Tennis Elbow: Causes, Symptoms and Diagnosis

Quick Answer

Tennis elbow is wear and small tears in the forearm tendon that attaches to the outside of the elbow, usually from repetitive gripping and wrist movements. It causes outer elbow pain and weak grip, and is diagnosed mainly by examination, with X-ray, ultrasound, MRI or nerve tests used to rule out other causes.

Tennis elbow is one of the most common causes of elbow pain in adults, and most people who get it have never played tennis. Understanding what is happening in the tendon, what tends to trigger it, and how doctors confirm the diagnosis can help you make sense of your symptoms and choose the right next step.

What is happening inside the elbow

The bony bump on the outside of your elbow is called the lateral epicondyle. Several forearm muscles that lift your wrist and fingers attach there through a shared tendon. According to the American Academy of Orthopaedic Surgeons (AAOS), the tendon most often involved in tennis elbow belongs to the extensor carpi radialis brevis (ECRB), a muscle that helps steady the wrist when the elbow is straight.

With repeated strain, small tears form where this tendon attaches to bone. AAOS describes the condition as degeneration, or wearing down, of the tendon, sometimes with microtearing. The name "epicondylitis" suggests inflammation, and a 2023 review by interventional radiologists described it as a low-grade inflammatory process. In practice, both tendon wear and low-level inflammation seem to play a part. Many patients also develop a cluster of abnormal small blood vessels around the damaged tendon. These vessels are the target of tennis elbow embolization.

Golfer's elbow is the mirror image on the inside of the elbow, where the forearm flexor and pronator muscles attach to the medial epicondyle. It is less common than tennis elbow.

Who gets tennis elbow, and why

Age

AAOS says most people who develop tennis elbow are between 30 and 50. In a Finnish population study of 4,783 adults aged 30 to 64, about 1.3% had definite tennis elbow at the time of examination, with the highest rate between 45 and 54. Men and women were affected equally.

Repetitive and forceful work

Jobs and hobbies that involve repeated gripping, twisting or wrist extension raise the risk. AAOS names painters, plumbers, carpenters, auto workers, cooks and butchers as more often affected than the general population. The Finnish study found that the combination of repetitive arm movements and forceful activity was strongly linked to tennis elbow.

Sports

Racquet sports are the classic cause. AAOS notes that poor stroke technique and equipment that does not fit well may contribute.

Smoking and weight

In the Finnish study, current and former smokers were about three times more likely to have tennis elbow. Smoking, obesity and physical workload were all linked to golfer's elbow.

No clear cause

Some people develop tennis elbow without any obvious repetitive activity. AAOS calls this idiopathic, meaning the cause is unknown.

Common symptoms

Symptoms usually build gradually over weeks to months without a single injury. AAOS lists:

Pain or burning on the outer part of the elbow.
Weak grip strength.
Sometimes, pain at night.

The pain is often worse with forearm activity such as holding a racquet, turning a wrench, shaking hands, lifting a cup or a full bag with the palm down, or using a computer mouse for long periods. The dominant arm is most often affected, but both arms can be.

Golfer's elbow causes similar pain on the inner elbow, typically worse with gripping, wrist flexion and forearm rotation. Because the ulnar nerve runs just behind the inner elbow bump, some people with golfer's elbow also notice tingling or numbness toward the ring and little fingers. That deserves a careful exam. See our golfer's elbow embolization page for more on the inner elbow.

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This article is part of our Embolization Guide.

How doctors diagnose tennis elbow

History and examination

Diagnosis is mostly clinical. Your doctor will ask how the pain started, what makes it worse, your work and sports, and any history of elbow injury, rheumatoid arthritis or nerve problems. During the exam, they press over the lateral epicondyle to check for tenderness and may ask you to straighten your wrist or fingers against resistance with the elbow straight. Pain with these tests points toward the extensor tendons.

Imaging and tests

Additional tests are used mainly to rule out other causes or measure tendon damage:

X-ray to look for arthritis or other bone problems.
Ultrasound to see tendon thickening, tears and, with Doppler, increased blood flow around the tendon.
MRI to show the extent of tendon damage or other injuries. If a neck problem is suspected, an MRI of the neck may be ordered.
Electromyography (EMG) to check for nerve compression, which AAOS notes can cause symptoms similar to tennis elbow.

If embolization is being considered, imaging helps confirm that the tendon is the pain source. A 2018 Korean study found that patients whose X-ray dye images showed a clear blush of abnormal vessels were more likely to improve after embolization.

Conditions that can look like tennis elbow

Nerve compression around the elbow or forearm.
A pinched nerve in the neck (cervical radiculopathy), which can cause arm pain.
Elbow arthritis, including inflammatory arthritis.
Ligament injuries, especially after a fall or in throwing athletes.
Bursitis at the back of the elbow.

Getting the diagnosis right matters because treatments aimed at the tendon, including embolization, will not fix pain coming from somewhere else.

How tennis elbow usually behaves over time

For most people, tennis elbow improves. A 2022 meta-analysis of untreated and placebo groups in 24 trials found about 89% of people were much better or recovered at one year. A large Minnesota population study found that new cases dropped from 4.5 per 1,000 people in 2000 to 2.4 per 1,000 in 2012, that about 8.5% of people had a recurrence within two years, and that about 1 in 10 of those still symptomatic at six months eventually had surgery.

If your pain has lasted many months despite good care, our candidate guide explains when embolization is worth considering. You can also learn about embolization for other joints in our embolization guide.

Preparing to describe your symptoms

A clear description of your pain makes the exam more useful. Before your visit, jot down:

When the pain started and whether anything specific set it off.
Exactly where it hurts. Point with one finger: outer bump, inner bump, back of the elbow, or the forearm.
Which movements trigger it, such as lifting with the palm down, gripping, twisting a lid or typing.
Any numbness, tingling, clicking, locking or swelling.
What you have tried so far and how long each helped.
How the pain affects your work, sport, sleep and daily tasks.

Bring any imaging reports or discs you already have. This saves time and may avoid repeat tests.

When to see a doctor promptly

Pain that began with a fall, a pop, or a sudden heavy lift.
An elbow that is hot, red and swollen, especially with fever.
Inability to fully bend or straighten the elbow.
Numbness, tingling or weakness in the hand or fingers.
Pain that wakes you every night or comes with unexplained weight loss.

Frequently Asked Questions

Can you get tennis elbow without playing tennis?

Yes. Most people with tennis elbow do not play tennis. Jobs and hobbies with repetitive gripping and wrist movements, such as painting, carpentry, plumbing and cooking, are common causes.

How is tennis elbow diagnosed?

Mainly through history and a physical exam, including pressing on the outer elbow and testing wrist extension against resistance. X-ray, ultrasound, MRI or nerve testing may be used to rule out other causes.

What is the difference between tennis elbow and golfer's elbow?

Tennis elbow affects tendons on the outside of the elbow; golfer's elbow affects tendons on the inside. Golfer's elbow is less common and can sometimes involve irritation of the nearby ulnar nerve.

Does tennis elbow go away on its own?

Often, yes. In the control groups of 24 trials, about 89% of people were much better or recovered at one year.

Keep Reading

Sources

Medically reviewed by David Fox, MD, FACS, RPVI. This article is general information, not a substitute for a medical evaluation.

Living with joint or tendon pain that hasn’t improved? Schedule a consultation with Dr. David Fox at Fox Vein & Vascular in Manhattan to find out whether embolization is right for you. Call (212) 362-3470 or request an appointment online.

Tennis Elbow Causes, Symptoms and Diagnosis