Epicondylitis

Epicondylitis, commonly known as tennis elbow, causes pain on the outside of the elbow due to overuse of forearm muscles. Despite its name, most people who develop this condition don’t play tennis – it affects anyone who performs repetitive gripping or wrist movements.

lateral epicondylitis, tennis elbow

Table of contents

• What is epicondylitis?
• Understanding the elbow anatomy
• What causes epicondylitis?
• Who is most affected?
• Symptoms
• How is it diagnosed?
• Treatment options
• Recovery and outlook

What is epicondylitis?

Epicondylitis is a painful condition that affects the elbow. It develops when the tendons (the strong, cord-like tissues that connect muscles to bones) on the outside of the elbow become damaged from overuse^[1]. The medical term for this condition is lateral epicondylitis, but it’s more commonly known as tennis elbow^[2].

This condition is a form of tendinopathy, which means the tendon has broken down or degenerated over time rather than simply becoming inflamed^[3]. The damage includes microscopic tears in the tendon where it attaches to the bone, leading to pain and tenderness^[2].

Although it’s called tennis elbow, most people who develop this condition don’t actually play tennis. In fact, tennis players make up only about 10% of people with epicondylitis^[3]. The condition can affect anyone who performs repetitive movements with their arm, wrist, or hand.

Understanding the elbow anatomy

• Humerus (upper arm bone)
• Radius (forearm bone)
• Ulna (forearm bone)
• Lateral epicondyle
• Forearm muscles and tendons

The elbow joint connects three bones: the humerus in the upper arm and the radius and ulna in the forearm^[2]. On the outer side of the elbow, there is a small bony bump called the lateral epicondyle. This is where several forearm muscles begin their course^[2].

The muscles that extend your wrist and fingers are attached to the lateral epicondyle through tendons. The tendon most commonly involved in epicondylitis is called the extensor carpi radialis brevis, or ECRB for short^[2]. This muscle helps stabilize your wrist when your elbow is straight, such as during a tennis groundstroke^[2].

What causes epicondylitis?

Epicondylitis develops when the forearm muscles and tendons are damaged from repeating the same motions over and over again^[1]. This repetitive strain causes tiny tears to form in the tendon where it attaches to the lateral epicondyle^[2].

The ECRB tendon may be particularly at risk because of its position. As the elbow bends and straightens, the muscle rubs against bony bumps, which can cause gradual wear and tear over time^[2].

Many different activities can lead to epicondylitis. These include:

• Playing racquet sports like tennis, squash, or badminton^[3]
• Manual work such as painting, plumbing, carpentry, or butchering^[2]
• Computer work, especially extensive typing or mouse use^[4]
• Using tools like screwdrivers or hammers^[4]
• Sewing or other activities involving repetitive hand movements^[4]
• Carrying heavy items like briefcases or shopping bags^[16]

Activities that involve loaded and repeated gripping or wrist extension, along with wrist radial deviation or forearm supination (turning the palm upward), are particularly likely to cause problems^[3]. In some cases, a single sudden injury where excessive strain is applied to the arm can also cause epicondylitis, though this is less common^[5].

Who is most affected?

Epicondylitis is the most common cause of elbow pain in people seeking medical care for elbow symptoms^[3]. The condition affects men and women equally^[3]. About 1 to 3 percent of adults will experience lateral elbow pain in any given year^[3].

Most people who develop epicondylitis are between 35 and 54 years of age, with the condition being more common in individuals over 40^[3][4]. This is because aging tendons are more vulnerable to repetitive stress^[15].

Certain factors increase the risk of developing epicondylitis:

• Regularly lifting objects heavier than 45 pounds (22 kilograms)^[10]
• Smoking^[3][7]
• Obesity^[3][10]
• Repetitive movements for at least two hours daily^[3]
• Vigorous activity involving physical loads over 20 kilograms^[3]
• Playing sports that require repetitive arm twisting or swinging^[10]
• Poor technique or improper equipment in athletes^[3]

Symptoms

The main symptom of epicondylitis is pain on the outside of the elbow^[4]. This pain typically develops gradually over weeks or months, though in some cases it may appear suddenly^[5].

The pain often feels sharp or burning and is usually located just below the bony bump on the outside of the elbow^[5][10]. It can spread down into the forearm and toward the wrist^[1][10].

Common symptoms include:

• Pain that worsens when lifting or bending the arm^[4]
• Increased pain when gripping objects or moving the wrist^[4]
• Discomfort during simple activities like turning a doorknob, holding a coffee cup, or shaking hands^[1][10]
• Weakness in the grip^[10]
• Tenderness or swelling in the elbow area^[4]
• Difficulty fully straightening the arm^[4]
• Pain that may affect sleep at night^[4][10]

The pain is typically worse during activities and may range from mild discomfort to constant severe pain^[4]. Most people develop epicondylitis in their dominant arm – the one they use most often for activities^[10].

How is it diagnosed?

Doctors diagnose epicondylitis primarily through medical history and physical examination^[9][16]. During your visit, the doctor will ask about your symptoms, when they started, what activities make them worse, and whether you have any occupational or recreational risk factors^[9].

During the physical exam, the doctor will typically:

• Press on the outside of your elbow to locate the tender area^[9]
• Ask you to move your elbow, wrist, and fingers in various ways^[9]
• Test your arm strength by having you straighten your wrist or fingers against resistance^[5]

Imaging tests are usually not needed to make the diagnosis^[6][15]. However, your doctor may order X-rays, ultrasound, or magnetic resonance imaging (MRI) if they suspect other conditions or if the diagnosis is unclear^[9]. X-rays can help rule out arthritis or bone problems, while MRI or ultrasound can show the condition of the tendons^[15].

Treatment options

The good news is that epicondylitis usually gets better on its own with rest and conservative care^[4][9]. About 70 to 90 percent of people recover within one to two years, with or without treatment^[3][11].

Self-care at home

The first step in treating epicondylitis is to rest the affected arm and avoid activities that cause pain^[4][16]. Simple self-care measures include:

• Resting the elbow and avoiding activities that make symptoms worse^[4]
• Applying ice wrapped in a towel for 15 to 20 minutes several times a day to reduce pain and swelling^[1][4]
• Taking over-the-counter pain relievers like paracetamol or ibuprofen^[4][8]
• Using anti-inflammatory gels rubbed onto the affected area^[4][8]
• Wearing a forearm strap, wrist brace, or elbow brace to support the injured tendon^[4][9]

Interestingly, wearing a wrist splint can help ease tennis elbow pain more than an elbow splint would. Because the tendon in the elbow connects to the same muscle as tendons in the wrist, keeping the wrist still also gives the elbow a rest^[16].

Exercise and physical therapy

Once the initial severe pain decreases, gentle stretching and strengthening exercises can help^[4][5]. Physical therapy typically includes exercises that stretch and strengthen the wrist and forearm muscles^[4][9].

A specific technique called eccentric strengthening has been found particularly helpful. These exercises strengthen the muscle as it lengthens and have been shown to improve long-term pain symptoms^[6][8].

Physical therapy may also include massage, ultrasound therapy (where high-frequency sound waves increase blood flow to reduce pain and speed healing), and other techniques^[4].

Medical treatments

If self-care measures don’t provide enough relief after several weeks, your doctor may recommend additional treatments:

• Corticosteroid injections: These shots can provide short-term pain relief, though the pain may return after a few weeks to months^[5][8][9]
• Platelet-rich plasma injections: This treatment uses components from your own blood to promote healing^[9][11]
• Dry needling: A needle gently pierces the damaged tendon in multiple places^[9]
• Iontophoresis: This uses a mild electrical current to deliver anti-inflammatory medication through the skin^[8]

Surgery

Surgery is considered only for people who still have disabling pain after 6 to 12 months of conservative treatment^[6][9]. Surgical options include open surgery or arthroscopic surgery (using small incisions and a camera)^[15].

During surgery, the damaged portion of the tendon can be removed, or a small chip of bone may be taken to increase blood flow to the area and promote healing^[15]. Recovery after surgery typically takes several weeks, followed by physical therapy to restore strength and function^[15].

Recovery and outlook

Most people with epicondylitis get better with conservative treatment and time^[10]. The natural course of the condition is generally favorable, with spontaneous recovery occurring in 80 to 90 percent of patients within one to two years^[3].

However, recovery does require patience. It’s important to know that pain can last for quite some time – sometimes a year or longer – even with treatment^[5]. Using a wrist splint, for example, can take 6 to 12 weeks or longer to relieve pain^[16].

The key to successful recovery is following your treatment plan and not pushing through the pain. Many people can return to work and daily activities while still experiencing some discomfort, as long as the overall trend is toward improvement^[5].

If you’ve been diagnosed with epicondylitis, you should see your doctor if:

• You still have elbow pain after resting and trying self-care treatments for at least 2 weeks^[4]
• Your pain is getting worse^[7]
• You develop fever-like symptoms or notice redness and heat around the elbow^[7]
• Your fingers or arm change color or you experience changes in sensation^[7]
• The condition is significantly affecting your daily activities or work^[5]

With proper care, most people with epicondylitis can expect to return to their normal activities without ongoing problems.