Epicondylitis (tennis elbow)

Synonyms

• Lateral epicondylitis
• Epicondylopathy

What is the difference between epicondylitis and epicondylopathy?

Epicondylitis and epicondylopathy often refer to the same pain on the outer side of the elbow, without indicating whether inflammation is present. This pain affects the tendons, the structures that connect muscles to bones. The term tendinopathy describes persistent pain in the tendon and difficulty using it when it is under strain.¹

Inflammation is the body’s defense and repair response. Persistent tendon pain is not always accompanied by the typical inflammatory response following a recent injury. More detailed studies have detected inflammatory cells in certain tendons and suggest that the underlying mechanisms may be more subtle. The presence or absence of pain is therefore not sufficient to settle this question.^{2, 3}

The term “tendinitis” suggests inflammation of the tendon. The term “tendinopathy” is more general: it does not imply a specific mechanism. The choice of treatment is based on your symptoms, your functional abilities, and the physical examination, rather than on this difference in terminology alone.

In this article, the term “epicondylitis” refers to pain in the tendons on the outside of the elbow. It does not mean that all elbow pain has the same cause.

What is epicondylitis of the elbow?

Elbow epicondylitis is pain in the tendons on the outer side of the elbow—the tendons of the muscles that lift the wrist and fingers. It can make it difficult to use the hand.

A model proposed by Cook and Purdam describes the different stages a tendon goes through when subjected to repeated stress. It ranges from a reaction to an unusual load to a more lasting disruption of the tendon’s structure. This model helps guide treatment decisions; it does not prove that everyone goes through the same stages.⁴

What is a tendon?

A tendon is the structure that attaches a muscle to a bone. When a muscle contracts, it pulls on its tendon, and the tendon transmits that force to the bone to move it. The epicondylar tendons are the tendons of the muscles that allow the wrist and fingers to be raised upward.

When the tendons on the inner side of the elbow are affected, the condition is calledepitrochleitis, a related condition described in detail in our comprehensive guide. Why is it called “tennis elbow”?

Epicondylitis is commonly known as “tennis elbow” because it particularly affects people who play tennis. The motions involved in playing tennis place repeated strain on the tendons of the elbow.

However, you don’t have to play tennis to develop this pain. People who do manual labor or perform repetitive arm movements may also be affected.⁵

What are the causes of epicondylitis of the elbow?

Repetitive strain or an unusual increase in activity can contribute to epicondylitis of the elbow. The exact cause is often difficult to determine in an individual. Changes in the tendon, muscle use, and pain sensitivity can all play a role.⁵

In particular, the elbow may be subjected to increased strain due to:

• Repetitive movements of the wrist or elbow
• Overuse of the elbow muscles (for example, after taking up a new sport or activity)

Elbow pain that resembles epicondylitis may be caused by something else, such as inflammatory arthritis, a condition that causes inflammation in the joints (learn more about inflammatory pain). This is one reason to have your condition evaluated.

The muscles of the arm and shoulder may also lack strength or control. A physical therapist can assess these abilities and recommend exercises as needed. The fact that a problem is observed does not prove that it caused the pain.⁵

What changes in physical activity can put more strain on the elbow?

• Spending much more time at the computer than usual, using the mouse or keyboard a lot
• Doing renovations all day without being used to it, doing a lot of painting, hammering, or using a screwdriver
• Starting your tennis or badminton season by increasing the duration or intensity of your sessions too quickly

Could this kind of pain be caused by a nerve?

A problem with the radial nerve—a nerve that runs through the upper arm and forearm—can also cause pain in this area. Some forms of this condition are difficult to distinguish from epicondylitis.⁶See our article on arm neuralgia to learn more.

What are the symptoms of epicondylitis of the elbow?

Symptoms of epicondylitis include pain on the outside of the elbow—which may extend to the forearm—and difficulty grasping objects. The pain often develops gradually.

The most common symptoms are:

• Specific pain on the outside of the elbow that has appeared gradually
• The pain may radiate down the forearm and even to the wrist and fingers
• Weakness and pain when picking up objects (picking up a pot, a coffee cup, a grocery bag)

Pain that radiates toward the shoulder or numbness in the hand also warrants an examination of the nerves and the neck. Brachial neuralgia—pain associated with a nerve—is a possibility; however, these symptoms alone are not enough to confirm it. Learn more about brachial neuralgia.

How is epicondylitis of the elbow diagnosed?

The healthcare professional diagnoses epicondylitis based on the patient’s description of symptoms and an examination of the elbow. In particular, the healthcare professional checks for pain on pressure, wrist movement, and hand strength.

Imaging tests aren’t always necessary. They can be helpful when symptoms persist despite first aid, to look for another cause, or to better pinpoint the problem. An X-ray mainly shows the bones; an ultrasound uses ultrasonic waves—sounds that the human ear cannot hear—to examine tendons, among other things. The results are best understood in the context of the examination, because an image alone cannot measure your pain.⁵

When should I see a physiotherapist for epicondylitis of the elbow?

A physical therapy appointment is recommended when elbow pain interferes with your daily activities, persists, or recurs. The physical therapist will assess your symptoms and may refer you to a doctor if another cause is suspected.

Epicondylitis may improve over time, but symptoms can persist or recur and lead to time off work. The course of the condition varies from person to person.⁵

You can see a physical therapist directly at a private clinic in Quebec without a doctor's prescription. However, some insurance plans may require a prescription for reimbursement.⁷

Which symptoms require urgent medical attention?

Arm pain that occurs during physical activity and goes away with rest requires urgent medical attention. The same applies to a swollen arm accompanied by a high fever or sensations of heat, cold, or chills.

Seek care at an urgent care center or the emergency room if your arm is very painful and difficult to move, if an injury is accompanied by a cracking sound or deformity, or if your arm tingles or becomes numb.

Call 911 if you experience sudden arm pain accompanied by pressure, heaviness, or tightness in your chest. Do not wait for a physical therapy appointment.⁸

What are the physiotherapy treatments for epicondylitis of the elbow?

Physical therapy treatments for epicondylitis include progressive exercises, guided movements assisted by the therapist’s hands, and advice on how to adapt your activities. The specific treatment plan depends on the results of your evaluation and your response to treatment.

Your physical therapist will assess the following to understand your difficulties:

• The possible ranges of motion in your joints
• How your nerves respond to arm movements, if your symptoms warrant it
• The quality of your movements
• Your strength and your ability to control your arm during exercise

Based on the assessment results, your physiotherapist will:

• - Will help mobilize your elbow to reduce pain and improve your range of motion - Will provide you with specific exercises to retrain your control over elbow and wrist movements - Will provide you with exercises to restore mobility, reduce pain, and regain muscle strength. - Will teach you how to properly balance your daily activities and leisure pursuits to optimize healing - Will provide advice on your posture and movement. Since eccentric training is the gold standard for tendons, we teach an eccentric elbow strengthening exercise with progressive resistance. This will help mobilize your elbow—that is, move it using your hands—to relieve pain and make it easier to use your hand.
• It will provide you with specific exercises to improve control of elbow and wrist movements
• Give you exercises to regain mobility, reduce pain and regain your muscle strength.
• This will help you adjust the duration, intensity, and breaks in your activities so you can gradually resume your routine
• Give you advice for your posture and movements.

The exercises primarily target the muscles that lift the wrist. They may involve holding a resistance without moving, lifting the wrist against resistance, or slowly lowering it while holding it in place. The 2022 guidelines recommend these strengthening exercises for persistent symptoms, adjusting the intensity according to the individual’s tolerance.⁵

Elbow mobilization techniques can reduce pain and improve pain-free grip strength in the short term. They can be used in conjunction with exercises or on their own, depending on your needs and tolerance. The program can also address shoulder issues if an examination reveals any problems there.⁵

What do studies on injections show?

A 2010 review supports temporary relief with cortisone, while a 2013 trial found no benefit of platelet-rich plasma (PRP) for pain compared with a saline injection at three months.

Cortisone is a medication that reduces inflammation and can be injected near the tendon. A 2010 review found short-term pain relief for epicondylitis. When compared to no intervention, this benefit was subsequently reversed in the medium and long term. The immediate benefit should therefore be discussed with a doctor, taking this trend into account.⁹

Platelet-rich plasma (PRP) is a blood-derived preparation concentrated in platelets, which are cell fragments that help stop bleeding. In a study of 60 people with persistent epicondylitis, a PRP injection did not provide any more pain relief at three months than a saline injection used as a comparison. At one month, cortisone provided greater relief than both of these injections; this advantage in terms of pain relief was no longer evident at three months.¹⁰

What to do at home for elbow epicondylitis?

Home care involves temporarily limiting activities that are too painful, and then gradually resuming them. Reducing activity does not mean completely immobilizing the arm.

When sleeping, try to keep your arm at your side or propped up on a pillow. Avoid placing your arm behind your head or under the pillow if that increases your pain. Choose a position that's comfortable for you.

Here are some other tips that may help relieve the pain:

• A wristband worn on the forearm, a few centimeters below the elbow, can relieve pain during physical activity. Keep wearing it only if it is comfortable and helpful. A 2020 review suggested a benefit during follow-up periods of less than six weeks and in people under 45, but its estimates did not confirm this benefit over other treatments. In the longer term, the results tended to favor physical therapy interventions, with outcomes varying depending on the comparisons.^{11, 5}
• Try lifting your shoulder slightly before lifting a light load. Only keep this adjustment if it reduces your pain; it isn't necessarily suitable for everyone.

If home remedies don’t help or if the pain returns, see a physical therapist. However, the urgent signs described above require immediate medical attention.

Sources

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1. Scott A, Squier K, Alfredson H, Bahr R, Cook JL, Coombes B, et al. ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. Br J Sports Med. 2020;54(5):260-262. (Back to section: 1)
2. Ashe MC, McCauley T, Khan KM. Tendinopathies of the upper extremity: a paradigm shift. J Hand Ther. 2004;17(3):329-34. (Back to section: 1)
3. Fredberg U, Stengaard-Pedersen K. Tissue pathology, pain mechanisms, and etiology of chronic tendinopathy, with a special focus on inflammation. Scand J Med Sci Sports. 2008;18(1):3-15. (Back to section: 1)
4. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-16. (Back to section: 1)
5. Lucado AM, Day JM, Vincent JI, MacDermid JC, Fedorczyk J, Grewal R, et al. Lateral Elbow Pain and Muscle Function Impairments. J Orthop Sports Phys Ther. 2022;52(12):CPG1-CPG111. (Back to sections: 1, 2, 3, 4, 5, 6, 7, 8)
6. Ang GG, Bolzonello DG, Johnstone BR. Radial Tunnel Syndrome: Case Report and Comprehensive Critical Review of a Compression Neuropathy Surrounded by Controversy. Hand (N Y). 2023;18(1_suppl):146S-153S. (Back to section: 1)
7. OPPQ. How does it work? (Back to section 1)
8. nhs.uk. Elbow and arm pain. 2017. (Back to section: 1)
9. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for the management of tendinopathy: a systematic review of randomized controlled trials. Lancet. 2010;376(9754):1751-67. (Back to section: 1)
10. Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625-35. (Back to section: 1)
11. Shahabi S, Bagheri Lankarani K, Heydari ST, Jalali M, Ghahramani S, Kamyab M, et al. The effects of a counterforce brace on pain in subjects with lateral elbow tendinopathy: A systematic review and meta-analysis of randomized controlled trials. Prosthet Orthot Int. 2020;44(5):341-354. (Back to section: 1)
12. Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2016;1(11):391-397.