Patient information: Elbow tendinitis (tennis and golf elbow)

ELBOW TENDINITIS OVERVIEW

Tendons are tough bands of tissue that connect muscles to bones. Repetitive activities and overuse can injure tendons and lead to inflammation, pain, and impaired function. This is called tendinitis. Although the most common cause of tendinitis is overuse, it can also be caused by other conditions including inflammatory rheumatic diseases.

Tendinitis is a common problem. The risk of getting tendinitis increases with age and is higher in people who routinely perform activities that require repetitive movement that increase stress on susceptible tendons. Treatment focuses on resting the injured tendon to allow healing, decreasing inflammation, and promoting muscle strength. In most patients, tendinitis readily resolves with treatment. In some cases, it goes away without treatment.

Tendinitis can affect many different tendons in the body. A separate topic review is available that discusses other types of tendinitis. (See "Patient information: Biceps tendinitis or tendinopathy" and "Patient information: Rotator cuff tendinitis and tear".)

Epicondylitis — The elbow is formed by two forearm bones (the radius and ulna) and the upper arm bone (the humerus). It is capable of moving in only two directions, bending (flexing) and straightening (extending). Movement of the elbow also affects the wrist; conditions affecting the elbow often cause problems at the wrist, and vice versa.

There are four major muscle/tendon groups that are important to the elbow: the biceps (in front); the triceps (in back); the muscles that help the wrist and fingers to extend up (on the outside or laterally); and the muscles that help the wrist and fingers to flex down (on the inside or medially).

Tendinitis (irritation and inflammation of the tendon tissue) is the most common condition affecting the elbow. It is frequently referred to as "tennis elbow" when there is an injury to the outer tendon and "golfer's elbow" when there is an injury to the inner tendon. However, elbow tendinitis may be caused by a variety of sports or work-related activities that involve heavy use of the wrist and forearm muscles.

Other names for tennis elbow and golfer's elbow are lateral epicondylitis and medial epicondylitis, respectively.

ELBOW TENDINITIS SYMPTOMS

Epicondylitis most often affects the dominant arm (eg, the right arm in people who are right-handed). A person may feel localized elbow pain that radiates into the upper arm or down to the forearm. Pain may cause weakness of the forearm. Symptoms of epicondylitis may occur suddenly or can develop gradually over time. Once they appear, symptoms are often persistent, although pain may come and go in some people

ELBOW TENDINITIS DIAGNOSIS

The diagnosis of epicondylitis is usually based upon an examination and symptoms of pain over the affected epicondyle. Sometimes, an anesthetic-injection test is performed to confirm the diagnosis. In this test, an anesthetic is injected into the affected area. Epicondylitis is confirmed if the pain is temporarily relieved.

ELBOW TENDINITIS TREATMENT

Pain relief — If needed, a pain medication such as acetaminophen (Tylenol®) can be taken; the usual dose of acetaminophen is two 375 mg tablets every four to six hours as needed. No more than 4000 mg of acetaminophen is recommended per day, and anyone with liver disease or who drinks alcohol regularly should speak with their healthcare provider before using acetaminophen.

A nonsteroidal antiinflammatory drug (NSAID), such as ibuprofen (eg, Advil®, Motrin®) or naproxen (eg, Aleve®) can also be used for pain. The dose of these NSAIDs is available in table 1 (table 1). (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)".)

Ice — The elbow joint and its supporting tendons are located just under the surface of the skin. Thus, local application of ice for 10 to 15 minutes, three to four times per day is very effective in controlling pain and inflammation. An iced towel wrapped around the elbow, blue ice packs, or an ice bag can all be used.

Immobilization — Wrist and hand movement tends to aggravate symptoms, and some patients find that immobilization with a wrist splint that has a metal stay extending up the forearm reduces symptoms. Immobilization is generally required for three to four weeks but may be necessary for a longer time in patients with severe symptoms. If symptoms persist, non-steroidal anti-inflammatory medications may be discontinued and other measures considered.

Flexibility exercises — Exercises can help to restore the strength and tone of the affected muscles and prevent recurrences. Exercises are usually started three to four weeks after elbow pain has resolved. The exercises are continued for up to 6 to 12 months in patients with recurrent tendinitis.

Tennis elbow — Stand at arm's length away from a wall, with the affected arm closest to the wall (picture 1). Place the back of the hand against the wall with the fingers pointing down. Apply gentle pressure to the hand to stretch the forearm muscles. Hold for 30 seconds; repeat 3 times. Perform this stretch daily

Golfers 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 to stretch the inner tendons and muscles. Hold for 30 seconds; repeat 3 times. Perform this stretch daily.

Strengthening exercises — Specific muscle strengthening exercises can usually begin two to three weeks after the initial pain of tendinitis has decreased. Strengthening the surrounding muscles helps to support the elbow and wrist tendons and reduces the risk of recurrent tendinitis. A strengthening program that slowly progresses is recommended.

Tennis elbow — People with tennis elbow should perform eccentric extension exercises. A mild amount of discomfort is expected with these exercises. If the pain becomes sharp or more than moderate, stop the exercise and rest for two to three days. Restart with a lighter weight or less repetitions.

Sit with the arm supported (on a table) at elbow height. The back of the hand should face the ceiling and the hand should hang off the table. Hold a one pound weight in the hand, and lift the hand with the weight upward with the unaffected hand (DO NOT use the hand with the weight to do the lift).

Once the wrist is extended up toward the ceiling as far as comfortable, slowly allow the hand to drop (picture 2). Repeat for a total of 3 sets of 15 repetitions with 1 minute rest between. Perform five times per week. After performing for one week, increase the weight by 1 to 2 pounds per week. Do not increase the weight unless the fifteen repetitions can be completed.

Golfer's elbow — People with irritation of the inner tendon (medial epicondylitis or golfer's elbow) should perform eccentric flexion exercises. A mild amount of discomfort is expected with these exercises. If the pain becomes sharp or more than moderate, stop the exercise and rest for two to three days. Restart with a lighter weight or less repetitions.

Sit with the arm supported (on a table) at shoulder height. The back of the hand should face the floor and the hand should hang off the table. Hold a one pound weight in the hand. Using the unaffected hand, lift the hand with the weight towards 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 for a total of 3 sets of 15 repetitions with 1 minute rest between. Perform five times per week. After performing for 1 week, increase the weight by one to two pounds per week. Do not increase the weight unless fifteen repetitions can be completed.

Response to treatment — Most people respond well to treatment. Pain at rest is often relieved after a few days of treatment, although patients may experience pain with arm use for up to 6 to 12 weeks. A small number of patients may need long-term physical therapy toning exercises and restrictions on use of the forearm. In patients with persistent symptoms, a diagnostic work-up to rule out other conditions may be considered. Surgery is rarely indicated, unless symptoms have persisted for one year or longer.

ELBOW TENDINITIS PREVENTION

A healthy elbow requires a healthy shoulder and wrist joint, strong peri-scapular, biceps and triceps to decrease the load on the smaller forearm muscles.

General measures prevent overuse and strain in the elbow and/or forearm include:

• 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 flexed 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. Some people benefit from use of a tennis elbow brace, although this is not universal. Some experts recommend changing the type of tennis racket used (for example, moving to a heavier, more flexible, racket with more weight in the tail and less in the head), although research in this area is limited (see www.racquetresearch.com).
• 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. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Biceps tendinitis or tendinopathy
Patient information: Rotator cuff tendinitis and tear
Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs)

Professional Level Information:
Elbow injuries in the young athlete
Epicondylitis
Evaluation of elbow pain in adults
Rehabilitation program for the upper limb

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

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

• American Academy of Orthopaedic Surgeons

      (http://orthoinfo.aaos.org/)

• National Institute of Arthritis and Musculoskeletal and Skin Disease

      (www.niams.nih.gov)

• American College of Rheumatology

      (www.rheumatology.org)

• Arthritis Foundation

      (www.arthritis.org)

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