INTRODUCTION

Tendons are tough bands of tissue that connect muscles to bones. There are several types of tendon problems (called tendinopathies):

• Repetitive activities and sudden trauma can injure tendons and lead to inflammation, pain, and difficulty using the joint. This is called tendinitis.
• As people age, tendons can break down (degenerate) or even tear; this is called tendinosis. Symptoms of tendinosis usually last more than a few weeks.
• Less commonly, tendon problems can be caused by other conditions, including rheumatic diseases.

Tendinopathies are common problems. The risk of having a tendinopathy increases with age and is greater in people who routinely perform activities that require repetitive movement that increases stress on susceptible tendons.

Treatment of tendinopathy focuses on resting and protecting the injured tendon so that it can heal, inflammation can resolve, and muscle strength can improve. In most people, tendinopathy resolves with little or no treatment.

Tendinopathy can affect many different tendons in the body. Separate articles discuss other types of tendon problems. (See "Patient information: Biceps tendinitis or tendinopathy (Beyond the Basics)" and "Patient information: Rotator cuff tendinitis and tear (Beyond the Basics)".) More detailed information about elbow tendinitis is available by subscription. (See "Epicondylitis (tennis and golf elbow)".)

WHAT IS ELBOW TENDINOPATHY?

Tendinopathy (tendinitis or tendinosis) is the most common condition affecting the elbow.

• It is called "tennis elbow" or lateral epicondylitis when there is an injury to the outer elbow tendon
• It is called "golfer's elbow" or medial epicondylitis when there is an injury to the inner elbow tendon

However, elbow tendinopathy can be caused by sports other than golf and tennis, as well as work-related activities that involve heavy use of the wrist and forearm muscles.

ELBOW TENDINOPATHY SYMPTOMS

Elbow tendinopathy most often affects the dominant arm (ie, the right arm in people who are right-handed, etc.). Symptoms include:

• Pain in the elbow that spreads into the upper arm or down to the forearm
• Weakness of the forearm
• Pain can begin suddenly or can develop gradually over time
• You might have a harder time with activities that require arm strength, including sports that require you to hit backhand or throw a ball

ELBOW TENDINOPATHY DIAGNOSIS

Elbow tendinopathy is usually diagnosed based on an exam and your description of pain.

ELBOW TENDINOPATHY TREATMENT

Pain relief — If needed, you can take a pain medicine, such as acetaminophen (sold as Tylenol® and other brands), ibuprofen (sold as Advil®, Motrin®), or naproxen (sold as Aleve®). (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".) You should not take more than 4000 mg of acetaminophen per day. If you have liver disease or drink alcohol regularly, you should speak with your doctor or nurse before taking acetaminophen.

Arm brace — A tennis elbow brace or strap applies pressure to the muscles of the forearm, reducing pressure on the injured tendon in the elbow. You can use the brace or strap while working or playing sports. Apply the brace so that the cushion is resting on your forearm muscles, about 3 to 4 inches (10 cm) from the tip of the elbow bone. You may need to wear the brace for up to six weeks. Avoid wearing a wrist splint (which prevents your forearm from moving).

Flexibility exercises — Flexibility exercises can help to improve your arm's strength and ability to move.

Tennis elbow — While standing or sitting upright, hold your injured arm straight out in front of you and point your fingers down toward the ground. With the hand of the uninjured arm, grasp the hand of the injured arm, thumb pressing on the palm, and try to bend the wrist further (picture 1). Hold for 30 seconds; repeat three times. Perform this stretch daily.

Golfer's elbow — Stand at arm's length away from a wall, with the affected arm closest to the wall. Place the palm against the wall with the fingers pointing down. Apply gentle pressure to the hand. Hold for 30 seconds; repeat three times. Perform this stretch daily.

Strengthening exercises — A special type of strengthening exercise, known as “eccentric strengthening,” is the most effective way to treat elbow tendinopathy. Patients can start these exercises once their flexibility has improved and they have little or no pain when performing a strengthening exercise. Eccentric strengthening involves working the affected wrist extensor tendon and muscle while they are lengthening. Patients can use a weight, elastic band, or a specially designed rubber bar to do these exercises, and they may be done under supervision or independently. Eccentric training was superior when compared to other types of strengthening [1].

Tennis elbow — People with tennis elbow should perform eccentric extension exercises (picture 2). You should expect to feel some mild discomfort with these exercises. If the pain becomes sharp or is more than moderate, stop the exercise and rest for two to three days. Restart with fewer repetitions.

Golfer's elbow — Golfer's elbow is treated with eccentric flexion exercises. You should expect to feel some mild discomfort with these exercises. If the pain becomes sharp or is more than moderate, stop the exercise and rest for two to three days. Restart with a lighter weight or fewer repetitions.

Sit with your arm supported (on a table) at shoulder height. The back of your hand should face the floor, and your hand should hang off the table. Start with your elbow bent, which is less painful, then progress to keeping your elbow straight. Hold a 1 pound weight in the hand. Using the unaffected hand, lift the hand with the weight toward the body (keep the arm flat against the table).

Move the unaffected hand away, and slowly allow the affected hand (with the weight) to drop. Repeat 15 times, then rest one minute. Repeat two more times. Perform five times per week.

After one week, try to lift the hand with the weight without assistance. Increase the weight by 1 to 2 pounds per week. Do not increase the weight unless you can complete 15 lifts.

Kinetic chain — If you play a sport that requires arm strength (such as tennis or golf), hold a 1 to 2 pound weight in your hand and reproduce the wrist and elbow motions of your sport. At the same time, brace your lower body and core (back and abdomen) muscles.

Then, replace the weight with a golf club or tennis racket and practice your swing (without the ball). If you do the exercises incorrectly, you may feel more pain. If you have pain with strengthening exercises, consider seeing a rehabilitation specialist, such as a physical therapist or athletic trainer, to help supervise your recovery.

When will I feel better? — Most people respond well to treatment. You might have some pain during work or sports for up to 6 to 12 weeks. Some people will need formal rehabilitation with a physical therapist.

If your pain persists, an injection into the painful tendon might help to relieve pain. In addition, there are many new treatments being developed to promote tendon healing, such as using blood products, shock wave therapy, acupuncture, and nitroglycerin patches. Surgery is not usually needed unless symptoms have not improved after six or more months of treatment. (See "Epicondylitis (tennis and golf elbow)".)

ELBOW TENDINOPATHY PREVENTION

A healthy elbow requires a healthy shoulder and wrist joint and strong muscles around the scapula (shoulder blades) and arms to decrease the load on the smaller forearm muscles.

To prevent overuse and strain in the elbow and forearm:

• Take frequent breaks from activities that require extensive hand/wrist motions.
• Reduce or avoid lifting objects with the arm extended.
• Reduce repetitive gripping and grasping with the hand and wrist. Decrease the overall tension of gripping.
• Avoid the extremes of bending and full extension.
• Work or weight-train with the elbow in a partially bent position. Use wrist supports when weight-training.
• When using tools, increase the gripping surface by wearing gloves or adding padding. Use a hammer with extra padding to reduce tension and impact. Hold heavy tools with two hands.
• Use a two-handed backhand in tennis. When hitting a tennis stroke, use your entire lower body, hip, pelvis, and back, and use less of your elbow. Using the proper technique in tennis can help reduce symptoms. Reevaluate the size of your grip, string tension, type of string, new strokes, and new grips for new strokes, which can all contribute to problems.
  
  Some suggest lowering string tension, finding the heaviest racket that does not affect your swing speed, finding the largest grip that is comfortable, and using softer strings.
• Apply grip tape or an oversized grip on golf clubs.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Bursitis (The Basics)
Patient information: Biceps tendinopathy (The Basics)
Patient information: Elbow tendinopathy (tennis and golf elbow) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Biceps tendinitis or tendinopathy (Beyond the Basics)
Patient information: Rotator cuff tendinitis and tear (Beyond the Basics)
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Elbow injuries in the young athlete
Epicondylitis (tennis and golf elbow)
Evaluation of elbow pain in adults

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• American Academy of Orthopaedic Surgeons

     (http://orthoinfo.aaos.org/main.cfm)

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