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Save Yourself from Tennis Elbow!

Not just for tennis players, straight-talking advice on healing from this common tendinitis (lateral epicondylitis)

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

Tennis elbow is a classic repetitive strain injury (RSI): a combination of chronic exhaustion and irritation in the muscles and tendons on the back of the arm and the outside of the elbow, which lift (extend) the wrist and fingers. Hotter, sharper pain right at the elbow probably indicates a classic case dominated by tendon trouble. Duller, more aching pain, spread more evenly around the back of the arm, usually suggests a more muscle-y case of tennis elbow — an idea that most articles neglect. Cases dominated by muscle pain may be much more treatable.

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The muscles of the back of the forearm gather into a single tendon. In tennis elbow, both the tendon and the muscles themselves may be the source of pain.

This is a surprisingly controversial condition. A 1999 scientific paper in the Journal of Shoulder And Elbow Surgery asks “Is there any science out there?” The authors pointed out that “all but one” study of tennis elbow had failed to find the inflammation that supposedly exists in the condition, and complain bitterly that, “Numerous nonoperative modalities have been described for the treatment of lateral tennis elbow. Most are lacking in sound scientific rationale.”1

When a lot of remedies are suggested for a disease, that means it can’t be cured.

Anton Chekhov, The Cherry Orchard

The science of conditions like this is generally much more of a mess than you might think. Although the situation is improving, and a fair bit more tennis elbow research has been done, it is still a surprisingly difficult, mysterious, and interesting condition — involving more mind and muscle than anyone suspects.

“Tennis” elbow

Obviously, this condition earned its name because whacking tennis balls around a lot was the original main cause, but these days it is much more commonly caused by computer usage. And heavy computer users outnumber serious tennis players at least a thousand to one.

Today, this condition would be better called “computer elbow.”

Reader John S. tells me he has “a minor case caused by screwing caps on beer bottles!” Home brew hazard!

You may have also heard of “golfer’s elbow,” which is exactly the same thing except that it affects the muscles and tendons that flex the wrist instead of extending it (on the inside of the elbow, instead of the outside). Computer users do not usually get this kind of elbow pain: golfers are still the most afflicted on that side of the elbow. Nevertheless, the conditions are extremely similar despite living on different sides of the elbow; anything I say about tennis elbow probably applies to golfer’s elbow, unless I mention otherwise.

There’s more trouble with labels.

Tennis elbow is not exactly a tendinitis

Tennis elbow is widely regarded as a tendinitis, meaning “tendon inflammation,” but it’s become increasingly clear to experts over the years that there is really no such thing as inflamed tendons — at least, not beyond the early stages2 — and so the name tendinitis doesn’t really make much sense. And the difference matters. Anti-inflamatory treatments are the popular first-line of defense against alleged tendinitises, which would make a lot more sense if the tendon were really inflamed. But it isn’t — not really — and so the most popular treatment has a major problem.

Instead of thinking of tennis elbow as a tendinitis, you should think of it as a “tendinopathy” which is Latin for “something wrong with a tendon.”

Tendinopathy is a deliberately broad term, used because we really don’t know what’s going on. According to a 2008 scientific paper by Andres et al, tendinopathy refers to “any painful condition occurring in and around tendons in response to overuse.” They also explain that “recent basic science research suggests little or no inflammation is present in these conditions.”3

For instance, in plantar fasciitis — think “foot tendinitis” — the tissue is not actually inflamed. Inflammation is only present in the early, acute stages of tendinitis.4 Instead it shows signs of connective tissue degeneration.56).

All of this goes a long way to explaining why your standard regimen of icing and ibuprofen doesn’t exactly work miracles with tennis elbow. But anti-inflammatory drugs may be useful as minor symptom control methods, and ice has some potential as a tissue stimulant (as opposed to fire-extinguisher) — more on this below.

Diagnosis: how do I know I’ve got tennis elbow?

Most elbow pain without any other obvious explanation is either tennis or golfer’s elbow, especially if you’ve been working at the computer a lot (or playing a lot of tennis or golf). Tissues right around and below the bony projection on the side of your elbow will be tender. The muscles on the back of the arm, if you dig into them, will also be tender — in fact, you may be amazed at how sore they are.

Long days at the keyboard will generally make it worse, but those stresses are happening in slow motion and it may not be obvious that typing and mousing are a problem. Whacking a ball with a racquet, on the other hand, yanks hard on the extensor muscles and their tendons — and that hurts, if you have tennis elbow. Whacking a ball with a racquet yanks hard on the extensor muscles and their tendons — and that hurts, if you have tennis elbow. Computer users can almost immediately confirm a tennis elbow diagnosis just by trying to hit a ball around a few times. Give it a try! Or swing a golf club, to test for golfer’s elbow — of course. (I didn’t really need to spell that out, did I?) It may be a little inconvenient to find an opportunity to test your elbow this way, but it’s a really reliable method.

There’s a more convenient test (although somewhat less reliable). The classic simple test for any tendinitis is to simply pull firmly on the tendon. In the case of tennis elbow, this means resisted extension from flexion. Flex the wrist, hold it in place, and then try to straighten it. It’s easy to do this against a wall. Specifically: if you sharply flex your wrist against the wall, and then try to straighten it, and it hurts quite a bit, you probably have got a case of tennis elbow. (Do the same test with the wrist bent the other way to test for Golfer’s elbow.) So this kind of test is easy, but it often won’t confirm a case that is dominated by muscle pain.

What’s the worst case scenario for tennis elbow?

If you depend heavily on your arms for intensive computer work, tennis elbow can be a major problem. (Of course, if you’re really serious about your racquet sports or golf, that’s also a major issue.) Although the pain rarely progresses to harsh intensities, its persistence can change lives by forcing career changes. Like carpal tunnel syndrome, some people simply give up trying to make a living with a keyboard. But there is hope, and most of those people probably shouldn’t quit their jobs — there are treatment options that, while hardly guaranteed to work, are worthwhile and often neglected.

For most people, the condition is usually just an annoyance for a while. It’s the minority of stubborn cases that make the condition notorious.

What can I do about tennis elbow?

There are plenty of non-surgical treatments out there for tennis elbow (lateral epicondylitis) — all of them are reported as having good results, yet none of them is any better than placebo.

Dr. Skeptic, Tennis elbow treatment: perception versus reality

Tennis elbow may respond well to some simple and inexpensive treatment methods. On the other hand, it’s not clear that any of them is anything more than an effective placebo.

Rest — Rest is your first line of defense against this condition. People find it persistent mainly because they don’t take the problem seriously enough. Even a minor injury like this will not just magically go away if you keep doing whatever irritated the forearm muscles and tendons in the first place. A week of resting the arm as much as possible is often enough to make a significant difference.

Exercise — Although resting is initially critical, a careful balance of rest and a variety of exercise is the basic formula for recovery from most RSIs. Nothing in biology seems to recover without a little stimulation — you just have to beware of overdoing it. Gradually and progressively train the flexor muscles and tendons to tolerate exercise again. Chances are good that you will need to go more slowly than you think; these conditions rarely change quickly. Mobilizations and stretching (next up) are good examples of easy, intermediate exercises — ways to start exercising without over-stimulating. But eventually you want to work up to working out with, say, spring-loaded hand grips … and then tennis, of course (even if you’re not a tennis player). At all stages, though, you start with small doses, and the need to give plenty of rest (recovery time) is crucial throughout. It’s never just exercise, and never just rest, but a long term balancing act between them.

Stretching and mobilizing — Although stretching is over-rated as a general tonic (see Quite a Stretch), it can be useful for specific therapy like this. Muscle trigger points (muscle knots) occasionally respond well to stretch (see Stretching for Trigger Points), and in my experience it’s a little more likely to work out in this muscle group. Since trigger points are almost always a factor in tennis elbow, I always recommend stretching for this condition. It is tricky to fully stretch the muscles involved in tennis elbow, but you can do it like this: while standing, with your arm in front of you, place the back of your hand against a wall with the fingers pointed out to the side, straighten your elbow, and then press into the wall so that your wrist is flexed sharply. Hold for a minute. Be cautious: do not stretch too hard, and release the stretch gradually, over several seconds at least.

I also recommend mobilizing (see Mobilize!), which is basically just rhythmically stretching the wrists one way and then the other: more stimulating and neurologically interesting than simple static stretching alone. To mobilize your forearms:

Photograph of an ice cube, isolated on white, representing cryotherapy.

Isometric contraction for pain relief. A small 2015 test showed a surprisingly robust pain-relief effect from briefly “clenching”:7 tensing the muscles on the back of the forearm without the wrist, basically just putting the tendon under strong tension for about a minute. The pain reduction was substantial and lasted for at least 45 minutes. It may be one of the best pain-control strategies, and a good alternative to medication. For tennis elbow, you want to pull on the common extensor tendon of the forearm. Probably the easiest way to do that is just to hold the hand firmly in a neutral position (with the other hand), and then attempted extend the hand (bend the wrist backwards). Start with a moderate intensity for about one minute, and tinker with the intensity and duration to see what works best for you.

Icing — Tendinitis supposedly hurts because of the “inflammation,” but as explained above inflammation is actually limited or missing entirely in chronic cases. In acute (fresh) cases, or serious flare-ups of a chronic condition, ice might actually control inflammation and potentially retard progression of the condition — a genuine biological benefit, as opposed to just a bit of pain control — but unfortunately no one knows if it actually works.

As a treatment for chronic cases, ice has a different and potentially more valuable role: it’s a way of strongly stimulating tissue without stressing it. This may help healing, and will do no harm — as long as you are careful to avoid “burning” your skin (frostbite). Never apply ice directly for more than a minute or two at a time. Icing many times per day may be therapetic. This treatment is not based on any evidence, however8 — it’s just a reasonable theory. For (much) more information, see Icing for Injuries, Tendinitis, and Inflammation.

Cases dominated by muscle pain will usually not respond to icing, and may even be aggravated by it — although that risk is probably quite low.

Contrast hydrotherapy — Contrasting is the alternating application of heat and cold to the area. This dramatically increases circulation to the entire arm and hand. Like icing, this is stressless tissue stimulation, but with a much greater impact on circulation in particular. Like icing, there’s no direct evidence that this actually works, but it’s a solid theory — and, done right, it is actually extremely pleasant! Obviously, please don’t burn yourself with too-hot water. By far the most convenient method of doing this is in a double-sink: one filled with cold water, the other with hot water. For more information about contrasting, see Contrast Hydrotherapy.

Self-massage — Your forearm is an easy body part to reach for self-massage! Tennis elbow is probably always aggravated by muscle tension in the forearms, regardless of whether muscle strain is part of the condition or not. It is often helpful to do some simple massage: firm, long, lubricated strokes from hand to elbow on the back of the arm. Be firm but not brutal. Visualize the muscles like a sponge full of dirty water that you are squeezing out! See Massage Therapy for Tennis Elbow and Wrist Pain, which explains exactly where the worst trigger points in the arm usually form.

A muscle in the neck, the anterior scalene muscle, is also known to have a surprisingly strong relationship with trigger points in your forearm muscles.9 Self-massage of this muscle is not particularly easy, but probably worth learning: see Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain for more information.

Friction massage — Like all tendinitises, tennis elbow may respond well to a specific massage technique called “friction massage.” Rub back and forth over the tendon (across it) gently with your thumb or finger pads until the sensitivity fades, which should take no more than a minute or two, and then increase the intensity slightly and repeat. If the intensity doesn’t ease, discontinue. Deep Friction Massage Therapy for Tendonitis.

Ergonomic adjustments — If you use a computer heavily, you may wish to invest in some improvements to your computer workstation to aid in healing from “computer elbow”.

Keyboards are straightforward, as there is really only one important thing to know: don’t lift the back of your keyboard. This is a bizarre anachronism that exists only because early keyboard manufacturers wanted computer keyboards to seem more like typewriter keyboards (i.e. steep). However, the ergonomic problem with this is significant. An elevated keyboard forces you to keep the wrists “cocked” into extension, holding all of the extensor muscles of the forearm in contraction. This is Very, Very Bad, and severely aggravates computer elbow situations. Avoid it at all costs. Mitigate it with a gel wrist pad (to lift the heel of the hand).

In my opinion, the type of mouse you use is a relatively minor factor in repetitive strain injuries,10 and consequently manufacturers have not responded with “ergonomic” mouse features in default designs. However, I certainly recommend choosing a mouse you like — one that seems comfortable to you, and does not annoy you with any design quirks. Wirelessness is a particularly good, basic feature for almost everyone. (And quite common now! Not so when I first wrote about this a decade ago.)

Although wirelessness is not advertised as an ergonomic feature, it is actually the best ergonomic feature there is for mice. First of all, understand that even relatively minor issues with computer use are amplified amazingly by the hours we spend on them. So although it may sound a bit silly, believe me when I tell you that even the slight tension of a mouse cord folding or snagging results in us failing to move the mouse freely to where we would be more comfortable, or constantly try to adjust for the sake of the cord, rather than for our own sake.

One woman’s “ergonomic” mouse is another’s hand torture device!

And we even fail to adjust when the cord outright snags! We get focussed on our work and simply put up with the cord being caught under a book or the corner of the keyboard. It’s not that the mouse is necessarily stuck in a “bad” position, but we aren’t free to move it to a better one. By contrast, wireless mice are surprisingly liberating. If your arm is getting uncomfortable using the mouse in one position, you can simply adjust.

For the same reason, I recommend basically the best quality mouse, which is laser these days.

Mouse shape and button design are pretty trivial factors. Basically, comfort is all you’re looking for, and people’s hand shapes and usage patterns are so different that one woman’s “ergonomic” mouse is another’s hand torture device.

Surgery for tennis elbow

If you went looking, you’d have no problem finding studies that make surgery for tennis elbow sound like a great deal. You don’t even have to go looking, because I’ll share a couple examples: in a classic 1961 article, the late, great British surgeon RS Garden reported that “no patient failed to benefit in some way from the operation.”11 Decades later, a modern paper reports 78 of 80 surgery patients had “improved clinical outcome at both short- and medium-term follow-ups with few complications.”12 But these studies did not compare surgery to a placebo — a common problem with surgical research.13

There’s only one (unpublished) study comparing real surgery to a fake surgery, from 2012, by Dr. Martin Kroslak.14 It was small pilot study, but the results were completely disappointing — hardly what you’d expect if surgery was really effective.

Eleven patients were treated with the Nirschl technique (surgical excision of the macroscopically degenerated portion of ECRB), and 11 received a sham operation: a skin incision, exposing the tendon. Both groups improved equally: “The only difference observed between the groups was that patients who underwent the Nirschl procedure for tennis elbow had significantly more pain with activity at 2 weeks.” Kroslak scathingly concludes:

There is no benefit to be gained from the gold standard tennis elbow surgery over placebo surgery in the management of chronic lateral epicondylitis. In fact, the Nirschl procedure may increase the morbidity of the condition in the immediate post-operative period.

If everyone generally got better, isn’t that a good thing? Quite the opposite: it means the benefit was pure placebo, and it didn’t matter what kind of surgery was done as long as the patient believed they were getting a powerful treatment.

Food for thought, isn’t it?

Shock wave therapy for tennis elbow

Extracorporeal shock wave therapy (ESWT) is the more expensive, intense, and high-tech and over-hyped cousin of regular ultrasound. ESWT uses much stronger sound waves — shock waves! Treatment is painfully intense and painfully pricey, though it would probably be worthwhile if it worked.

On the one hand, ESWT is just a “more is better” version of standard ultrasound, because it is often used with the same imprecise clinical intention to stimulate/provoke tissues. On the other hand, because it was originally developed for smashing gall stones, ESWT is strong enough to actually disrupt tissue, such as, say, calcifications in tendons — which is a nice precise clinical goal and a whole different kettle of fish. And there is evidence that it can be effective in exactly that circumstance: if your tendons are calcifying.

Unfortunately, the evidence strongly suggests that it just doesn’t seem to work for most tendinitis, probably because there’s not much calcifying going on.

This was settled quite a while ago. A biggish review in 2006 of nine studies produced “platinum” level (better than gold!) evidence that “ESWT provides little or no benefit in terms of pain and function in lateral elbow pain.”15 That’s right: platinum negative evidence. Nothing important has changed since. ESWT simply does not work for the average case of tennis elbow. sad trombone


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and assistant editor of ScienceBasedMedicine.org. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

What’s new in this article?

Isometric contraction for pain control.

ESWT ultrasound.

General editing and more details throughout first half. New section about exercise. Improved description of forearm mobilizations.

Traffic to this article has increased sharply, so I gave it some love: a thorough general upgrade. I particularly clarified icing rationale and diagnosis.

Added surgery section with fascinating results of placebo surgery.

Corrected some typographic errors.

Notes

  1. Boyer MI, Hastings H2. Lateral tennis elbow: "Is there any science out there?". Journal of Shoulder And Elbow Surgery. 1999;8(5):481–491. BACK TO TEXT
  2. Millar NL, Hueber AJ, Reilly JH, et al. Inflammation Is Present in Early Human Tendinopathy. Am J Sports Med. 2010 Jul. PubMed #20595553. BACK TO TEXT
  3. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008;466(7):1539–1554. BACK TO TEXT
  4. Millar NL, Hueber AJ, Reilly JH, et al. Inflammation Is Present in Early Human Tendinopathy. Am J Sports Med. 2010 Jul. PubMed #20595553. BACK TO TEXT
  5. Khan KM, Cook JL, Taunton JE, Bonar F. Overuse tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical problem (part 1). Phys Sportsmed. 2000;28(5):38–48. PubMed #20086639. BACK TO TEXT
  6. Young CS, Rutherford DS, Niedfeldt MW. Treatment of Plantar Fasciitis. Am Fam Physician. 2001 Feb 1;63:467–74. PainSci #56910. Such degeneration is “similar to the chronic necrosis of tendonosis, which features loss of collagen continuity, increases in ground substance (matrix of connective tissue) and vascularity, and the presence of fibroblasts rather than the inflamatory cells usually seen with the acute inflammation of tendonitis.” BACK TO TEXT
  7. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015 Oct;49(19):1277–83. PubMed #25979840. PainSci #54162. This was a study of patellar tendinopathy, not tennis elbow, but it’s true of patellar tendinopathy, it’s probably true of other tendinopathies as well. BACK TO TEXT
  8. Collins NC. Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? Emerg Med J. 2008 Feb;25(2):65–8. PubMed #18212134.

    This is a 2008 review of just 6 studies of therapeutic icing, only two of them any good: one with slightly positive results, the other showing no effect. So that’s two studies that showed little or no benefit, which is leaning towards bad news, but it’s just not enough data to clinch it. (Four animal studies showed reduced swelling, but we can’t take animal studies to the bank.) The bottom line is just that “there is insufficient evidence.”

    <#comments#> BACK TO TEXT
  9. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999. The ultimate myofascial pain syndrome reference, the product of decades of extraordinary dedication by two doctors famously devoted to the subject of soft tissue pain. The two-volume set is also brilliantly illustrated. The introductory chapters constitute an excellent overview of the subject, albeit a dauntingly technical one. Note: although a landmark and important text, more recent information has been published in Muscle Pain: Understanding its nature, diagnosis and treatment by Siegfried Mense and David Simons. Volume 1, p513. “Scalene muscle trigger points are frequently the key to [treatment of] forearm extensor digitorum trigger points.” BACK TO TEXT
  10. That’s not to say it isn’t a factor at all, just one of the lesser variables in the equation. Citation needed, yes, I know, I know! It’s on the to-do list, but meanwhile: there are several other ergonomic factors that are probably a bigger deal. BACK TO TEXT
  11. Garden RS. Tennis Elbow. J Bone Joint Surg Br. 1961. PainSci #54538. BACK TO TEXT
  12. Solheim E, Hegna J, Øyen J. Extensor tendon release in tennis elbow: results and prognostic factors in 80 elbows. Knee Surg Sports Traumatol Arthrosc. 2011 Jun;19(6):1023–7. PubMed #21409461. PainSci #54539. BACK TO TEXT
  13. Doctorskeptic.blogspot.ca [Internet]. Skeptic D. Doctor Skeptic: Why placebo surgery is ethical, and necessary; 2012 Nov 29 [cited 14 Sep 23].

    Placebo surgery: necessary, ethical? Yes! Here’s a fine short post on this topic from Doctor Skeptic (doctorskeptic.blogspot.com.au). You “need a placebo [surgery] trial when the outcomes are ‘soft’ (subjective: pain).” I’ve been arguing this for many, many years. We really need to compare surgeries for pain problems to shams, because, by golly, that method sure does reveal some useless surgeries. One of the best examples of why is Moseley’s fascinating 2002 knee trial.

    BACK TO TEXT
  14. Kroslak M. Surgical treatment of lateral epicondylitis: A prospective, randomised, blinded, placebo controlled pilot study. Unpublished. 2012 Nov. PainSci #54536. BACK TO TEXT
  15. Buchbinder R, Green SE, Youd JM, et al. Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. J Rheumatol. 2006 Jul;33(7):1351–63. PubMed #16821270. BACK TO TEXT