Tennis Elbow and Golfer’s Elbow: Causes, Exercises and Recovery

The muscles that lift your wrist and fingers (the extensors) share one short tendon that attaches to the bony bump on the outside of the elbow. The muscles that bend your wrist and grip (the flexors) attach at the bump on the inside. Every time you grip, those muscles pull on their tendon at the elbow, which is why a kettle, a jar lid or a handshake hurts at the elbow and not in the hand.

When the load on a tendon rises faster than it can adapt, it becomes sensitive and thickened. That is a tendinopathy. The older name, "epicondylitis", suggests inflammation, but the problem is mostly in the tendon itself, which is why anti-inflammatory fixes work less well than people expect and loading works better.

It usually follows a spell of more gripping, lifting or repetitive wrist work than the tendon was ready for: a busy stretch of housework, a new job, a new baby to carry, more time on a keyboard or mouse, a few weeks of badminton or tennis. Scroll on to see it in 3D.

They are the same kind of tendon problem in two places. Where it hurts, and what makes it worse, usually tells them apart. Pain at the bony bump on the outside, worse when you lift with the palm down or twist, is tennis elbow. Pain on the inside, worse when you grip hard, carry or bend the wrist, is golfer’s elbow. You can have both.

Most people with tennis elbow do not play tennis. The common triggers are ordinary:

• Cooking and housework: rolling dough, lifting heavy pots and the kettle, wringing out cloths, long spells of scrubbing.
• Carrying: shopping bags, a baby or toddler on one arm, a heavy handbag.
• Desk work: a keyboard and mouse for hours, with the wrist held up.
• Sewing, gardening and repetitive hand tasks.
• Sport: racket sports, cricket, golf and weight training, especially after a sudden increase, or with a grip that is too small or a technique that loads the wrist.

It is commonest between 40 and 60, which overlaps with perimenopause, and tendon problems are reported more often around that time. The research on why is still developing, so it is a reason to keep your arms strong, not a diagnosis.

The honest picture is that tennis elbow usually gets better on its own over months, and the right treatment shortens and steadies that recovery. A well-known trial (Bisset and colleagues, BMJ, 2006) found that a steroid injection gave the fastest relief at six weeks, but by one year physiotherapy had done better and the injection group had more recurrences. A larger trial (Coombes and colleagues, JAMA, 2013) found that steroid injections gave worse results than placebo at a year. Injections are a decision to make with your doctor, knowing that trade-off.

These are the loading exercises used in physiotherapy for elbow tendinopathy. Use the ones your physiotherapist agrees with; discomfort up to mild is fine, sharp pain is not. Rest your forearm on a table, palm down for tennis elbow.

1. Held wrist lift (isometric): forearm on a table, palm down, hand over the edge. Lift the back of the hand against your other hand, which stops it moving. Hold the push steady, then relax. Five holds of 30 to 45 seconds.
2. Slow wrist lowering: holding a water bottle, use the other hand to help lift the wrist, then lower it slowly on its own over three to four seconds. Three sets of 15, once a day.
3. Grip squeeze: squeeze a rolled towel or soft ball firmly but comfortably, hold a few seconds, release slowly. Ten squeezes, two to three times a day.
4. Towel twist: wring a rolled towel in both hands as if squeezing out water, then reverse. Ten each way.
5. Forearm turning: forearm on the table holding a hammer or bottle by one end, slowly turn the palm down, then up. Ten each way, holding nearer the end to make it lighter.
6. Palm-up wrist curl (for golfer’s elbow): palm up, hold a light weight, curl the wrist up, then lower over three seconds. Three sets of 15.

Stop and get advice if the pain is sharp, keeps building, or your hand tingles or feels weak.

• Lift with your palm up, or use two hands, for bags, pans and the kettle.
• Use bigger handles on cutlery, pens and tools; a jar opener saves the twist.
• Break up repeated gripping: shorter spells of chopping, cleaning and wringing, swapping hands where you can.
• Set up your keyboard: rest the wrist level, keep the mouse close and take short breaks.
• Try a strap just below the elbow for heavy tasks, and take it off at rest.
• Cold for a flare, or heat for an aching forearm, for 15 to 20 minutes wrapped in a towel.
• Keep the rest of the arm strong: shoulder and shoulder-blade strength takes load off the elbow.

Most elbow pain is tendon pain, but see a doctor promptly for:

• A sudden pop with pain at the front of the elbow, bruising, a change in the shape of the upper arm or weakness turning the palm up: this can be a torn biceps tendon, and a repair works best early.
• Tingling, numbness or weakness in the hand, which points to a nerve (the ulnar nerve on the inside of the elbow, the radial nerve, or a nerve from the neck) and needs assessment, urgently if weakness is getting worse.
• A hot, swollen elbow with fever, a deformed arm after a fall, or a cold, pale or blue hand.
• Arm pain with chest pressure, breathlessness, sweating or faintness, or sudden arm weakness with a drooping face: call 1122.

Munaza Physio Studio in Allama Iqbal Town, Lahore, is a women-only practice. Your elbow is assessed one-to-one by a female physiotherapist in a private room, at the studio or at home across Lahore. We find which tendon is sensitive, rule out a tear, a nerve or the neck, ease the tasks that flare it, and build a graded loading programme around your day, with hands-on treatment where it helps. See the full page on elbow tendinopathy.