is involved &endash; as in tennis (especially where there is poor backhand technique) and knitting. Golfer's elbow is related to overuse of the muscles causing flexion of the forearms; it is associated with certain manual or household activities, racquet sports, bowling, and occasionally golf. Both conditions typically affect people aged 35-50 years, and both men and women equally. (Pain at the sites of muscle origin is uncommon in people under 30, probably because the healing ability of the musculotendinous tissues is better below that age.)

How do I know I have it?

As noted above, tennis and golfer's elbow are associated with pain about the outside and inside of the elbow, respectively. Certain tasks produce the pain, such as picking up a cup of coffee (tennis elbow). There is usually tenderness over the lateral epicondyle in tennis elbow (and over the medial epicondyle in golfer's elbow).

What should I do if I think I have tennis or golfer's elbow?

If you're concerned that you may have either of these conditions, you should consult your family doctor, to have the diagnosis confirmed and to commence treatment.

Your doctor will examine the elbow for tenderness over the relevant epicondyle, and try to reproduce the pain by asking you to perform certain tasks (e.g. resisting extension of the wrist). Blood tests are generally unnecessary, and other tests such as ultrasound and x-rays of the area are usually normal.

How are tennis and golfer's elbow treated?

The initial treatment of these conditions is conservative and similar to that of any muscle/tendon injury: rest, ice applications, and compression. A specific wrist and forearm support splint may be helpful in resting the forearm. Such splints differ from 'tennis elbow bands' or straps, which are of limited usefulness.

Painful activity should be avoided (including racquet sports, shaking hands, unscrewing jars, use of a screwdriver and hammering); however, it is important that the range of motion of the elbow and forearm is maintained. Once there is no further pain about the lateral epicondyle, there should be gradual resumption of specific activities to strengthen the affected muscles, for which a course of physiotherapy may be best.

There is some debate about the use of anti-inflammatory drugs in tennis elbow. Non-steroidal anti-inflammatory drugs are often prescribed for this condition, but a recent study in patients with new tennis elbow showed no difference in pain at 4 weeks in the groups given placebo (inactive tablet) or naproxen (a commonly used non-steroidal anti-inflammatory agent).

Occasionally, a local steroid injection into the affected area is used. Whilst many doctors advise reserving such treatment for patients whose tennis (or golfer's) elbow does not resolve with 6-8 weeks of conservative treatment, others have suggested using steroid injections at the outset. In the same study mentioned above, a third group of patients was treated with a steroid injection into the painful area. Patients in this group had significantly less pain at 4 weeks compared to the other two groups. However, by 12 months, over 80% of patients in all three groups had little pain (including those who received no active drug treatment). Thus, whatever drug or treatment is used initially, the long-term outcome is good.

Rarely, surgery to release the muscle origin from the lateral (or medial) epicondyle is performed in patients who have had continuing pain for at least 6 (and preferably 12) months.

Can I prevent tennis or golfer's elbow?

The key to preventing further episodes is to complete a proper course of stretching and strengthening exercises of the affected muscles. If the condition is related to tennis or elbow, an analysis of swing and form by the local professional coach may be of benefit.