Epidemiology

The annual incidence of tennis elbow in general practice is 4-7 cases per 1,000 patients, with a peak in patients 35-54 years of age.1 The peak incidence is between 40 and 50 years of age.
Golfer's elbow is the most common cause of medial elbow pain, but the incidence is about one fifth as common as tennis elbow.
Tennis elbow and golfer's elbow may be seen in any age group if hobbies, jobs or sports activities can lead to overuse injuries.

Tennis Elbow	Golfer's Elbow	Bursitis
(lateral epicondylitis) Outside of Elbow Cause & Symptoms The onset of pain, on the outside (lateral) of the elbow, is usually gradual with tenderness felt on or below the joint's bony prominence. Movements such as gripping, lifting and carrying tend to be troublesome.	(medial epicondylitis) Inside of Elbow Cause & Symptoms The causes of golfer's elbow are similar to tennis elbow but pain and tenderness are felt on the inside (medial) of the elbow, on or around the joint's bony prominence.	Back of Elbow Cause & Symptoms Often due to excessive leaning on the joint or a direct blow or fall onto the tip of the elbow. A lump can often be seen and the elbow is painful at the back of the joint.

The Physiology of underlying problem.

The muscles of the forearm that pull the wrist down are called wrist flexors. They begin at a common tendon attachment on the inside bump of the elbow called the medial epicondyle (below). As the wrist is flexed or the hand made to grip, the muscles tense and pull against the tendons. Force placed on the flexor muscles during a golf swing pulls on the tendons at the medial epicondyle.

Golfer's Elbow, is similar to its counterpart, Tennis Elbow. The primary difference between the two is the location of the pain and the activity that leads to injury. However, both conditions are caused by overuse of the muscles of the forearm leading to inflammation and pain around the elbow joint.

These problems, Tennis Elbow and Golfer's Elbow, are forms of tendonitis. Tendons are the ends of muscles that attach to bone. Because of the force of the muscle, the points of insertion of the tendon on the bone are often pointed prominences.

The medical names of Tennis Elbow (lateral epicondylitis) and Golfer's Elbow (medial epicondylitis) come from the names of these bony prominences where the tendons insert, and where the inflammation causes the pain. The pain of Golfer's Elbow is usually at the elbow joint on the inside of the arm; a shooting sensation down the forearm is also common while gripping.

Risk factors

Any activity that causes repetitive strain on forearm extensors (tennis elbow) or forearm flexors (golfer's elbow), such as golf, racquet and throwing sports, using a computer, driving and DIY.
May also be caused by acute trauma, driver involved in a road traffic accident.

Presentation

There is often a clear history of a likely cause of repetitive strain or possibly a history of acute injury.

Tennis elbow

Pain and tenderness over the lateral epicondyle of the humerus, radiating into the forearm, and pain on resisted dorsiflexion of the wrist, middle finger or both.
The onset of pain is usually gradual and worse with use of affected muscles, e.g. opening a jar.
Usually unilateral but 10-20% of cases are bilateral.

Golfer's elbow

Pain and tenderness maximal over the medial epicondyle, radiating into the forearm, which is aggravated by wrist flexion and pronation.
Dull ache at medial epicondyle.
The onset of pain is usually gradual and aggravated by using the affected muscles, e.g. grasping objects and shaking hands.
Worsened with affected muscle use, e.g. forearm rotation or grasping, opening a jar.
An associated ulnar neuropathy may cause decreased sensation and/or a tingling sensation in the 4th and 5th fingers and, in more severe cases, muscle weakness in the hand.

Differential diagnosis

Olecranon bursitis
Elbow arthritis
Cervical nerve root entrapment
Radiation of pain from shoulder or wrist injuries
Carpal tunnel syndrome

Investigations

Usually not required but may be indicated if the diagnosis is uncertain, e.g. CRP, elbow X-ray, MRI.
Nerve conduction study and electromyography may be indicated if ulnar nerve involvement is suspected in patients with golfer's elbow.

Management

Many treatments have been used to treat tennis or golfer's elbow, but it is not clear whether these treatments work or if the pain simply goes away on its own.

General advice:
- Rest, ice treatment after exercise.
- Activity restriction: avoid lifting, gripping and pronation or supination of the affected extremity.
- Ergonomic workplace and sports' modifications.
Rehabilitation exercises: for example, painless passive wrist flexion, progressive resisted wrist extension.
NSAIDs are beneficial for short-term pain relief but there is no established benefit for longer-term therapy. Consider use of a topical NSAID in preference to an oral NSAID because adverse effects are less likely. There is some evidence for the use of topical NSAIDs to relieve lateral elbow pain at least in the short term.
Acupuncture: acupuncture may be effective in the reduction of pain and improvement in the functioning of the arm.
Local steroid injection:
- The benefits of injections are not established. In one study, short-term success rates were greater than for physiotherapy or a wait-and-see policy. However, in the long-term (one year), success rates were greater for both physiotherapy and a wait-and-see policy than for injections.
- Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait-and-see in the first six weeks and to corticosteroid injections after six weeks.
- The significant short-term benefits of corticosteroid injection are paradoxically reversed after six weeks, with high recurrence rates.
- Extra care is required with injecting golfer's elbow to ensure avoiding the ulnar nerve. Steroid injections can be repeated after 6 weeks to 2 months.
- Superficial injections should be avoided as they are ineffective and may cause skin atrophy.
Orthotic devices: the effectiveness of orthotic devices is not proven.
Extracorporeal shock wave therapy has not been shown to be effective for treating tennis elbow.
Surgery: release of the extensor/flexor origin is occasionally indicated, followed by gentle strengthening exercises and return to mild sport or other relevant activity at about 6 weeks.

Prognosis

Lateral epicondylitis is a self-limiting condition. The average duration of a typical episode is about 6 months to 2 years, but most patients (89%) recover within 1 year.

Golfer's elbow is also a self-limiting condition with a similar prognosis.
One study found that 80% of the people with elbow pain of longer than 4 weeks' duration had recovered by 1 year.

Prevention

Patients often have to modify their activities or the particular techniques that lead them to develop this overuse injury.
This may need to include the help of a coach for sporting activities.