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{{other uses|Tennis Elbow (video game)}}
{{short description|Condition in which the outer part of the elbow becomes sore and tender}}
{{Infobox medical condition (new)
| name = Tennis elbow
| synonyms = Lateral epicondylitis, lateral elbow tendinopathy<ref name=Hub2018/>
| image = File:En-elbow joint.svg
| width = 150px
| width = 150px
| caption = Left [[elbow-joint]], showing posterior and radial collateral [[ligaments]]. ([[Lateral epicondyle of the humerus|Lateral epicondyle]] visible at center.)
| caption = Left [[elbow-joint]], showing posterior and radial collateral [[ligaments]]. ([[Lateral epicondyle of the humerus|Lateral epicondyle]] visible at center.)

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'{{other uses|Tennis Elbow (video game)}} {{short description|Condition in which the outer part of the elbow becomes sore and tender}} {{Infobox medical condition (new) | name = Tennis elbow | synonyms = Lateral epicondylitis, lateral elbow tendinopathy<ref name=Hub2018/> | image = File:En-elbow joint.svg | width = 150px | caption = Left [[elbow-joint]], showing posterior and radial collateral [[ligaments]]. ([[Lateral epicondyle of the humerus|Lateral epicondyle]] visible at center.) | pronounce = | field = [[Orthopedics]], [[sports medicine]] | symptoms = Painful and tender outer part of the elbow<ref name=Hub2018/> | complications = | onset = Gradual<ref name=AI2015/> | duration = Less than 1 to 2 years<ref name=Vaq2016/> | types = | causes = Excessive use of the muscles of the [[posterior compartment of the forearm|back of the forearm]]<ref name=AI2015/> | risks = Smoking, [[obesity]]<ref name=Vaq2016/> | diagnosis = Based on symptoms with [[medical imaging]] used to rule out other potential causes<ref name=AI2015/> | differential = [[Osteochondritis dissecans]], [[osteoarthritis]], [[radiculopathy]]<ref name=Vaq2016/> | prevention = | treatment = Changing activities, [[physical therapy]], pain medication<ref name=Hub2018/> | medication = | prognosis = | frequency = c. 2%<ref name=Vaq2016/> | deaths = }} <!-- Definition and symptoms --> '''Tennis elbow''', also known as '''lateral epicondylitis''', is a condition in which the outer part of the [[Elbow-joint|elbow]] becomes painful and tender.<ref name=Hub2018>{{cite journal |last1=Hubbard |first1=MJ |last2=Hildebrand |first2=BA |last3=Battafarano |first3=MM |last4=Battafarano |first4=DF |title=Common Soft Tissue Musculoskeletal Pain Disorders. |journal=Primary Care |date=June 2018 |volume=45 |issue=2 |pages=289–303 |doi=10.1016/j.pop.2018.02.006 |pmid=29759125}}</ref> The pain may also extend into the back of the [[forearm]] and [[grip strength]] may be weak.<ref name=AI2015/><ref name=Hub2018/> Onset of symptoms is generally gradual.<ref name=AI2015/> [[Golfer's elbow]] is a similar condition that affects the [[Medial epicondyle of the humerus|inside of the elbow]].<ref name=Hub2018/> <!-- Cause and diagnosis --> It is due to excessive use of the muscles of the [[posterior compartment of the forearm|back of the forearm]].<ref name=AI2015>{{cite web |title=Tennis Elbow (Lateral Epicondylitis) |url=http://orthoinfo.aaos.org/topic.cfm?topic=a00068 |website=OrthoInfo |access-date=21 June 2018 |date=July 2015}}</ref> Typically this occurs as a result of work or sports, classically [[racquet sports]].<ref name=Hub2018/><ref name=AI2015/> The diagnosis is typically based on the symptoms with [[medical imaging]] used to rule out other potential causes.<ref name=AI2015/> It is more likely if pain increases when a subject tries to [[dorsiflexion|bend back]] the wrist when the wrist is held in a neutral position.<ref name=Hub2018/> A powered screwdriver can cause this injury if overused one-handed. It is classified as a chronic [[tendinosis]], not a [[tendinitis]].<ref name=Hub2018/> <!-- Treatment and prognosis--> Treatment involves decreasing activities that bring on the symptoms together with [[physical therapy]] or other treatment gradually increasing loads.<ref>{{cite journal |last1=Orchard |first1=J |last2=Kountouris |first2=A |title=The management of tennis elbow. |journal=BMJ (Clinical Research Ed.) |date=10 May 2011 |volume=342 |pages=d2687 |doi=10.1136/bmj.d2687 |pmid=21558359|s2cid=8358075 }}</ref><ref name=Hub2018/> Pain medications such as [[NSAIDS]] or [[acetaminophen]] (paracetamol) may be used.<ref name=Hub2018/> A brace over the upper forearm may also be helpful.<ref name=AI2015/> If the condition does not improve [[corticosteroid]] injections or surgery may be recommended <ref name=Hub2018/> although some experts recommend avoiding cortisone injections due to poor long-term results in high-quality trials.<ref>{{Cite journal|last1=Olaussen|first1=Morten|last2=Holmedal|first2=Øystein|last3=Mdala|first3=Ibrahimu|last4=Brage|first4=Søren|last5=Lindbæk|first5=Morten|date=2015-05-20|title=Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial|url=https://doi.org/10.1186/s12891-015-0582-6|journal=BMC Musculoskeletal Disorders|volume=16|issue=1|pages=122|doi=10.1186/s12891-015-0582-6|issn=1471-2474|pmc=4438532|pmid=25989985}}</ref><ref>{{Cite journal|last1=Bisset|first1=Leanne|last2=Beller|first2=Elaine|last3=Jull|first3=Gwendolen|last4=Brooks|first4=Peter|last5=Darnell|first5=Ross|last6=Vicenzino|first6=Bill|date=2006-11-02|title=Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial|url=https://www.bmj.com/content/333/7575/939|journal=BMJ|language=en|volume=333|issue=7575|pages=939|doi=10.1136/bmj.38961.584653.AE|issn=0959-8138|pmc=1633771|pmid=17012266}}</ref><ref>{{Cite journal|last1=Coombes|first1=Brooke K.|last2=Bisset|first2=Leanne|last3=Brooks|first3=Peter|last4=Khan|first4=Asad|last5=Vicenzino|first5=Bill|date=2013-02-06|title=Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial|url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2013.129|journal=JAMA|language=en|volume=309|issue=5|pages=461–9|doi=10.1001/jama.2013.129|pmid=23385272|issn=0098-7484|doi-access=free}}</ref><ref>{{cite journal |last1=Orchard |first1=JW |last2=Vicenzino |first2=B |title=Cortisone injections for tennis elbow should be an "avoid", rather than a recommended procedure. |journal=The Medical Journal of Australia |date=20 November 2017 |volume=207 |issue=10 |pages=453 |doi=10.5694/mja17.00445 |pmid=29129178|s2cid=20903534 }}</ref> Many people get better within one month to two years.<ref name=Vaq2016>{{cite journal |last1=Vaquero-Picado |first1=A |last2=Barco |first2=R |last3=Antuña |first3=SA |title=Lateral epicondylitis of the elbow. |journal=EFORT Open Reviews |date=November 2016 |volume=1 |issue=11 |pages=391–397 |doi=10.1302/2058-5241.1.000049 |pmid=28461918|pmc=5367546 }}</ref><ref name=Lian2018>{{Cite journal|last1=Lian|first1=Jayson|last2=Mohamadi|first2=Amin|last3=Chan|first3=Jimmy J.|last4=Hanna|first4=Phillip|last5=Hemmati|first5=David|last6=Lechtig|first6=Aron|last7=Nazarian|first7=Ara|s2cid=53148287|date=2018-10-31|title=Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Extensor Carpi Radialis Brevis: A Systematic Review and Meta-analysis of Randomized Placebo-Controlled Trials|journal=The American Journal of Sports Medicine|volume=47|issue=12|pages=3019–3029|doi=10.1177/0363546518801914|issn=1552-3365|pmid=30380334}}</ref> <!-- Epidemiology and history --> About 2% of people are affected.<ref name=Vaq2016/> Those 30 to 50 years old are most commonly affected.<ref name=AI2015/> The condition was initially described in 1873.<ref name=Vaq2016/> The name "[[lawn tennis]] elbow" first came into use for the condition in 1882.<ref>{{cite book |last1=Wolf |first1=Jennifer Moriatis |title=Tennis Elbow: Clinical Management |date=2015 |publisher=Springer |isbn=9781489975348 |page=1 |url=https://books.google.com/books?id=pZxqCQAAQBAJ&pg=PA1 |language=en}}</ref> ==Signs and Symptoms== * Pain on the outer part of the elbow ([[Lateral epicondyle of the humerus|lateral epicondyle]]) * Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow * Pain from gripping and movements of the [[wrist]], especially wrist extension (e.g. turning a screwdriver) and lifting movements<ref name=":0">{{Cite book|title=Essentials of musculoskeletal care|date=2010|publisher=American Academy of Orthopaedic Surgeons|others=Sarwark, John F.|isbn=978-0892035793|location=Rosemont, Ill.|oclc=706805938}}</ref> Symptoms associated with tennis elbow include, but are not limited to, radiating pain from the outside of the elbow to the [[forearm]] and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing a [[doorknob]], and not being able to hold relatively heavy items in the hand.<ref>{{Cite journal|last1=Geoffroy|first1=P.|last2=Yaffe|first2=M. J.|last3=Rohan|first3=I.|date=January 1994|title=Diagnosing and treating lateral epicondylitis.|journal=Canadian Family Physician|volume=40|pages=73–78|issn=0008-350X|pmc=2379994|pmid=8312757}}</ref> The pain is similar to the condition known as ''[[golfer's elbow]]'', but the latter occurs at the medial side of the elbow.<ref name="mayoclinic.com">"Tennis Elbow – MayoClinic.com." Mayo Clinic Medical Information and Tools for Healthy Living – MayoClinic.com. 15 Oct. 2008. Web. 10 Oct. 2010. [http://www.mayoclinic.com/health/tennis-elbow/DS00469]</ref> ===Terminology=== The term "tennis elbow" is widely used (although informal), but the condition should be understood as not limited to tennis players.<ref name= "cleveland_clinic">[https://my.clevelandclinic.org/treatment-guides/22-0069-elbow-pain-guide#fractures-sports-injuries-tab "Tennis elbow (lateral epicondylitis)"], ''Elbow Pain,'' Cleveland Clinic, 2018. Accessed 23 January 2018.</ref><ref name= "mayo_clinic">[https://www.mayoclinic.org/diseases-conditions/tennis-elbow/symptoms-causes/syc-20351987 "Tennis elbow"], Mayo Clinic, Aug. 2, 2017. Accessed 23 January 2018.</ref> Historically, the medical term "lateral epicondylitis" was most commonly used for the condition.<ref name= AI2015 /><ref name= "cleveland_clinic" /><ref name= "mayo_clinic" /><ref name="bbcsport" /> Since histological findings reveal noninflammatory tissue, the term “lateral elbow [[tendinopathy]]," "[[tendinosis]],” or “angio-fibroblastic tendinosis” have been suggested instead of “lateral epicondylitis”.<ref name="pmid16998100"/><ref name="du ToitStieler2008"/> Most recently, in 2019, a group of international experts agreed that "lateral elbow tendinopathy" was the most appropriate terminology.<ref>{{Cite journal|last1=Scott|first1=Alex|last2=Squier|first2=Kipling|last3=Alfredson|first3=Hakan|last4=Bahr|first4=Roald|last5=Cook|first5=Jill L|last6=Coombes|first6=Brooke|last7=de Vos|first7=Robert-Jan|last8=Fu|first8=Siu Ngor|last9=Grimaldi|first9=Alison|last10=Lewis|first10=Jeremy S|last11=Maffulli|first11=Nicola|date=March 2020|title=ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology|url=https://bjsm.bmj.com/lookup/doi/10.1136/bjsports-2019-100885|journal=British Journal of Sports Medicine|language=en|volume=54|issue=5|pages=260–262|doi=10.1136/bjsports-2019-100885|pmid=31399426|s2cid=199517946|issn=0306-3674|doi-access=free}}</ref> ==Causes== [[File:Tennis Elbow.png|thumb|Location of tennis elbow]] Tennis elbow is a type of [[repetitive strain injury]] resulting from tendon overuse and failed healing of the tendon. In addition, the [[extensor carpi radialis brevis]] muscle plays a key role.<ref name="du ToitStieler2008">{{cite journal|last1=du Toit|first1=C|last2=Stieler|first2=M|last3=Saunders|first3=R|last4=Bisset|first4=L|last5=Vicenzino|first5=B|s2cid=3274396|title=Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow|journal=British Journal of Sports Medicine|volume=42|issue=11|year=2008|pages=572–576|issn=0306-3674|doi=10.1136/bjsm.2007.043901|pmid=18308874|hdl=10072/22142|hdl-access=free}}</ref><ref name="pmid15116648">{{cite journal |vauthors=Nirschl RP, Ashman ES |title=Tennis elbow tendinosis (epicondylitis) |journal=Instr Course Lect |volume=53 |pages=587–98 |year=2004 |pmid=15116648 }}</ref> [[File:Tenniselbow.JPG|thumb|Example of repetitive movement that may cause tennis elbow]] Early [[experiment]]s suggested that tennis elbow was primarily caused by overexertion. However, studies show that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension cause more than half of these injuries.<ref name="KURPPA, K. 1979">KURPPA, K., WARIS, P. and ROKKANEN, P. Tennis elbow: Lateral elbow pain syndrome. ''Scand j. work environ. & health'' 5 (1979): suppl. 3, 15–18. A review of the etiology, occurrence and pathogenesis of "tennis elbow" is presented.</ref> Repeatedly mis-hitting a tennis ball in the early stages of learning the sport causes shock to the elbow joint and may contribute to contracting the condition.<ref>{{Cite web|url=https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/|title=Tennis Elbow (Lateral Epicondylitis)|date=July 2015|website=OrthoInfo|access-date=February 20, 2018|quote=In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.}}</ref> There are multiple aspects of tennis that may cause a player to develop “tennis elbow”. From a technical perspective, leading a backhand with your elbow, excessive pronation of the forearm when putting topspin on a forehand, and excessive flexion of the wrist on a serve can all greatly lead to tennis elbow. Other things that can be improved are: racquet type, grip size, string tension, type of court surface, and ball weight.<ref>{{Cite journal|last1=Keijsers|first1=Renée|last2=de Vos|first2=Robert-Jan|last3=Kuijer|first3=P Paul FM|last4=van den Bekerom|first4=Michel PJ|last5=van der Woude|first5=Henk-Jan|last6=Eygendaal|first6=Denise|date=2018-09-18|title=Tennis elbow|journal=Shoulder & Elbow|language=en-US|volume=11|issue=5|pages=384–392|doi=10.1177/1758573218797973|issn=1758-5732|pmc=6739751|pmid=31534489}}</ref> ==Pathophysiology== Histological findings include granulation tissue, micro-rupture, degenerative changes, and there is no traditional inflammation.<ref name="du ToitStieler2008"/><ref name="pmid1423702">{{cite journal |author=Nirschl RP |title=Elbow tendinosis/tennis elbow |journal=Clin Sports Med |volume=11 |issue=4 |pages=851–70 |date=October 1992 |pmid=1423702 |doi= 10.1016/S0278-5919(20)30489-0}}</ref><ref name=Lian2018/> Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term “epicondylitis” is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which replaces normal tissue with a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as ''tendinosis'' or ''tendinopathy'' rather than ''[[tendinitis]].''<ref name="pmid16998100">{{cite journal |vauthors=McShane JM, Nazarian LN, Harwood MI |title=Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow |journal=J Ultrasound Med |volume=25 |issue=10 |pages=1281–9 |date=October 2006 |pmid=16998100 |doi= 10.7863/jum.2006.25.10.1281|s2cid=22963436 |doi-access=free }}</ref> Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin.<ref name="ZeisigÖhberg2006">{{cite journal|last1=Zeisig|first1=Eva|last2=Öhberg|first2=Lars|last3=Alfredson|first3=Håkan|s2cid=23469092|title=Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study|journal=Knee Surgery, Sports Traumatology, Arthroscopy|volume=14|issue=11|year=2006|pages=1218–1224|issn=0942-2056|doi=10.1007/s00167-006-0156-0|pmid=16960741}}</ref> The [[pathophysiology]] of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the [[extensor carpi radialis brevis muscle|extensor carpi radialis brevis (ECRB) muscle]] are identified in surgical [[pathology]] specimens.<ref name="boyer">{{cite journal |vauthors=Boyer MI, Hastings H |title=Lateral tennis elbow: "Is there any science out there?" |journal=Journal of Shoulder and Elbow Surgery |volume=8 |issue=5 |pages=481–91 |year=1999 |pmid=10543604 |doi=10.1016/S1058-2746(99)90081-2}}</ref> It is unclear if the pathology is affected by prior injection of [[corticosteroid]].{{citation needed|date=October 2020}} Tennis players generally believe tennis elbow is caused by the repetitive nature of hitting thousands of [[tennis balls]], which leads to tiny tears in the forearm tendon attachment at the elbow.<ref name="bbcsport">Craig Smith, [http://news.bbc.co.uk/sportacademy/hi/sa/treatment_room/features/newsid_3818000/3818931.stm "What is tennis elbow?"], [[BBC]] Sport Academy. Accessed 23 January 2018.</ref> The [[extensor digiti minimi]] also has a small origin site medial to the elbow that this condition can affect. The muscle involves the extension of the [[little finger]] and some extension of the wrist allowing for adaption to "snap" or flick the wrist—usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist—creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing [[irritation]] and inflammation.{{citation needed|date=October 2020}} At least one author questions that lateral epicondylitis is caused by repetitive [[microtrauma]]/overuse, maintaining the theory is likely overstated and lacks scientific support.<ref name="boyer"/> Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased [[mental chronometry]] and speed and repetitive [[eccentric contraction]] of muscle (controlled lengthening of a muscle group). ==Diagnosis== ===Physical examination=== To diagnose tennis elbow, [[physician]]s perform a battery of tests in which they place pressure on the affected area while asking the patient to move the elbow, wrist, and fingers. Diagnosis is made by clinical signs and symptoms that are discrete and characteristic. For example, when the elbow fully extended, the patient feels points of tenderness over the affected point on the elbow. The most common location of tenderness is at the origin of the [[extensor carpi radialis brevis muscle]] from the lateral epicondyle (extensor carpi radialis brevis origin), 1&nbsp;cm [[Anatomical terms of location|distal]] and slightly [[Anatomical terms of location|anterior]] to the lateral epicondyle.<ref name=":0" /> There is also pain with passive wrist [[flexion]] and resistive wrist [[Extension (kinesiology)|extension]] ([[Cozen's test]]).<ref name="nihgov">[https://www.nlm.nih.gov/medlineplus/ency/article/000449.htm Tennis elbow] from the MedlinePlus Medical Encyclopedia</ref> ===Medical imaging=== X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as [[fracture]] or [[arthritis]]. Rarely, calcification can be found where the extensor muscles attach to the lateral epicondyle.<ref name=":0" /> [[Medical ultrasonography]] and [[magnetic resonance imaging]] (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost.<ref name="mayoclinic.com" /> [[MRI]] screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis muscle. ==Prevention== Where lateral epicondylitis is caused by playing tennis, another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore, an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases.<ref name="mayoclinic.com"/> Other ways to prevent tennis elbow: * Decrease the amount of playing time if already injured or feeling pain in outside part of the elbow. * Stay in overall good physical shape. * Strengthen the muscles of the forearm: ([[pronator quadratus]], [[pronator teres]], [[supinator muscle]]) and Extensor Carpi Radialis Longus and Brevis<ref>{{Cite journal|last1=Alizadehkhaiyat|first1=Omid|last2=Frostick|first2=Simon P.|date=2015-12-01|title=Electromyographic assessment of forearm muscle function in tennis players with and without Lateral Epicondylitis|journal=Journal of Electromyography and Kinesiology|language=en|volume=25|issue=6|pages=876–886|doi=10.1016/j.jelekin.2015.10.013|pmid=26559462|issn=1050-6411|url=http://hira.hope.ac.uk/id/eprint/610/1/Electromyographic%20Assessment%20of%20Forearm%20Muscle%20Function%20in%20Tennis%20Players%20With%20and%20Without%20Lateral%20Epicondylitis.pdf}}</ref>—the upper arm: ([[biceps]], [[triceps]])—and the [[shoulder]] ([[deltoid muscle]]) and upper back ([[trapezius]]). Increased muscular strength increases stability of joints such as the elbow. * Like other sports, use equipment appropriate to your ability, body size, and muscular strength.<ref name="mayoclinic.com"/> * Avoid any repetitive lifting or pulling of heavy objects (especially over your head)<ref>{{Cite news|url=http://www.dovemed.com/tennis-elbow/|title=Tennis Elbow|newspaper=DoveMed|access-date=2016-12-15}}</ref> Vibration dampers (otherwise known as "gummies") are not believed to be a reliable preventative measure. Rather, proper weight distribution in the racket is thought to be a more viable option in negating shock.<ref>http://www.racquetresearch.com/sevencri.htm#What Causes Tennis Elbow?</ref> ==Treatment== Evidence for the treatment of lateral epicondylitis before 2010 was poor.<ref name="BrJSportsMed2005-Bisset">{{cite journal |vauthors=Bisset L, Paungmali A, Vicenzino B, Beller E |title=A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia |journal=British Journal of Sports Medicine |volume=39 |issue=7 |pages=411–22; discussion 411–22 |date=July 2005 |pmid=15976161 |pmc=1725258 |doi=10.1136/bjsm.2004.016170}}</ref> There were clinical trials addressing many proposed treatments, but the trials were of poor quality.<ref>{{cite journal |vauthors=Cowan J, Lozano-Calderón S, Ring D |title=Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example |journal=The Journal of Bone and Joint Surgery |volume=89 |issue=8 |pages=1693–9 |date=August 2007 |pmid=17671006 |doi=10.2106/JBJS.F.00858}}</ref> In some cases, severity of tennis elbow symptoms mend without any treatment, within six to 24 months. Tennis elbow left untreated can lead to chronic pain that degrades quality of daily living.<ref name="mayoclinic.com"/> ===Physical therapy=== There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including stretches and progressive strengthening exercises to prevent re-irritation of the tendon<ref name="BrJSportsMed2005-Stasinopoulos">{{cite journal |vauthors=Stasinopoulos D, Stasinopoulou K, Johnson MI |title=An exercise programme for the management of lateral elbow tendinopathy |journal=British Journal of Sports Medicine |volume=39 |issue=12 |pages=944–7 |date=December 2005 |pmid=16306504 |pmc=1725102 |doi=10.1136/bjsm.2005.019836}}</ref> and other exercise measures.<ref>{{cite web |url=http://www.tenniselbowsolutions.co.uk/cure-your-tennis-elbow.html |title=Archived copy |access-date=2015-03-12 |url-status=dead |archive-url=https://web.archive.org/web/20150402151902/http://www.tenniselbowsolutions.co.uk/cure-your-tennis-elbow.html |archive-date=2015-04-02 }}</ref> One way to help treat minor cases of tennis elbow is simply to relax the affected arm. The rest lets stress and tightness within the forearm slowly relax and eventually have the arm in working condition—in a day or two, depending on the case. Eccentric exercise using a rubber bar is highly effective at eliminating pain and increasing strength.<ref name="Tyler">{{cite journal|author1=Tyler Timothy F.|author2=Thomas Gregory C.|author3=Nicholas Stephen J.|author4=McHuch Malachy P.|year=2010|title=Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis:a radomized trial|journal=Journal of Shoulder and Elbow Surgery|volume=19|issue=6|pages=917–922|doi=10.1016/j.jse.2010.04.041|pmid=20579907}}</ref><ref name="Reynolds">Reynolds, Gretchen, "Phys Ed:An Easy Fix for Tennis Elbow?", ''The New York Times'', August 25, 2009, 11:54 pm</ref> The exercise involves grasping a rubber bar, twisting it, then slowly untwisting it.<ref name="Tyler" /><ref>[http://www.thera-bandacademy.com/elements/clients/docs/Tyler%20et%20al%20JSES%202010__201009DD_123442.pdf]</ref> Although it can be considered an evidence-based practice, long-term results have not yet been determined.<ref>{{Cite journal|last=Page|first=Phil|date=September 2010|journal=North American Journal of Sports Physical Therapy : NAJSPT|volume=5|issue=3|pages=189–193|issn=1558-6162|pmc=2971639|pmid=21589674|title=A new exercise for tennis elbow that works!}}</ref> There are differences in opinions on whether it is okay if pain occurs during these exercises.<ref name=Coom2015/> Some suggest pain of less than 5/10 is okay.<ref name=Coom2015>{{Cite journal|last1=Coombes|first1=Brooke K.|last2=Bisset|first2=Leanne|last3=Vicenzino|first3=Bill|date=November 2015|title=Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All|journal=Journal of Orthopaedic & Sports Physical Therapy|language=en|volume=45|issue=11|pages=938–949|doi=10.2519/jospt.2015.5841|issn=0190-6011|pmid=26381484|doi-access=free}}</ref> Moderate evidence exists demonstrating that [[joint manipulation]] directed at the elbow and wrist and [[spinal manipulation]] directed at the cervical and thoracic spinal regions results in clinical changes to pain and function.<ref>{{cite journal |journal=Journal of Manual & Manipulative Therapy |year=2007 |volume=15 |issue=1 |pages=50–56 |title=Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary |vauthors=Vicenzino B, Cleland JA, Bisset L |doi= 10.1179/106698107791090132|pmid=19066643 | pmc=2565595 }}</ref><ref>{{cite journal |journal= Journal of Manual & Manipulative Therapy |year=2008 |volume=16 |issue=4 |pages=225–37 |title= A Systematic Review of the Effectiveness of Manipulative Therapy in Treating Lateral Epicondylalgia |vauthors=Herd CR, Meserve BB |doi= 10.1179/106698108790818288|pmid=19771195 |pmc= 2716156}}</ref> There is also moderate evidence for short-term and mid-term effectiveness of cervical and thoracic spine manipulation as an add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. Although not yet conclusive, the short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises, resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.<ref>{{cite journal |journal=Br J Sports Med |year=2013 |volume= 47|issue= 17|pages= 1112–9|title=Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. |vauthors=Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM |s2cid=1679092 |doi= 10.1136/bjsports-2012-091990|pmid=23709519 }}</ref> Low level laser therapy, administered at specific doses and wavelengths directly to the lateral elbow tendon insertions, may result in short-term pain relief and less disability.<ref>{{cite journal |journal= BMC Musculoskeletal Disorders |year=2008 |volume=9 |page=75 |title= A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow) |vauthors=Bjordal JM, Lopes-Martins RA, Joensen J, Couppe C, Ljunggren AE, Stergioulas A, Johnson MI |doi= 10.1186/1471-2474-9-75|pmid=18510742 | pmc=2442599}}</ref> Extracorporeal shockwave therapy, while safe, is of unclear benefit.<ref>{{cite web|url=https://www.nice.org.uk/guidance/ipg313/chapter/1-Guidance |work=Interventional procedures guidance |id=IPG313 |date=August 2009 |title=Extracorporeal shockwave therapy for refractory tennis elbow |publisher=National Institute for Health and Clinical Excellence}}</ref><ref>{{cite journal |vauthors=Thiele S, Thiele R, Gerdesmeyer L |title=Lateral epicondylitis: This is still a main indication for extracorporeal shockwave therapy |journal=International Journal of Surgery |volume= 24|issue= Pt B|pages= 165–70|year=2015 |pmid=26455532 |doi=10.1016/j.ijsu.2015.09.034 |doi-access=free }}</ref> ===Orthotic devices=== [[File:Counterforce brace YM.jpg|thumb|Counterforce orthosis reduces the elongation within the musculotendinous fibers]] [[File:Wrist brace.jpg|thumb|Wrist extensor orthosis reduces the overloading strain at the lesion area]] Orthosis is a device externally used on the limb to improve the function or reduce the pain. Orthotics may be useful in tennis elbow, however long-term effects are unknown.<ref>{{Cite journal|last1=Struijs|first1=Peter AA|last2=Smidt|first2=Nynke|last3=Arola|first3=H|last4=van Dijk|first4=C N|author-link5=Rachelle Buchbinder |last5=Buchbinder|first5=Rachelle|last6=Assendelft|first6=Willem JJ|date=2002-01-21|title=Orthotic devices for the treatment of tennis elbow|journal=Cochrane Database of Systematic Reviews|doi=10.1002/14651858.cd001821|issn=1465-1858}}</ref> There are two main types of orthoses prescribed for this problem: counterforce elbow orthoses and wrist extension orthoses. Counterforce orthosis has a circumferential structure surrounding the arm. This orthosis usually has a strap which applies a binding force over the origin of the wrist extensors. The applied force by orthosis reduces the elongation within the musculotendinous fibers. Wrist extensor orthosis maintains the wrist in the slight extension. This position reduces the overloading strain at the lesion area.{{citation needed|date=October 2020}} Studies indicated both type of orthoses improve the hand function<ref name="pmid19487823">{{cite journal | vauthors = Jafarian FS, Demneh ES, Tyson SF | title = The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis | journal = J Orthop Sports Phys Ther | volume = 39 | issue = 6 | pages = 484–9 | date = June 2009 | pmid = 19487823 | doi = 10.2519/jospt.2009.2988 |issn = 0190-6011| doi-access = free }}</ref> and reduce the pain<ref>{{Cite journal|title = The Immediate Effects of Orthoses on Pain in People with Lateral Epicondylalgia|journal = Pain Research and Treatment|date = 2013-01-01|pmc = 3854508|pmid = 24349776|volume = 2013|doi = 10.1155/2013/353597|first1 = Ebrahim|last1 = Sadeghi-Demneh|first2 = Fahimehsadat|last2 = Jafarian|pages=353597}}</ref> in people with tennis elbow. ===Medication=== Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit.<ref name=uptodate>{{cite web|last1=Jayanthi|first1=Neeru|title=Epicondylitis (tennis and golf elbow)|url=http://www.uptodate.com/contents/epicondylitis-tennis-and-golf-elbow|website=UpToDate|publisher=UpToDate, Inc.|access-date=17 August 2015|ref=uptodate}}</ref> A systematic review found that topical [[non-steroidal anti-inflammatory drug]]s (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues.<ref name=Patt2013/> Evidence for oral NSAIDs is mixed.<ref name=Patt2013>{{cite journal|last=Pattanittum|first=P|author2=Turner, T |author3=Green, S |author-link4=Rachelle Buchbinder |author4= Buchbinder, R |title=Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults.|journal=The Cochrane Database of Systematic Reviews|date=May 31, 2013|volume=5|issue=5|pages=CD003686|pmid=23728646|doi=10.1002/14651858.CD003686.pub2|pmc=7173751}}</ref> Evidence is poor for long term improvement from injections of any type, whether [[corticosteroids]], [[botulinum toxin]], [[prolotherapy]] or other substances.<ref>{{cite journal|last=Krogh|first=TP|author2=Bartels, EM |author3=Ellingsen, T |author4=Stengaard-Pedersen, K |author-link5=Rachelle Buchbinder|author5=Buchbinder, R |author6=Fredberg, U |author7=Bliddal, H |author8= Christensen, R |s2cid=25355427|title=Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials.|journal=The American Journal of Sports Medicine|date=June 2013|volume=41|issue=6|pages=1435–46|pmid=22972856|doi=10.1177/0363546512458237}}</ref> Corticosteroid injection may be effective in the short term<ref name="PMID20970844">{{cite journal|last=Coombes|first=BK|author2=Bisset, L |author3=Vicenzino, B |s2cid=45054853|title=Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials|journal=Lancet|date=Nov 20, 2010|volume=376|issue=9754|pages=1751–67|pmid=20970844|doi=10.1016/S0140-6736(10)61160-9|url=http://espace.library.uq.edu.au/view/UQ:225158/UQ225158_OA.pdf|hdl=10072/35812}}</ref> however are of little benefit after a year, compared to a wait-and-see approach.<ref>{{cite journal |vauthors=Haines T, Stringer B |s2cid=43254510 |title=Corticosteroid injections or physiotherapy were not more effective than "wait-and-see" for tennis elbow at one year |journal= Evidence-Based Medicine|volume=12 |issue=2 |page=39 |date=April 2007 |pmid=17400631 |doi=10.1136/ebm.12.2.39}}</ref> A recent [[randomized control trial]] comparing the effect of [[corticosteroid]] injection, [[physiotherapy]], or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year ([[Relative risk]] 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23).<ref>{{cite journal|last=Coombes|first=BK|author2=Bisset, L |author3=Brooks, P |author4=Khan, A |author5= Vicenzino, B |title=Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.|journal=JAMA: The Journal of the American Medical Association|date=Feb 6, 2013|volume=309|issue=5|pages=461–9|pmid=23385272 |doi=10.1001/jama.2013.129|url=https://espace.library.uq.edu.au/view/UQ:294650/UQ294650_OA.pdf}}</ref> Complications from repeated steroid injections include skin problems such as [[hypopigmentation]] and fat atrophy leading to indentation of the skin around the injection site.<ref name="PMID20970844" /> Steroid injections against appear to be more effective than shock wave therapy.<ref>{{Cite journal|author-link=Rachelle Buchbinder|last1=Buchbinder|first1=Rachelle|last2=Green|first2=Sally|last3=Youd|first3=Joanne M|last4=Assendelft|first4=Willem JJ|last5=Barnsley|first5=Les|last6=Smidt|first6=Nynke|date=2005-10-19|title=Shock wave therapy for lateral elbow pain|journal=Cochrane Database of Systematic Reviews|issue=4|pages=CD003524|doi=10.1002/14651858.cd003524.pub2|pmid=16235324|issn=1465-1858}}</ref> [[Botulinum toxin]] type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be viable.<ref>{{cite journal|last=Kalichman|first=L |author2=Bannuru, RR |author3=Severin, M |author4=Harvey, W|title=Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis|journal=Seminars in Arthritis and Rheumatism|date=June 2011|volume=40|issue=6|pages=532–8|pmid=20822798|doi=10.1016/j.semarthrit.2010.07.002}}</ref> ===Surgery=== In recalcitrant cases [[surgery]] may be an option.<ref>{{cite journal|last1=Monto|first1=R|s2cid=58020081|title=Tennis elbow repair with or without suture anchors: a randomized clinical trial|journal=Techniques in Shoulder and ELbow Surgery|date=September 2014|volume=15|issue=3|pages=92–97|doi=10.1097/BTE.0000000000000027}}</ref><ref name="pmi17632419">{{cite journal|last=Lo|first=MY|author2=Safran, MR |title=Surgical treatment of lateral epicondylitis: a systematic review|journal=Clinical Orthopaedics and Related Research|date=October 2007|volume=463|pages=98–106|pmid=17632419|doi=10.1097/BLO.0b013e3181483dc4|s2cid=6954029}}</ref><ref name="pmid23388420">{{cite journal | vauthors = Solheim E, Hegna J, Øyen J | title = Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows | journal = Arthroscopy | volume = 29 | issue = 5 | pages = 854–9 | date = May 2013 | pmid = 23388420 | doi = 10.1016/j.arthro.2012.12.012 }}</ref> Surgical methods include:<ref name="FaroWolf2007">{{cite journal|last1=Faro|first1=Frances|last2=Wolf|first2=Jennifer Moriatis|title=Lateral Epicondylitis: Review and Current Concepts|journal=The Journal of Hand Surgery|volume=32|issue=8|year=2007|pages=1271–1279|issn=0363-5023|doi=10.1016/j.jhsa.2007.07.019|pmid=17923315}}</ref> * Lengthening, release, debridement, or repair of the origin of the [[extrinsic extensor muscles of the hand]] at the [[lateral epicondyle of the humerus|lateral epicondyle]] * Rotation of the [[anconeus muscle]] * Denervation of the [[lateral epicondyle of the humerus|lateral epicondyle]] * Decompression of the [[posterior interosseous nerve]] Surgical techniques for lateral epicondylitis can be done by [[open surgery]], [[percutaneous surgery]] or [[arthroscopic surgery]], with no high-quality evidence that any particular type is better or worse than another.<ref name=":1">{{Cite journal|last1=Bateman|first1=Marcus|last2=Littlewood|first2=Chris|last3=Rawson|first3=Beth|last4=Tambe|first4=Amol A.|date=February 2019|title=Surgery for tennis elbow: a systematic review|url=http://journals.sagepub.com/doi/10.1177/1758573217745041|journal=Shoulder & Elbow|language=en|volume=11|issue=1|pages=35–44|doi=10.1177/1758573217745041|issn=1758-5732|pmc=6348580|pmid=30719096}}</ref><ref name="pmi17632419"/> Side effects include infection, damage to nerves and inability to straighten the arm.<ref>{{Cite journal|author-link=Rachelle Buchbinder|last1=Buchbinder|first1=Rachelle|last2=Johnston|first2=Renea V|last3=Barnsley|first3=Les|last4=Assendelft|first4=Willem JJ|last5=Bell|first5=Simon N|last6=Smidt|first6=Nynke|date=2011-03-16|title=Surgery for lateral elbow pain|journal=Cochrane Database of Systematic Reviews|issue=3|pages=CD003525|doi=10.1002/14651858.cd003525.pub2|pmid=21412883|issn=1465-1858|pmc=7154580}}</ref> A review of the evidence related to surgery found that published studies were of low quality and did not show that surgery was any more effective than other treatments.<ref name=":1" /> A subsequent research trial showed that surgery was no more effective than sham surgery, where patients only received a skin incision, although the trial was limited by a small number of patients.<ref>{{Cite journal|last1=Kroslak|first1=Martin|last2=Murrell|first2=George A. C.|date=2018-03-02|title=Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial|url=https://journals.sagepub.com/doi/10.1177/0363546517753385|journal=The American Journal of Sports Medicine|volume=46|issue=5|pages=1106–1113|language=en|doi=10.1177/0363546517753385|pmid=29498885|s2cid=4487650}}</ref> ==Prognosis== Response to initial therapy is common, but so is relapse (25% to 50%) and/or prolonged, moderate discomfort (40%).{{citation needed|date=October 2020}} Depending upon severity and quantity of multiple tendon injuries that have built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl defines four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2. # Inflammatory changes that are reversible # Nonreversible pathologic changes to origin of the extensor carpi radialis brevis muscle # Rupture of ECRB muscle origin # Secondary changes such as fibrosis or calcification.<ref name="Lateral Epicondylitis: Workup">{{cite web|url=http://emedicine.medscape.com/article/1231903-diagnosis|title=Lateral Epicondylitis: Workup|last1=Owens|first1=Brett D|last2=Moriatis Wolf|first2=Jennifer|date=2009-11-03|publisher=eMedicine Orthopedic Surgery|access-date=2010-04-19|last3=Murphy|first3=Kevin P}}</ref> ==Epidemiology== In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling," while 42% over the age of 50 did. More women (36%) than men (24%) considered their symptoms severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a four-fold increase among men and two-fold increase among women. Tennis elbow equally affects both sexes and, although men have a marginally higher overall prevalence rate as compared to women, this is not consistent within each age group, nor is it a statistically significant difference.<ref>{{cite journal | author = Gruchow William, Pelletier Douglas | s2cid = 20360265 | year = 1979 | title = An epidemiologic study of tennis elbow: Incidence, recurrence, and effectiveness of prevention strategies | journal = American Journal of Sports Medicine | volume = 7 | issue = 4| pages = 234–238 | doi=10.1177/036354657900700405| pmid = 474862 }}</ref> Playing time is a significant factor in tennis elbow occurrence, with increased incidence with increased playing time being greater for respondents under 40. Individuals over 40 who played over two hours doubled their chance of injury. Those under 40 increased it 3.5 fold compared to those who played less than two hours per day.<ref name="mayoclinic.com"/> ==History== German physician F. Runge<ref>{{cite journal | year = 1886 | url = http://www.thelancet.com/action/doSearch?journalCode=lancet&searchText1=tennis&occurrences1=all&op1=and&searchText2=&occurrences2=all&seriesISSNFltraddfilter=0140-6736&date=custom&fMonth=1&fYear=1800&lMonth=1&lYear=1900&searchAttempt=&searchType=advanced& | journal = The Lancet | volume = 128 | issue = 3301| page = 1083 | doi=10.1016/s0140-6736(00)49587-5| title = Tennis Elbow-Cap }}</ref> is usually credited for the first description of the condition, calling it "writer's cramp" (''Schreibekrampf'') in 1873.<ref>{{cite journal | author = Runge F | year = 1873 | title = Zur Genese und Behandlung des Schreibekrampfes. | journal = Berliner Klin Wochenschr | volume = 10 | pages = 245–248 }}</ref> Later, it was called "washer women's elbow".<ref>[https://books.google.ae/books?id=oaH9AQAAQBAJ&pg=PA155&lpg=PA155&dq=tennis+is+played+today+by+millions+of+people+around+the+world&source=bl&ots=v3ysjkT6ek&sig=tJlKj7JNBBZsOjXLWRhUuEie4PI&hl=ar&sa=X&ved=0ahUKEwijnYO4ko3KAhXJ2xoKHU_aADAQ6AEIHDAA#v=onepage&q=tennis%20is%20played%20today%20by%20millions%20of%20people%20around%20the%20world&f=false Science and Racket Sports] Edited by: T. Reilly, M. Hughes and A.Lees. Published by E & FN Spon {{ISBN|0-419-18500-3}}.</ref> British surgeon Henry Morris published an article in ''[[The Lancet]]'' describing "lawn tennis arm" in 1883.<ref>{{cite journal | author = Flatt Adrian E | date = Oct 2008 | title = Tennis elbow | journal = Proc (Bayl Univ Med Cent). | volume = 21 | issue = 4| pages = 400–402 | pmc=2566914 | pmid=18982084| doi = 10.1080/08998280.2008.11928437 }}</ref><ref>{{cite journal | year = 1886 | url = http://www.thelancet.com/action/doSearch?journalCode=lancet&searchText1=tennis&occurrences1=all&op1=and&searchText2=&occurrences2=all&seriesISSNFltraddfilter=0140-6736&date=custom&fMonth=1&fYear=1800&lMonth=1&lYear=1900&searchAttempt=&searchType=advanced&doSearch=Search | journal = The Lancet | volume = 128 | issue = 3301| page = 1083 | doi=10.1016/s0140-6736(00)49587-5| title = Tennis Elbow-Cap }}</ref> The popular term "tennis elbow" first appeared the same year in a paper by H. P. Major, described as "lawn-tennis elbow".<ref>{{cite journal | author = Major HP | year = 1883 | title = Lawn-tennis elbow | pmc = 2372911 | journal = BMJ | volume = 2 | issue = 1185| pages = 556–558 | doi = 10.1136/bmj.2.1185.556 }}</ref><ref name="TechHandUpExtremSurg2003-Kaminsky">{{cite journal |author=Kaminsky SB, Baker CL |title=Lateral epicondylitis of the elbow |journal=Techniques in Hand & Upper Limb Surgery |volume=7 |issue=4 |pages=179–89 |date=December 2003 |pmid=16518219 |doi=10.1097/00130911-200312000-00009 |last2=Baker|s2cid=128648 }}</ref> ==See also== {{Portal|Tennis}} * [[Olecranon bursitis]] * [[Repetitive strain injury]] * [[Radial tunnel syndrome]] ==References== {{Reflist}} ==External links== * {{cite journal |vauthors=Wilson JJ, Best TM |title=Common overuse tendon problems: A review and recommendations for treatment |journal=American Family Physician |volume=72 |issue=5 |pages=811–8 |date=September 2005 |pmid=16156339 |url=http://www.aafp.org/afp/20050901/811.html}} {{Medical resources | DiseasesDB = 12950 | ICD10 = {{ICD10|M|77|1|m|70}} | ICD9 = {{ICD9|726.32}} | ICDO = | OMIM = | MedlinePlus = 000449 | eMedicineSubj = orthoped | eMedicineTopic = 510 | eMedicine_mult = {{eMedicine2|pmr|64}} {{eMedicine2|sports|59}} | MeshID = D013716 }} {{Soft tissue disorders}} {{Inflammation}} {{DEFAULTSORT:Tennis Elbow}} [[Category:Inflammations]] [[Category:Overuse injuries]] [[Category:Tennis terminology]] [[Category:Sports injuries]] [[Category:Soft tissue disorders]] [[Category:Tennis culture]] [[Category:Wikipedia medicine articles ready to translate]]'
New page wikitext, after the edit (new_wikitext)
' | width = 150px | caption = Left [[elbow-joint]], showing posterior and radial collateral [[ligaments]]. ([[Lateral epicondyle of the humerus|Lateral epicondyle]] visible at center.) | pronounce = | field = [[Orthopedics]], [[sports medicine]] | symptoms = Painful and tender outer part of the elbow<ref name=Hub2018/> | complications = | onset = Gradual<ref name=AI2015/> | duration = Less than 1 to 2 years<ref name=Vaq2016/> | types = | causes = Excessive use of the muscles of the [[posterior compartment of the forearm|back of the forearm]]<ref name=AI2015/> | risks = Smoking, [[obesity]]<ref name=Vaq2016/> | diagnosis = Based on symptoms with [[medical imaging]] used to rule out other potential causes<ref name=AI2015/> | differential = [[Osteochondritis dissecans]], [[osteoarthritis]], [[radiculopathy]]<ref name=Vaq2016/> | prevention = | treatment = Changing activities, [[physical therapy]], pain medication<ref name=Hub2018/> | medication = | prognosis = | frequency = c. 2%<ref name=Vaq2016/> | deaths = }} <!-- Definition and symptoms --> '''Tennis elbow''', also known as '''lateral epicondylitis''', is a condition in which the outer part of the [[Elbow-joint|elbow]] becomes painful and tender.<ref name=Hub2018>{{cite journal |last1=Hubbard |first1=MJ |last2=Hildebrand |first2=BA |last3=Battafarano |first3=MM |last4=Battafarano |first4=DF |title=Common Soft Tissue Musculoskeletal Pain Disorders. |journal=Primary Care |date=June 2018 |volume=45 |issue=2 |pages=289–303 |doi=10.1016/j.pop.2018.02.006 |pmid=29759125}}</ref> The pain may also extend into the back of the [[forearm]] and [[grip strength]] may be weak.<ref name=AI2015/><ref name=Hub2018/> Onset of symptoms is generally gradual.<ref name=AI2015/> [[Golfer's elbow]] is a similar condition that affects the [[Medial epicondyle of the humerus|inside of the elbow]].<ref name=Hub2018/> <!-- Cause and diagnosis --> It is due to excessive use of the muscles of the [[posterior compartment of the forearm|back of the forearm]].<ref name=AI2015>{{cite web |title=Tennis Elbow (Lateral Epicondylitis) |url=http://orthoinfo.aaos.org/topic.cfm?topic=a00068 |website=OrthoInfo |access-date=21 June 2018 |date=July 2015}}</ref> Typically this occurs as a result of work or sports, classically [[racquet sports]].<ref name=Hub2018/><ref name=AI2015/> The diagnosis is typically based on the symptoms with [[medical imaging]] used to rule out other potential causes.<ref name=AI2015/> It is more likely if pain increases when a subject tries to [[dorsiflexion|bend back]] the wrist when the wrist is held in a neutral position.<ref name=Hub2018/> A powered screwdriver can cause this injury if overused one-handed. It is classified as a chronic [[tendinosis]], not a [[tendinitis]].<ref name=Hub2018/> <!-- Treatment and prognosis--> Treatment involves decreasing activities that bring on the symptoms together with [[physical therapy]] or other treatment gradually increasing loads.<ref>{{cite journal |last1=Orchard |first1=J |last2=Kountouris |first2=A |title=The management of tennis elbow. |journal=BMJ (Clinical Research Ed.) |date=10 May 2011 |volume=342 |pages=d2687 |doi=10.1136/bmj.d2687 |pmid=21558359|s2cid=8358075 }}</ref><ref name=Hub2018/> Pain medications such as [[NSAIDS]] or [[acetaminophen]] (paracetamol) may be used.<ref name=Hub2018/> A brace over the upper forearm may also be helpful.<ref name=AI2015/> If the condition does not improve [[corticosteroid]] injections or surgery may be recommended <ref name=Hub2018/> although some experts recommend avoiding cortisone injections due to poor long-term results in high-quality trials.<ref>{{Cite journal|last1=Olaussen|first1=Morten|last2=Holmedal|first2=Øystein|last3=Mdala|first3=Ibrahimu|last4=Brage|first4=Søren|last5=Lindbæk|first5=Morten|date=2015-05-20|title=Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial|url=https://doi.org/10.1186/s12891-015-0582-6|journal=BMC Musculoskeletal Disorders|volume=16|issue=1|pages=122|doi=10.1186/s12891-015-0582-6|issn=1471-2474|pmc=4438532|pmid=25989985}}</ref><ref>{{Cite journal|last1=Bisset|first1=Leanne|last2=Beller|first2=Elaine|last3=Jull|first3=Gwendolen|last4=Brooks|first4=Peter|last5=Darnell|first5=Ross|last6=Vicenzino|first6=Bill|date=2006-11-02|title=Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial|url=https://www.bmj.com/content/333/7575/939|journal=BMJ|language=en|volume=333|issue=7575|pages=939|doi=10.1136/bmj.38961.584653.AE|issn=0959-8138|pmc=1633771|pmid=17012266}}</ref><ref>{{Cite journal|last1=Coombes|first1=Brooke K.|last2=Bisset|first2=Leanne|last3=Brooks|first3=Peter|last4=Khan|first4=Asad|last5=Vicenzino|first5=Bill|date=2013-02-06|title=Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial|url=http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2013.129|journal=JAMA|language=en|volume=309|issue=5|pages=461–9|doi=10.1001/jama.2013.129|pmid=23385272|issn=0098-7484|doi-access=free}}</ref><ref>{{cite journal |last1=Orchard |first1=JW |last2=Vicenzino |first2=B |title=Cortisone injections for tennis elbow should be an "avoid", rather than a recommended procedure. |journal=The Medical Journal of Australia |date=20 November 2017 |volume=207 |issue=10 |pages=453 |doi=10.5694/mja17.00445 |pmid=29129178|s2cid=20903534 }}</ref> Many people get better within one month to two years.<ref name=Vaq2016>{{cite journal |last1=Vaquero-Picado |first1=A |last2=Barco |first2=R |last3=Antuña |first3=SA |title=Lateral epicondylitis of the elbow. |journal=EFORT Open Reviews |date=November 2016 |volume=1 |issue=11 |pages=391–397 |doi=10.1302/2058-5241.1.000049 |pmid=28461918|pmc=5367546 }}</ref><ref name=Lian2018>{{Cite journal|last1=Lian|first1=Jayson|last2=Mohamadi|first2=Amin|last3=Chan|first3=Jimmy J.|last4=Hanna|first4=Phillip|last5=Hemmati|first5=David|last6=Lechtig|first6=Aron|last7=Nazarian|first7=Ara|s2cid=53148287|date=2018-10-31|title=Comparative Efficacy and Safety of Nonsurgical Treatment Options for Enthesopathy of the Extensor Carpi Radialis Brevis: A Systematic Review and Meta-analysis of Randomized Placebo-Controlled Trials|journal=The American Journal of Sports Medicine|volume=47|issue=12|pages=3019–3029|doi=10.1177/0363546518801914|issn=1552-3365|pmid=30380334}}</ref> <!-- Epidemiology and history --> About 2% of people are affected.<ref name=Vaq2016/> Those 30 to 50 years old are most commonly affected.<ref name=AI2015/> The condition was initially described in 1873.<ref name=Vaq2016/> The name "[[lawn tennis]] elbow" first came into use for the condition in 1882.<ref>{{cite book |last1=Wolf |first1=Jennifer Moriatis |title=Tennis Elbow: Clinical Management |date=2015 |publisher=Springer |isbn=9781489975348 |page=1 |url=https://books.google.com/books?id=pZxqCQAAQBAJ&pg=PA1 |language=en}}</ref> ==Signs and Symptoms== * Pain on the outer part of the elbow ([[Lateral epicondyle of the humerus|lateral epicondyle]]) * Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow * Pain from gripping and movements of the [[wrist]], especially wrist extension (e.g. turning a screwdriver) and lifting movements<ref name=":0">{{Cite book|title=Essentials of musculoskeletal care|date=2010|publisher=American Academy of Orthopaedic Surgeons|others=Sarwark, John F.|isbn=978-0892035793|location=Rosemont, Ill.|oclc=706805938}}</ref> Symptoms associated with tennis elbow include, but are not limited to, radiating pain from the outside of the elbow to the [[forearm]] and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing a [[doorknob]], and not being able to hold relatively heavy items in the hand.<ref>{{Cite journal|last1=Geoffroy|first1=P.|last2=Yaffe|first2=M. J.|last3=Rohan|first3=I.|date=January 1994|title=Diagnosing and treating lateral epicondylitis.|journal=Canadian Family Physician|volume=40|pages=73–78|issn=0008-350X|pmc=2379994|pmid=8312757}}</ref> The pain is similar to the condition known as ''[[golfer's elbow]]'', but the latter occurs at the medial side of the elbow.<ref name="mayoclinic.com">"Tennis Elbow – MayoClinic.com." Mayo Clinic Medical Information and Tools for Healthy Living – MayoClinic.com. 15 Oct. 2008. Web. 10 Oct. 2010. [http://www.mayoclinic.com/health/tennis-elbow/DS00469]</ref> ===Terminology=== The term "tennis elbow" is widely used (although informal), but the condition should be understood as not limited to tennis players.<ref name= "cleveland_clinic">[https://my.clevelandclinic.org/treatment-guides/22-0069-elbow-pain-guide#fractures-sports-injuries-tab "Tennis elbow (lateral epicondylitis)"], ''Elbow Pain,'' Cleveland Clinic, 2018. Accessed 23 January 2018.</ref><ref name= "mayo_clinic">[https://www.mayoclinic.org/diseases-conditions/tennis-elbow/symptoms-causes/syc-20351987 "Tennis elbow"], Mayo Clinic, Aug. 2, 2017. Accessed 23 January 2018.</ref> Historically, the medical term "lateral epicondylitis" was most commonly used for the condition.<ref name= AI2015 /><ref name= "cleveland_clinic" /><ref name= "mayo_clinic" /><ref name="bbcsport" /> Since histological findings reveal noninflammatory tissue, the term “lateral elbow [[tendinopathy]]," "[[tendinosis]],” or “angio-fibroblastic tendinosis” have been suggested instead of “lateral epicondylitis”.<ref name="pmid16998100"/><ref name="du ToitStieler2008"/> Most recently, in 2019, a group of international experts agreed that "lateral elbow tendinopathy" was the most appropriate terminology.<ref>{{Cite journal|last1=Scott|first1=Alex|last2=Squier|first2=Kipling|last3=Alfredson|first3=Hakan|last4=Bahr|first4=Roald|last5=Cook|first5=Jill L|last6=Coombes|first6=Brooke|last7=de Vos|first7=Robert-Jan|last8=Fu|first8=Siu Ngor|last9=Grimaldi|first9=Alison|last10=Lewis|first10=Jeremy S|last11=Maffulli|first11=Nicola|date=March 2020|title=ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology|url=https://bjsm.bmj.com/lookup/doi/10.1136/bjsports-2019-100885|journal=British Journal of Sports Medicine|language=en|volume=54|issue=5|pages=260–262|doi=10.1136/bjsports-2019-100885|pmid=31399426|s2cid=199517946|issn=0306-3674|doi-access=free}}</ref> ==Causes== [[File:Tennis Elbow.png|thumb|Location of tennis elbow]] Tennis elbow is a type of [[repetitive strain injury]] resulting from tendon overuse and failed healing of the tendon. In addition, the [[extensor carpi radialis brevis]] muscle plays a key role.<ref name="du ToitStieler2008">{{cite journal|last1=du Toit|first1=C|last2=Stieler|first2=M|last3=Saunders|first3=R|last4=Bisset|first4=L|last5=Vicenzino|first5=B|s2cid=3274396|title=Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow|journal=British Journal of Sports Medicine|volume=42|issue=11|year=2008|pages=572–576|issn=0306-3674|doi=10.1136/bjsm.2007.043901|pmid=18308874|hdl=10072/22142|hdl-access=free}}</ref><ref name="pmid15116648">{{cite journal |vauthors=Nirschl RP, Ashman ES |title=Tennis elbow tendinosis (epicondylitis) |journal=Instr Course Lect |volume=53 |pages=587–98 |year=2004 |pmid=15116648 }}</ref> [[File:Tenniselbow.JPG|thumb|Example of repetitive movement that may cause tennis elbow]] Early [[experiment]]s suggested that tennis elbow was primarily caused by overexertion. However, studies show that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension cause more than half of these injuries.<ref name="KURPPA, K. 1979">KURPPA, K., WARIS, P. and ROKKANEN, P. Tennis elbow: Lateral elbow pain syndrome. ''Scand j. work environ. & health'' 5 (1979): suppl. 3, 15–18. A review of the etiology, occurrence and pathogenesis of "tennis elbow" is presented.</ref> Repeatedly mis-hitting a tennis ball in the early stages of learning the sport causes shock to the elbow joint and may contribute to contracting the condition.<ref>{{Cite web|url=https://orthoinfo.aaos.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/|title=Tennis Elbow (Lateral Epicondylitis)|date=July 2015|website=OrthoInfo|access-date=February 20, 2018|quote=In racquet sports like tennis, improper stroke technique and improper equipment may be risk factors.}}</ref> There are multiple aspects of tennis that may cause a player to develop “tennis elbow”. From a technical perspective, leading a backhand with your elbow, excessive pronation of the forearm when putting topspin on a forehand, and excessive flexion of the wrist on a serve can all greatly lead to tennis elbow. Other things that can be improved are: racquet type, grip size, string tension, type of court surface, and ball weight.<ref>{{Cite journal|last1=Keijsers|first1=Renée|last2=de Vos|first2=Robert-Jan|last3=Kuijer|first3=P Paul FM|last4=van den Bekerom|first4=Michel PJ|last5=van der Woude|first5=Henk-Jan|last6=Eygendaal|first6=Denise|date=2018-09-18|title=Tennis elbow|journal=Shoulder & Elbow|language=en-US|volume=11|issue=5|pages=384–392|doi=10.1177/1758573218797973|issn=1758-5732|pmc=6739751|pmid=31534489}}</ref> ==Pathophysiology== Histological findings include granulation tissue, micro-rupture, degenerative changes, and there is no traditional inflammation.<ref name="du ToitStieler2008"/><ref name="pmid1423702">{{cite journal |author=Nirschl RP |title=Elbow tendinosis/tennis elbow |journal=Clin Sports Med |volume=11 |issue=4 |pages=851–70 |date=October 1992 |pmid=1423702 |doi= 10.1016/S0278-5919(20)30489-0}}</ref><ref name=Lian2018/> Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term “epicondylitis” is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which replaces normal tissue with a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as ''tendinosis'' or ''tendinopathy'' rather than ''[[tendinitis]].''<ref name="pmid16998100">{{cite journal |vauthors=McShane JM, Nazarian LN, Harwood MI |title=Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow |journal=J Ultrasound Med |volume=25 |issue=10 |pages=1281–9 |date=October 2006 |pmid=16998100 |doi= 10.7863/jum.2006.25.10.1281|s2cid=22963436 |doi-access=free }}</ref> Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin.<ref name="ZeisigÖhberg2006">{{cite journal|last1=Zeisig|first1=Eva|last2=Öhberg|first2=Lars|last3=Alfredson|first3=Håkan|s2cid=23469092|title=Sclerosing polidocanol injections in chronic painful tennis elbow-promising results in a pilot study|journal=Knee Surgery, Sports Traumatology, Arthroscopy|volume=14|issue=11|year=2006|pages=1218–1224|issn=0942-2056|doi=10.1007/s00167-006-0156-0|pmid=16960741}}</ref> The [[pathophysiology]] of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the [[extensor carpi radialis brevis muscle|extensor carpi radialis brevis (ECRB) muscle]] are identified in surgical [[pathology]] specimens.<ref name="boyer">{{cite journal |vauthors=Boyer MI, Hastings H |title=Lateral tennis elbow: "Is there any science out there?" |journal=Journal of Shoulder and Elbow Surgery |volume=8 |issue=5 |pages=481–91 |year=1999 |pmid=10543604 |doi=10.1016/S1058-2746(99)90081-2}}</ref> It is unclear if the pathology is affected by prior injection of [[corticosteroid]].{{citation needed|date=October 2020}} Tennis players generally believe tennis elbow is caused by the repetitive nature of hitting thousands of [[tennis balls]], which leads to tiny tears in the forearm tendon attachment at the elbow.<ref name="bbcsport">Craig Smith, [http://news.bbc.co.uk/sportacademy/hi/sa/treatment_room/features/newsid_3818000/3818931.stm "What is tennis elbow?"], [[BBC]] Sport Academy. Accessed 23 January 2018.</ref> The [[extensor digiti minimi]] also has a small origin site medial to the elbow that this condition can affect. The muscle involves the extension of the [[little finger]] and some extension of the wrist allowing for adaption to "snap" or flick the wrist—usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist—creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing [[irritation]] and inflammation.{{citation needed|date=October 2020}} At least one author questions that lateral epicondylitis is caused by repetitive [[microtrauma]]/overuse, maintaining the theory is likely overstated and lacks scientific support.<ref name="boyer"/> Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased [[mental chronometry]] and speed and repetitive [[eccentric contraction]] of muscle (controlled lengthening of a muscle group). ==Diagnosis== ===Physical examination=== To diagnose tennis elbow, [[physician]]s perform a battery of tests in which they place pressure on the affected area while asking the patient to move the elbow, wrist, and fingers. Diagnosis is made by clinical signs and symptoms that are discrete and characteristic. For example, when the elbow fully extended, the patient feels points of tenderness over the affected point on the elbow. The most common location of tenderness is at the origin of the [[extensor carpi radialis brevis muscle]] from the lateral epicondyle (extensor carpi radialis brevis origin), 1&nbsp;cm [[Anatomical terms of location|distal]] and slightly [[Anatomical terms of location|anterior]] to the lateral epicondyle.<ref name=":0" /> There is also pain with passive wrist [[flexion]] and resistive wrist [[Extension (kinesiology)|extension]] ([[Cozen's test]]).<ref name="nihgov">[https://www.nlm.nih.gov/medlineplus/ency/article/000449.htm Tennis elbow] from the MedlinePlus Medical Encyclopedia</ref> ===Medical imaging=== X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as [[fracture]] or [[arthritis]]. Rarely, calcification can be found where the extensor muscles attach to the lateral epicondyle.<ref name=":0" /> [[Medical ultrasonography]] and [[magnetic resonance imaging]] (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost.<ref name="mayoclinic.com" /> [[MRI]] screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis muscle. ==Prevention== Where lateral epicondylitis is caused by playing tennis, another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore, an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases.<ref name="mayoclinic.com"/> Other ways to prevent tennis elbow: * Decrease the amount of playing time if already injured or feeling pain in outside part of the elbow. * Stay in overall good physical shape. * Strengthen the muscles of the forearm: ([[pronator quadratus]], [[pronator teres]], [[supinator muscle]]) and Extensor Carpi Radialis Longus and Brevis<ref>{{Cite journal|last1=Alizadehkhaiyat|first1=Omid|last2=Frostick|first2=Simon P.|date=2015-12-01|title=Electromyographic assessment of forearm muscle function in tennis players with and without Lateral Epicondylitis|journal=Journal of Electromyography and Kinesiology|language=en|volume=25|issue=6|pages=876–886|doi=10.1016/j.jelekin.2015.10.013|pmid=26559462|issn=1050-6411|url=http://hira.hope.ac.uk/id/eprint/610/1/Electromyographic%20Assessment%20of%20Forearm%20Muscle%20Function%20in%20Tennis%20Players%20With%20and%20Without%20Lateral%20Epicondylitis.pdf}}</ref>—the upper arm: ([[biceps]], [[triceps]])—and the [[shoulder]] ([[deltoid muscle]]) and upper back ([[trapezius]]). Increased muscular strength increases stability of joints such as the elbow. * Like other sports, use equipment appropriate to your ability, body size, and muscular strength.<ref name="mayoclinic.com"/> * Avoid any repetitive lifting or pulling of heavy objects (especially over your head)<ref>{{Cite news|url=http://www.dovemed.com/tennis-elbow/|title=Tennis Elbow|newspaper=DoveMed|access-date=2016-12-15}}</ref> Vibration dampers (otherwise known as "gummies") are not believed to be a reliable preventative measure. Rather, proper weight distribution in the racket is thought to be a more viable option in negating shock.<ref>http://www.racquetresearch.com/sevencri.htm#What Causes Tennis Elbow?</ref> ==Treatment== Evidence for the treatment of lateral epicondylitis before 2010 was poor.<ref name="BrJSportsMed2005-Bisset">{{cite journal |vauthors=Bisset L, Paungmali A, Vicenzino B, Beller E |title=A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia |journal=British Journal of Sports Medicine |volume=39 |issue=7 |pages=411–22; discussion 411–22 |date=July 2005 |pmid=15976161 |pmc=1725258 |doi=10.1136/bjsm.2004.016170}}</ref> There were clinical trials addressing many proposed treatments, but the trials were of poor quality.<ref>{{cite journal |vauthors=Cowan J, Lozano-Calderón S, Ring D |title=Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example |journal=The Journal of Bone and Joint Surgery |volume=89 |issue=8 |pages=1693–9 |date=August 2007 |pmid=17671006 |doi=10.2106/JBJS.F.00858}}</ref> In some cases, severity of tennis elbow symptoms mend without any treatment, within six to 24 months. Tennis elbow left untreated can lead to chronic pain that degrades quality of daily living.<ref name="mayoclinic.com"/> ===Physical therapy=== There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including stretches and progressive strengthening exercises to prevent re-irritation of the tendon<ref name="BrJSportsMed2005-Stasinopoulos">{{cite journal |vauthors=Stasinopoulos D, Stasinopoulou K, Johnson MI |title=An exercise programme for the management of lateral elbow tendinopathy |journal=British Journal of Sports Medicine |volume=39 |issue=12 |pages=944–7 |date=December 2005 |pmid=16306504 |pmc=1725102 |doi=10.1136/bjsm.2005.019836}}</ref> and other exercise measures.<ref>{{cite web |url=http://www.tenniselbowsolutions.co.uk/cure-your-tennis-elbow.html |title=Archived copy |access-date=2015-03-12 |url-status=dead |archive-url=https://web.archive.org/web/20150402151902/http://www.tenniselbowsolutions.co.uk/cure-your-tennis-elbow.html |archive-date=2015-04-02 }}</ref> One way to help treat minor cases of tennis elbow is simply to relax the affected arm. The rest lets stress and tightness within the forearm slowly relax and eventually have the arm in working condition—in a day or two, depending on the case. Eccentric exercise using a rubber bar is highly effective at eliminating pain and increasing strength.<ref name="Tyler">{{cite journal|author1=Tyler Timothy F.|author2=Thomas Gregory C.|author3=Nicholas Stephen J.|author4=McHuch Malachy P.|year=2010|title=Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis:a radomized trial|journal=Journal of Shoulder and Elbow Surgery|volume=19|issue=6|pages=917–922|doi=10.1016/j.jse.2010.04.041|pmid=20579907}}</ref><ref name="Reynolds">Reynolds, Gretchen, "Phys Ed:An Easy Fix for Tennis Elbow?", ''The New York Times'', August 25, 2009, 11:54 pm</ref> The exercise involves grasping a rubber bar, twisting it, then slowly untwisting it.<ref name="Tyler" /><ref>[http://www.thera-bandacademy.com/elements/clients/docs/Tyler%20et%20al%20JSES%202010__201009DD_123442.pdf]</ref> Although it can be considered an evidence-based practice, long-term results have not yet been determined.<ref>{{Cite journal|last=Page|first=Phil|date=September 2010|journal=North American Journal of Sports Physical Therapy : NAJSPT|volume=5|issue=3|pages=189–193|issn=1558-6162|pmc=2971639|pmid=21589674|title=A new exercise for tennis elbow that works!}}</ref> There are differences in opinions on whether it is okay if pain occurs during these exercises.<ref name=Coom2015/> Some suggest pain of less than 5/10 is okay.<ref name=Coom2015>{{Cite journal|last1=Coombes|first1=Brooke K.|last2=Bisset|first2=Leanne|last3=Vicenzino|first3=Bill|date=November 2015|title=Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All|journal=Journal of Orthopaedic & Sports Physical Therapy|language=en|volume=45|issue=11|pages=938–949|doi=10.2519/jospt.2015.5841|issn=0190-6011|pmid=26381484|doi-access=free}}</ref> Moderate evidence exists demonstrating that [[joint manipulation]] directed at the elbow and wrist and [[spinal manipulation]] directed at the cervical and thoracic spinal regions results in clinical changes to pain and function.<ref>{{cite journal |journal=Journal of Manual & Manipulative Therapy |year=2007 |volume=15 |issue=1 |pages=50–56 |title=Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary |vauthors=Vicenzino B, Cleland JA, Bisset L |doi= 10.1179/106698107791090132|pmid=19066643 | pmc=2565595 }}</ref><ref>{{cite journal |journal= Journal of Manual & Manipulative Therapy |year=2008 |volume=16 |issue=4 |pages=225–37 |title= A Systematic Review of the Effectiveness of Manipulative Therapy in Treating Lateral Epicondylalgia |vauthors=Herd CR, Meserve BB |doi= 10.1179/106698108790818288|pmid=19771195 |pmc= 2716156}}</ref> There is also moderate evidence for short-term and mid-term effectiveness of cervical and thoracic spine manipulation as an add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. Although not yet conclusive, the short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises, resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.<ref>{{cite journal |journal=Br J Sports Med |year=2013 |volume= 47|issue= 17|pages= 1112–9|title=Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. |vauthors=Hoogvliet P, Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM |s2cid=1679092 |doi= 10.1136/bjsports-2012-091990|pmid=23709519 }}</ref> Low level laser therapy, administered at specific doses and wavelengths directly to the lateral elbow tendon insertions, may result in short-term pain relief and less disability.<ref>{{cite journal |journal= BMC Musculoskeletal Disorders |year=2008 |volume=9 |page=75 |title= A systematic review with procedural assessments and meta-analysis of Low Level Laser Therapy in lateral elbow tendinopathy (tennis elbow) |vauthors=Bjordal JM, Lopes-Martins RA, Joensen J, Couppe C, Ljunggren AE, Stergioulas A, Johnson MI |doi= 10.1186/1471-2474-9-75|pmid=18510742 | pmc=2442599}}</ref> Extracorporeal shockwave therapy, while safe, is of unclear benefit.<ref>{{cite web|url=https://www.nice.org.uk/guidance/ipg313/chapter/1-Guidance |work=Interventional procedures guidance |id=IPG313 |date=August 2009 |title=Extracorporeal shockwave therapy for refractory tennis elbow |publisher=National Institute for Health and Clinical Excellence}}</ref><ref>{{cite journal |vauthors=Thiele S, Thiele R, Gerdesmeyer L |title=Lateral epicondylitis: This is still a main indication for extracorporeal shockwave therapy |journal=International Journal of Surgery |volume= 24|issue= Pt B|pages= 165–70|year=2015 |pmid=26455532 |doi=10.1016/j.ijsu.2015.09.034 |doi-access=free }}</ref> ===Orthotic devices=== [[File:Counterforce brace YM.jpg|thumb|Counterforce orthosis reduces the elongation within the musculotendinous fibers]] [[File:Wrist brace.jpg|thumb|Wrist extensor orthosis reduces the overloading strain at the lesion area]] Orthosis is a device externally used on the limb to improve the function or reduce the pain. Orthotics may be useful in tennis elbow, however long-term effects are unknown.<ref>{{Cite journal|last1=Struijs|first1=Peter AA|last2=Smidt|first2=Nynke|last3=Arola|first3=H|last4=van Dijk|first4=C N|author-link5=Rachelle Buchbinder |last5=Buchbinder|first5=Rachelle|last6=Assendelft|first6=Willem JJ|date=2002-01-21|title=Orthotic devices for the treatment of tennis elbow|journal=Cochrane Database of Systematic Reviews|doi=10.1002/14651858.cd001821|issn=1465-1858}}</ref> There are two main types of orthoses prescribed for this problem: counterforce elbow orthoses and wrist extension orthoses. Counterforce orthosis has a circumferential structure surrounding the arm. This orthosis usually has a strap which applies a binding force over the origin of the wrist extensors. The applied force by orthosis reduces the elongation within the musculotendinous fibers. Wrist extensor orthosis maintains the wrist in the slight extension. This position reduces the overloading strain at the lesion area.{{citation needed|date=October 2020}} Studies indicated both type of orthoses improve the hand function<ref name="pmid19487823">{{cite journal | vauthors = Jafarian FS, Demneh ES, Tyson SF | title = The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis | journal = J Orthop Sports Phys Ther | volume = 39 | issue = 6 | pages = 484–9 | date = June 2009 | pmid = 19487823 | doi = 10.2519/jospt.2009.2988 |issn = 0190-6011| doi-access = free }}</ref> and reduce the pain<ref>{{Cite journal|title = The Immediate Effects of Orthoses on Pain in People with Lateral Epicondylalgia|journal = Pain Research and Treatment|date = 2013-01-01|pmc = 3854508|pmid = 24349776|volume = 2013|doi = 10.1155/2013/353597|first1 = Ebrahim|last1 = Sadeghi-Demneh|first2 = Fahimehsadat|last2 = Jafarian|pages=353597}}</ref> in people with tennis elbow. ===Medication=== Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit.<ref name=uptodate>{{cite web|last1=Jayanthi|first1=Neeru|title=Epicondylitis (tennis and golf elbow)|url=http://www.uptodate.com/contents/epicondylitis-tennis-and-golf-elbow|website=UpToDate|publisher=UpToDate, Inc.|access-date=17 August 2015|ref=uptodate}}</ref> A systematic review found that topical [[non-steroidal anti-inflammatory drug]]s (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues.<ref name=Patt2013/> Evidence for oral NSAIDs is mixed.<ref name=Patt2013>{{cite journal|last=Pattanittum|first=P|author2=Turner, T |author3=Green, S |author-link4=Rachelle Buchbinder |author4= Buchbinder, R |title=Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults.|journal=The Cochrane Database of Systematic Reviews|date=May 31, 2013|volume=5|issue=5|pages=CD003686|pmid=23728646|doi=10.1002/14651858.CD003686.pub2|pmc=7173751}}</ref> Evidence is poor for long term improvement from injections of any type, whether [[corticosteroids]], [[botulinum toxin]], [[prolotherapy]] or other substances.<ref>{{cite journal|last=Krogh|first=TP|author2=Bartels, EM |author3=Ellingsen, T |author4=Stengaard-Pedersen, K |author-link5=Rachelle Buchbinder|author5=Buchbinder, R |author6=Fredberg, U |author7=Bliddal, H |author8= Christensen, R |s2cid=25355427|title=Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials.|journal=The American Journal of Sports Medicine|date=June 2013|volume=41|issue=6|pages=1435–46|pmid=22972856|doi=10.1177/0363546512458237}}</ref> Corticosteroid injection may be effective in the short term<ref name="PMID20970844">{{cite journal|last=Coombes|first=BK|author2=Bisset, L |author3=Vicenzino, B |s2cid=45054853|title=Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials|journal=Lancet|date=Nov 20, 2010|volume=376|issue=9754|pages=1751–67|pmid=20970844|doi=10.1016/S0140-6736(10)61160-9|url=http://espace.library.uq.edu.au/view/UQ:225158/UQ225158_OA.pdf|hdl=10072/35812}}</ref> however are of little benefit after a year, compared to a wait-and-see approach.<ref>{{cite journal |vauthors=Haines T, Stringer B |s2cid=43254510 |title=Corticosteroid injections or physiotherapy were not more effective than "wait-and-see" for tennis elbow at one year |journal= Evidence-Based Medicine|volume=12 |issue=2 |page=39 |date=April 2007 |pmid=17400631 |doi=10.1136/ebm.12.2.39}}</ref> A recent [[randomized control trial]] comparing the effect of [[corticosteroid]] injection, [[physiotherapy]], or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year ([[Relative risk]] 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23).<ref>{{cite journal|last=Coombes|first=BK|author2=Bisset, L |author3=Brooks, P |author4=Khan, A |author5= Vicenzino, B |title=Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.|journal=JAMA: The Journal of the American Medical Association|date=Feb 6, 2013|volume=309|issue=5|pages=461–9|pmid=23385272 |doi=10.1001/jama.2013.129|url=https://espace.library.uq.edu.au/view/UQ:294650/UQ294650_OA.pdf}}</ref> Complications from repeated steroid injections include skin problems such as [[hypopigmentation]] and fat atrophy leading to indentation of the skin around the injection site.<ref name="PMID20970844" /> Steroid injections against appear to be more effective than shock wave therapy.<ref>{{Cite journal|author-link=Rachelle Buchbinder|last1=Buchbinder|first1=Rachelle|last2=Green|first2=Sally|last3=Youd|first3=Joanne M|last4=Assendelft|first4=Willem JJ|last5=Barnsley|first5=Les|last6=Smidt|first6=Nynke|date=2005-10-19|title=Shock wave therapy for lateral elbow pain|journal=Cochrane Database of Systematic Reviews|issue=4|pages=CD003524|doi=10.1002/14651858.cd003524.pub2|pmid=16235324|issn=1465-1858}}</ref> [[Botulinum toxin]] type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be viable.<ref>{{cite journal|last=Kalichman|first=L |author2=Bannuru, RR |author3=Severin, M |author4=Harvey, W|title=Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis|journal=Seminars in Arthritis and Rheumatism|date=June 2011|volume=40|issue=6|pages=532–8|pmid=20822798|doi=10.1016/j.semarthrit.2010.07.002}}</ref> ===Surgery=== In recalcitrant cases [[surgery]] may be an option.<ref>{{cite journal|last1=Monto|first1=R|s2cid=58020081|title=Tennis elbow repair with or without suture anchors: a randomized clinical trial|journal=Techniques in Shoulder and ELbow Surgery|date=September 2014|volume=15|issue=3|pages=92–97|doi=10.1097/BTE.0000000000000027}}</ref><ref name="pmi17632419">{{cite journal|last=Lo|first=MY|author2=Safran, MR |title=Surgical treatment of lateral epicondylitis: a systematic review|journal=Clinical Orthopaedics and Related Research|date=October 2007|volume=463|pages=98–106|pmid=17632419|doi=10.1097/BLO.0b013e3181483dc4|s2cid=6954029}}</ref><ref name="pmid23388420">{{cite journal | vauthors = Solheim E, Hegna J, Øyen J | title = Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows | journal = Arthroscopy | volume = 29 | issue = 5 | pages = 854–9 | date = May 2013 | pmid = 23388420 | doi = 10.1016/j.arthro.2012.12.012 }}</ref> Surgical methods include:<ref name="FaroWolf2007">{{cite journal|last1=Faro|first1=Frances|last2=Wolf|first2=Jennifer Moriatis|title=Lateral Epicondylitis: Review and Current Concepts|journal=The Journal of Hand Surgery|volume=32|issue=8|year=2007|pages=1271–1279|issn=0363-5023|doi=10.1016/j.jhsa.2007.07.019|pmid=17923315}}</ref> * Lengthening, release, debridement, or repair of the origin of the [[extrinsic extensor muscles of the hand]] at the [[lateral epicondyle of the humerus|lateral epicondyle]] * Rotation of the [[anconeus muscle]] * Denervation of the [[lateral epicondyle of the humerus|lateral epicondyle]] * Decompression of the [[posterior interosseous nerve]] Surgical techniques for lateral epicondylitis can be done by [[open surgery]], [[percutaneous surgery]] or [[arthroscopic surgery]], with no high-quality evidence that any particular type is better or worse than another.<ref name=":1">{{Cite journal|last1=Bateman|first1=Marcus|last2=Littlewood|first2=Chris|last3=Rawson|first3=Beth|last4=Tambe|first4=Amol A.|date=February 2019|title=Surgery for tennis elbow: a systematic review|url=http://journals.sagepub.com/doi/10.1177/1758573217745041|journal=Shoulder & Elbow|language=en|volume=11|issue=1|pages=35–44|doi=10.1177/1758573217745041|issn=1758-5732|pmc=6348580|pmid=30719096}}</ref><ref name="pmi17632419"/> Side effects include infection, damage to nerves and inability to straighten the arm.<ref>{{Cite journal|author-link=Rachelle Buchbinder|last1=Buchbinder|first1=Rachelle|last2=Johnston|first2=Renea V|last3=Barnsley|first3=Les|last4=Assendelft|first4=Willem JJ|last5=Bell|first5=Simon N|last6=Smidt|first6=Nynke|date=2011-03-16|title=Surgery for lateral elbow pain|journal=Cochrane Database of Systematic Reviews|issue=3|pages=CD003525|doi=10.1002/14651858.cd003525.pub2|pmid=21412883|issn=1465-1858|pmc=7154580}}</ref> A review of the evidence related to surgery found that published studies were of low quality and did not show that surgery was any more effective than other treatments.<ref name=":1" /> A subsequent research trial showed that surgery was no more effective than sham surgery, where patients only received a skin incision, although the trial was limited by a small number of patients.<ref>{{Cite journal|last1=Kroslak|first1=Martin|last2=Murrell|first2=George A. C.|date=2018-03-02|title=Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial|url=https://journals.sagepub.com/doi/10.1177/0363546517753385|journal=The American Journal of Sports Medicine|volume=46|issue=5|pages=1106–1113|language=en|doi=10.1177/0363546517753385|pmid=29498885|s2cid=4487650}}</ref> ==Prognosis== Response to initial therapy is common, but so is relapse (25% to 50%) and/or prolonged, moderate discomfort (40%).{{citation needed|date=October 2020}} Depending upon severity and quantity of multiple tendon injuries that have built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl defines four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2. # Inflammatory changes that are reversible # Nonreversible pathologic changes to origin of the extensor carpi radialis brevis muscle # Rupture of ECRB muscle origin # Secondary changes such as fibrosis or calcification.<ref name="Lateral Epicondylitis: Workup">{{cite web|url=http://emedicine.medscape.com/article/1231903-diagnosis|title=Lateral Epicondylitis: Workup|last1=Owens|first1=Brett D|last2=Moriatis Wolf|first2=Jennifer|date=2009-11-03|publisher=eMedicine Orthopedic Surgery|access-date=2010-04-19|last3=Murphy|first3=Kevin P}}</ref> ==Epidemiology== In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling," while 42% over the age of 50 did. More women (36%) than men (24%) considered their symptoms severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a four-fold increase among men and two-fold increase among women. Tennis elbow equally affects both sexes and, although men have a marginally higher overall prevalence rate as compared to women, this is not consistent within each age group, nor is it a statistically significant difference.<ref>{{cite journal | author = Gruchow William, Pelletier Douglas | s2cid = 20360265 | year = 1979 | title = An epidemiologic study of tennis elbow: Incidence, recurrence, and effectiveness of prevention strategies | journal = American Journal of Sports Medicine | volume = 7 | issue = 4| pages = 234–238 | doi=10.1177/036354657900700405| pmid = 474862 }}</ref> Playing time is a significant factor in tennis elbow occurrence, with increased incidence with increased playing time being greater for respondents under 40. Individuals over 40 who played over two hours doubled their chance of injury. Those under 40 increased it 3.5 fold compared to those who played less than two hours per day.<ref name="mayoclinic.com"/> ==History== German physician F. Runge<ref>{{cite journal | year = 1886 | url = http://www.thelancet.com/action/doSearch?journalCode=lancet&searchText1=tennis&occurrences1=all&op1=and&searchText2=&occurrences2=all&seriesISSNFltraddfilter=0140-6736&date=custom&fMonth=1&fYear=1800&lMonth=1&lYear=1900&searchAttempt=&searchType=advanced& | journal = The Lancet | volume = 128 | issue = 3301| page = 1083 | doi=10.1016/s0140-6736(00)49587-5| title = Tennis Elbow-Cap }}</ref> is usually credited for the first description of the condition, calling it "writer's cramp" (''Schreibekrampf'') in 1873.<ref>{{cite journal | author = Runge F | year = 1873 | title = Zur Genese und Behandlung des Schreibekrampfes. | journal = Berliner Klin Wochenschr | volume = 10 | pages = 245–248 }}</ref> Later, it was called "washer women's elbow".<ref>[https://books.google.ae/books?id=oaH9AQAAQBAJ&pg=PA155&lpg=PA155&dq=tennis+is+played+today+by+millions+of+people+around+the+world&source=bl&ots=v3ysjkT6ek&sig=tJlKj7JNBBZsOjXLWRhUuEie4PI&hl=ar&sa=X&ved=0ahUKEwijnYO4ko3KAhXJ2xoKHU_aADAQ6AEIHDAA#v=onepage&q=tennis%20is%20played%20today%20by%20millions%20of%20people%20around%20the%20world&f=false Science and Racket Sports] Edited by: T. Reilly, M. Hughes and A.Lees. Published by E & FN Spon {{ISBN|0-419-18500-3}}.</ref> British surgeon Henry Morris published an article in ''[[The Lancet]]'' describing "lawn tennis arm" in 1883.<ref>{{cite journal | author = Flatt Adrian E | date = Oct 2008 | title = Tennis elbow | journal = Proc (Bayl Univ Med Cent). | volume = 21 | issue = 4| pages = 400–402 | pmc=2566914 | pmid=18982084| doi = 10.1080/08998280.2008.11928437 }}</ref><ref>{{cite journal | year = 1886 | url = http://www.thelancet.com/action/doSearch?journalCode=lancet&searchText1=tennis&occurrences1=all&op1=and&searchText2=&occurrences2=all&seriesISSNFltraddfilter=0140-6736&date=custom&fMonth=1&fYear=1800&lMonth=1&lYear=1900&searchAttempt=&searchType=advanced&doSearch=Search | journal = The Lancet | volume = 128 | issue = 3301| page = 1083 | doi=10.1016/s0140-6736(00)49587-5| title = Tennis Elbow-Cap }}</ref> The popular term "tennis elbow" first appeared the same year in a paper by H. P. Major, described as "lawn-tennis elbow".<ref>{{cite journal | author = Major HP | year = 1883 | title = Lawn-tennis elbow | pmc = 2372911 | journal = BMJ | volume = 2 | issue = 1185| pages = 556–558 | doi = 10.1136/bmj.2.1185.556 }}</ref><ref name="TechHandUpExtremSurg2003-Kaminsky">{{cite journal |author=Kaminsky SB, Baker CL |title=Lateral epicondylitis of the elbow |journal=Techniques in Hand & Upper Limb Surgery |volume=7 |issue=4 |pages=179–89 |date=December 2003 |pmid=16518219 |doi=10.1097/00130911-200312000-00009 |last2=Baker|s2cid=128648 }}</ref> ==See also== {{Portal|Tennis}} * [[Olecranon bursitis]] * [[Repetitive strain injury]] * [[Radial tunnel syndrome]] ==References== {{Reflist}} ==External links== * {{cite journal |vauthors=Wilson JJ, Best TM |title=Common overuse tendon problems: A review and recommendations for treatment |journal=American Family Physician |volume=72 |issue=5 |pages=811–8 |date=September 2005 |pmid=16156339 |url=http://www.aafp.org/afp/20050901/811.html}} {{Medical resources | DiseasesDB = 12950 | ICD10 = {{ICD10|M|77|1|m|70}} | ICD9 = {{ICD9|726.32}} | ICDO = | OMIM = | MedlinePlus = 000449 | eMedicineSubj = orthoped | eMedicineTopic = 510 | eMedicine_mult = {{eMedicine2|pmr|64}} {{eMedicine2|sports|59}} | MeshID = D013716 }} {{Soft tissue disorders}} {{Inflammation}} {{DEFAULTSORT:Tennis Elbow}} [[Category:Inflammations]] [[Category:Overuse injuries]] [[Category:Tennis terminology]] [[Category:Sports injuries]] [[Category:Soft tissue disorders]] [[Category:Tennis culture]] [[Category:Wikipedia medicine articles ready to translate]]'
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'@@ -1,8 +1,3 @@ -{{other uses|Tennis Elbow (video game)}} -{{short description|Condition in which the outer part of the elbow becomes sore and tender}} -{{Infobox medical condition (new) -| name = Tennis elbow -| synonyms = Lateral epicondylitis, lateral elbow tendinopathy<ref name=Hub2018/> -| image = File:En-elbow joint.svg + | width = 150px | caption = Left [[elbow-joint]], showing posterior and radial collateral [[ligaments]]. ([[Lateral epicondyle of the humerus|Lateral epicondyle]] visible at center.) '
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'<div class="mw-parser-output"><p>| width = 150px | caption = Left <a href="/enwiki/wiki/Elbow-joint" class="mw-redirect" title="Elbow-joint">elbow-joint</a>, showing posterior and radial collateral <a href="/enwiki/wiki/Ligaments" class="mw-redirect" title="Ligaments">ligaments</a>. (<a href="/enwiki/wiki/Lateral_epicondyle_of_the_humerus" title="Lateral epicondyle of the humerus">Lateral epicondyle</a> visible at center.) | pronounce = | field = <a href="/enwiki/wiki/Orthopedics" class="mw-redirect" title="Orthopedics">Orthopedics</a>, <a href="/enwiki/wiki/Sports_medicine" title="Sports medicine">sports medicine</a> | symptoms = Painful and tender outer part of the elbow<sup id="cite_ref-Hub2018_1-0" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> | complications = | onset = Gradual<sup id="cite_ref-AI2015_2-0" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> | duration = Less than 1 to 2 years<sup id="cite_ref-Vaq2016_3-0" class="reference"><a href="#cite_note-Vaq2016-3">&#91;3&#93;</a></sup> | types = | causes = Excessive use of the muscles of the <a href="/enwiki/wiki/Posterior_compartment_of_the_forearm" title="Posterior compartment of the forearm">back of the forearm</a><sup id="cite_ref-AI2015_2-1" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> | risks = Smoking, <a href="/enwiki/wiki/Obesity" title="Obesity">obesity</a><sup id="cite_ref-Vaq2016_3-1" class="reference"><a href="#cite_note-Vaq2016-3">&#91;3&#93;</a></sup> | diagnosis = Based on symptoms with <a href="/enwiki/wiki/Medical_imaging" title="Medical imaging">medical imaging</a> used to rule out other potential causes<sup id="cite_ref-AI2015_2-2" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> | differential = <a href="/enwiki/wiki/Osteochondritis_dissecans" title="Osteochondritis dissecans">Osteochondritis dissecans</a>, <a href="/enwiki/wiki/Osteoarthritis" title="Osteoarthritis">osteoarthritis</a>, <a href="/enwiki/wiki/Radiculopathy" title="Radiculopathy">radiculopathy</a><sup id="cite_ref-Vaq2016_3-2" class="reference"><a href="#cite_note-Vaq2016-3">&#91;3&#93;</a></sup> | prevention = | treatment = Changing activities, <a href="/enwiki/wiki/Physical_therapy" title="Physical therapy">physical therapy</a>, pain medication<sup id="cite_ref-Hub2018_1-1" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> | medication = | prognosis = | frequency = c. 2%<sup id="cite_ref-Vaq2016_3-3" class="reference"><a href="#cite_note-Vaq2016-3">&#91;3&#93;</a></sup> | deaths = }} <b>Tennis elbow</b>, also known as <b>lateral epicondylitis</b>, is a condition in which the outer part of the <a href="/enwiki/wiki/Elbow-joint" class="mw-redirect" title="Elbow-joint">elbow</a> becomes painful and tender.<sup id="cite_ref-Hub2018_1-2" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> The pain may also extend into the back of the <a href="/enwiki/wiki/Forearm" title="Forearm">forearm</a> and <a href="/enwiki/wiki/Grip_strength" title="Grip strength">grip strength</a> may be weak.<sup id="cite_ref-AI2015_2-3" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup><sup id="cite_ref-Hub2018_1-3" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> Onset of symptoms is generally gradual.<sup id="cite_ref-AI2015_2-4" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> <a href="/enwiki/wiki/Golfer%27s_elbow" title="Golfer&#39;s elbow">Golfer's elbow</a> is a similar condition that affects the <a href="/enwiki/wiki/Medial_epicondyle_of_the_humerus" title="Medial epicondyle of the humerus">inside of the elbow</a>.<sup id="cite_ref-Hub2018_1-4" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> </p><p>It is due to excessive use of the muscles of the <a href="/enwiki/wiki/Posterior_compartment_of_the_forearm" title="Posterior compartment of the forearm">back of the forearm</a>.<sup id="cite_ref-AI2015_2-5" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> Typically this occurs as a result of work or sports, classically <a href="/enwiki/wiki/Racquet_sports" class="mw-redirect" title="Racquet sports">racquet sports</a>.<sup id="cite_ref-Hub2018_1-5" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup><sup id="cite_ref-AI2015_2-6" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> The diagnosis is typically based on the symptoms with <a href="/enwiki/wiki/Medical_imaging" title="Medical imaging">medical imaging</a> used to rule out other potential causes.<sup id="cite_ref-AI2015_2-7" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> It is more likely if pain increases when a subject tries to <a href="/enwiki/wiki/Dorsiflexion" class="mw-redirect" title="Dorsiflexion">bend back</a> the wrist when the wrist is held in a neutral position.<sup id="cite_ref-Hub2018_1-6" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> A powered screwdriver can cause this injury if overused one-handed. It is classified as a chronic <a href="/enwiki/wiki/Tendinosis" class="mw-redirect" title="Tendinosis">tendinosis</a>, not a <a href="/enwiki/wiki/Tendinitis" class="mw-redirect" title="Tendinitis">tendinitis</a>.<sup id="cite_ref-Hub2018_1-7" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> </p><p>Treatment involves decreasing activities that bring on the symptoms together with <a href="/enwiki/wiki/Physical_therapy" title="Physical therapy">physical therapy</a> or other treatment gradually increasing loads.<sup id="cite_ref-4" class="reference"><a href="#cite_note-4">&#91;4&#93;</a></sup><sup id="cite_ref-Hub2018_1-8" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> Pain medications such as <a href="/enwiki/wiki/NSAIDS" class="mw-redirect" title="NSAIDS">NSAIDS</a> or <a href="/enwiki/wiki/Acetaminophen" class="mw-redirect" title="Acetaminophen">acetaminophen</a> (paracetamol) may be used.<sup id="cite_ref-Hub2018_1-9" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> A brace over the upper forearm may also be helpful.<sup id="cite_ref-AI2015_2-8" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> If the condition does not improve <a href="/enwiki/wiki/Corticosteroid" title="Corticosteroid">corticosteroid</a> injections or surgery may be recommended <sup id="cite_ref-Hub2018_1-10" class="reference"><a href="#cite_note-Hub2018-1">&#91;1&#93;</a></sup> although some experts recommend avoiding cortisone injections due to poor long-term results in high-quality trials.<sup id="cite_ref-5" class="reference"><a href="#cite_note-5">&#91;5&#93;</a></sup><sup id="cite_ref-6" class="reference"><a href="#cite_note-6">&#91;6&#93;</a></sup><sup id="cite_ref-7" class="reference"><a href="#cite_note-7">&#91;7&#93;</a></sup><sup id="cite_ref-8" class="reference"><a href="#cite_note-8">&#91;8&#93;</a></sup> Many people get better within one month to two years.<sup id="cite_ref-Vaq2016_3-4" class="reference"><a href="#cite_note-Vaq2016-3">&#91;3&#93;</a></sup><sup id="cite_ref-Lian2018_9-0" class="reference"><a href="#cite_note-Lian2018-9">&#91;9&#93;</a></sup> </p><p>About 2% of people are affected.<sup id="cite_ref-Vaq2016_3-5" class="reference"><a href="#cite_note-Vaq2016-3">&#91;3&#93;</a></sup> Those 30 to 50 years old are most commonly affected.<sup id="cite_ref-AI2015_2-9" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup> The condition was initially described in 1873.<sup id="cite_ref-Vaq2016_3-6" class="reference"><a href="#cite_note-Vaq2016-3">&#91;3&#93;</a></sup> The name "<a href="/enwiki/wiki/Lawn_tennis" class="mw-redirect" title="Lawn tennis">lawn tennis</a> elbow" first came into use for the condition in 1882.<sup id="cite_ref-10" class="reference"><a href="#cite_note-10">&#91;10&#93;</a></sup> </p> <div id="toc" class="toc" role="navigation" aria-labelledby="mw-toc-heading"><input type="checkbox" role="button" id="toctogglecheckbox" class="toctogglecheckbox" style="display:none" /><div class="toctitle" lang="en" dir="ltr"><h2 id="mw-toc-heading">Contents</h2><span class="toctogglespan"><label class="toctogglelabel" for="toctogglecheckbox"></label></span></div> <ul> <li class="toclevel-1 tocsection-1"><a href="#Signs_and_Symptoms"><span class="tocnumber">1</span> <span class="toctext">Signs and Symptoms</span></a> <ul> <li class="toclevel-2 tocsection-2"><a href="#Terminology"><span class="tocnumber">1.1</span> <span class="toctext">Terminology</span></a></li> </ul> </li> <li class="toclevel-1 tocsection-3"><a href="#Causes"><span class="tocnumber">2</span> <span class="toctext">Causes</span></a></li> <li class="toclevel-1 tocsection-4"><a href="#Pathophysiology"><span class="tocnumber">3</span> <span class="toctext">Pathophysiology</span></a></li> <li class="toclevel-1 tocsection-5"><a href="#Diagnosis"><span class="tocnumber">4</span> <span class="toctext">Diagnosis</span></a> <ul> <li class="toclevel-2 tocsection-6"><a href="#Physical_examination"><span class="tocnumber">4.1</span> <span class="toctext">Physical examination</span></a></li> <li class="toclevel-2 tocsection-7"><a href="#Medical_imaging"><span class="tocnumber">4.2</span> <span class="toctext">Medical imaging</span></a></li> </ul> </li> <li class="toclevel-1 tocsection-8"><a href="#Prevention"><span class="tocnumber">5</span> <span class="toctext">Prevention</span></a></li> <li class="toclevel-1 tocsection-9"><a href="#Treatment"><span class="tocnumber">6</span> <span class="toctext">Treatment</span></a> <ul> <li class="toclevel-2 tocsection-10"><a href="#Physical_therapy"><span class="tocnumber">6.1</span> <span class="toctext">Physical therapy</span></a></li> <li class="toclevel-2 tocsection-11"><a href="#Orthotic_devices"><span class="tocnumber">6.2</span> <span class="toctext">Orthotic devices</span></a></li> <li class="toclevel-2 tocsection-12"><a href="#Medication"><span class="tocnumber">6.3</span> <span class="toctext">Medication</span></a></li> <li class="toclevel-2 tocsection-13"><a href="#Surgery"><span class="tocnumber">6.4</span> <span class="toctext">Surgery</span></a></li> </ul> </li> <li class="toclevel-1 tocsection-14"><a href="#Prognosis"><span class="tocnumber">7</span> <span class="toctext">Prognosis</span></a></li> <li class="toclevel-1 tocsection-15"><a href="#Epidemiology"><span class="tocnumber">8</span> <span class="toctext">Epidemiology</span></a></li> <li class="toclevel-1 tocsection-16"><a href="#History"><span class="tocnumber">9</span> <span class="toctext">History</span></a></li> <li class="toclevel-1 tocsection-17"><a href="#See_also"><span class="tocnumber">10</span> <span class="toctext">See also</span></a></li> <li class="toclevel-1 tocsection-18"><a href="#References"><span class="tocnumber">11</span> <span class="toctext">References</span></a></li> <li class="toclevel-1 tocsection-19"><a href="#External_links"><span class="tocnumber">12</span> <span class="toctext">External links</span></a></li> </ul> </div> <h2><span class="mw-headline" id="Signs_and_Symptoms">Signs and Symptoms</span></h2> <ul><li>Pain on the outer part of the elbow (<a href="/enwiki/wiki/Lateral_epicondyle_of_the_humerus" title="Lateral epicondyle of the humerus">lateral epicondyle</a>)</li> <li>Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow</li> <li>Pain from gripping and movements of the <a href="/enwiki/wiki/Wrist" title="Wrist">wrist</a>, especially wrist extension (e.g. turning a screwdriver) and lifting movements<sup id="cite_ref-:0_11-0" class="reference"><a href="#cite_note-:0-11">&#91;11&#93;</a></sup></li></ul> <p>Symptoms associated with tennis elbow include, but are not limited to, radiating pain from the outside of the elbow to the <a href="/enwiki/wiki/Forearm" title="Forearm">forearm</a> and wrist, pain during extension of wrist, weakness of the forearm, a painful grip while shaking hands or torquing a <a href="/enwiki/wiki/Doorknob" class="mw-redirect" title="Doorknob">doorknob</a>, and not being able to hold relatively heavy items in the hand.<sup id="cite_ref-12" class="reference"><a href="#cite_note-12">&#91;12&#93;</a></sup> The pain is similar to the condition known as <i><a href="/enwiki/wiki/Golfer%27s_elbow" title="Golfer&#39;s elbow">golfer's elbow</a></i>, but the latter occurs at the medial side of the elbow.<sup id="cite_ref-mayoclinic.com_13-0" class="reference"><a href="#cite_note-mayoclinic.com-13">&#91;13&#93;</a></sup> </p> <h3><span class="mw-headline" id="Terminology">Terminology</span></h3> <p>The term "tennis elbow" is widely used (although informal), but the condition should be understood as not limited to tennis players.<sup id="cite_ref-cleveland_clinic_14-0" class="reference"><a href="#cite_note-cleveland_clinic-14">&#91;14&#93;</a></sup><sup id="cite_ref-mayo_clinic_15-0" class="reference"><a href="#cite_note-mayo_clinic-15">&#91;15&#93;</a></sup> Historically, the medical term "lateral epicondylitis" was most commonly used for the condition.<sup id="cite_ref-AI2015_2-10" class="reference"><a href="#cite_note-AI2015-2">&#91;2&#93;</a></sup><sup id="cite_ref-cleveland_clinic_14-1" class="reference"><a href="#cite_note-cleveland_clinic-14">&#91;14&#93;</a></sup><sup id="cite_ref-mayo_clinic_15-1" class="reference"><a href="#cite_note-mayo_clinic-15">&#91;15&#93;</a></sup><sup id="cite_ref-bbcsport_16-0" class="reference"><a href="#cite_note-bbcsport-16">&#91;16&#93;</a></sup> </p><p>Since histological findings reveal noninflammatory tissue, the term “lateral elbow <a href="/enwiki/wiki/Tendinopathy" title="Tendinopathy">tendinopathy</a>," "<a href="/enwiki/wiki/Tendinosis" class="mw-redirect" title="Tendinosis">tendinosis</a>,” or “angio-fibroblastic tendinosis” have been suggested instead of “lateral epicondylitis”.<sup id="cite_ref-pmid16998100_17-0" class="reference"><a href="#cite_note-pmid16998100-17">&#91;17&#93;</a></sup><sup id="cite_ref-du_ToitStieler2008_18-0" class="reference"><a href="#cite_note-du_ToitStieler2008-18">&#91;18&#93;</a></sup> Most recently, in 2019, a group of international experts agreed that "lateral elbow tendinopathy" was the most appropriate terminology.<sup id="cite_ref-19" class="reference"><a href="#cite_note-19">&#91;19&#93;</a></sup> </p> <h2><span class="mw-headline" id="Causes">Causes</span></h2> <div class="thumb tright"><div class="thumbinner" style="width:222px;"><a href="/enwiki/wiki/File:Tennis_Elbow.png" class="image"><img alt="" src="/upwiki/wikipedia/commons/thumb/b/bb/Tennis_Elbow.png/220px-Tennis_Elbow.png" decoding="async" width="220" height="220" class="thumbimage" data-file-width="1200" data-file-height="1200" /></a> <div class="thumbcaption"><div class="magnify"><a href="/enwiki/wiki/File:Tennis_Elbow.png" class="internal" title="Enlarge"></a></div>Location of tennis elbow</div></div></div> <p>Tennis elbow is a type of <a href="/enwiki/wiki/Repetitive_strain_injury" title="Repetitive strain injury">repetitive strain injury</a> resulting from tendon overuse and failed healing of the tendon. In addition, the <a href="/enwiki/wiki/Extensor_carpi_radialis_brevis" class="mw-redirect" title="Extensor carpi radialis brevis">extensor carpi radialis brevis</a> muscle plays a key role.<sup id="cite_ref-du_ToitStieler2008_18-1" class="reference"><a href="#cite_note-du_ToitStieler2008-18">&#91;18&#93;</a></sup><sup id="cite_ref-pmid15116648_20-0" class="reference"><a href="#cite_note-pmid15116648-20">&#91;20&#93;</a></sup> </p> <div class="thumb tright"><div class="thumbinner" style="width:222px;"><a href="/enwiki/wiki/File:Tenniselbow.JPG" class="image"><img alt="" src="/upwiki/wikipedia/commons/thumb/a/a5/Tenniselbow.JPG/220px-Tenniselbow.JPG" decoding="async" width="220" height="83" class="thumbimage" data-file-width="653" data-file-height="245" /></a> <div class="thumbcaption"><div class="magnify"><a href="/enwiki/wiki/File:Tenniselbow.JPG" class="internal" title="Enlarge"></a></div>Example of repetitive movement that may cause tennis elbow</div></div></div> <p>Early <a href="/enwiki/wiki/Experiment" title="Experiment">experiments</a> suggested that tennis elbow was primarily caused by overexertion. However, studies show that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension cause more than half of these injuries.<sup id="cite_ref-KURPPA,_K._1979_21-0" class="reference"><a href="#cite_note-KURPPA,_K._1979-21">&#91;21&#93;</a></sup> Repeatedly mis-hitting a tennis ball in the early stages of learning the sport causes shock to the elbow joint and may contribute to contracting the condition.<sup id="cite_ref-22" class="reference"><a href="#cite_note-22">&#91;22&#93;</a></sup> </p><p>There are multiple aspects of tennis that may cause a player to develop “tennis elbow”. From a technical perspective, leading a backhand with your elbow, excessive pronation of the forearm when putting topspin on a forehand, and excessive flexion of the wrist on a serve can all greatly lead to tennis elbow. Other things that can be improved are: racquet type, grip size, string tension, type of court surface, and ball weight.<sup id="cite_ref-23" class="reference"><a href="#cite_note-23">&#91;23&#93;</a></sup> </p> <h2><span class="mw-headline" id="Pathophysiology">Pathophysiology</span></h2> <p>Histological findings include granulation tissue, micro-rupture, degenerative changes, and there is no traditional inflammation.<sup id="cite_ref-du_ToitStieler2008_18-2" class="reference"><a href="#cite_note-du_ToitStieler2008-18">&#91;18&#93;</a></sup><sup id="cite_ref-pmid1423702_24-0" class="reference"><a href="#cite_note-pmid1423702-24">&#91;24&#93;</a></sup><sup id="cite_ref-Lian2018_9-1" class="reference"><a href="#cite_note-Lian2018-9">&#91;9&#93;</a></sup> </p><p>Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term “epicondylitis” is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which replaces normal tissue with a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as <i>tendinosis</i> or <i>tendinopathy</i> rather than <i><a href="/enwiki/wiki/Tendinitis" class="mw-redirect" title="Tendinitis">tendinitis</a>.</i><sup id="cite_ref-pmid16998100_17-1" class="reference"><a href="#cite_note-pmid16998100-17">&#91;17&#93;</a></sup> </p><p>Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin.<sup id="cite_ref-ZeisigÖhberg2006_25-0" class="reference"><a href="#cite_note-ZeisigÖhberg2006-25">&#91;25&#93;</a></sup> </p><p>The <a href="/enwiki/wiki/Pathophysiology" title="Pathophysiology">pathophysiology</a> of lateral epicondylitis is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the <a href="/enwiki/wiki/Extensor_carpi_radialis_brevis_muscle" title="Extensor carpi radialis brevis muscle">extensor carpi radialis brevis (ECRB) muscle</a> are identified in surgical <a href="/enwiki/wiki/Pathology" title="Pathology">pathology</a> specimens.<sup id="cite_ref-boyer_26-0" class="reference"><a href="#cite_note-boyer-26">&#91;26&#93;</a></sup> It is unclear if the pathology is affected by prior injection of <a href="/enwiki/wiki/Corticosteroid" title="Corticosteroid">corticosteroid</a>.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">&#91;<i><a href="/enwiki/wiki/Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (October 2020)">citation needed</span></a></i>&#93;</sup> </p><p>Tennis players generally believe tennis elbow is caused by the repetitive nature of hitting thousands of <a href="/enwiki/wiki/Tennis_balls" class="mw-redirect" title="Tennis balls">tennis balls</a>, which leads to tiny tears in the forearm tendon attachment at the elbow.<sup id="cite_ref-bbcsport_16-1" class="reference"><a href="#cite_note-bbcsport-16">&#91;16&#93;</a></sup> </p><p>The <a href="/enwiki/wiki/Extensor_digiti_minimi" class="mw-redirect" title="Extensor digiti minimi">extensor digiti minimi</a> also has a small origin site medial to the elbow that this condition can affect. The muscle involves the extension of the <a href="/enwiki/wiki/Little_finger" title="Little finger">little finger</a> and some extension of the wrist allowing for adaption to "snap" or flick the wrist—usually associated with a racquet swing. Most often, the extensor muscles become painful due to tendon breakdown from over-extension. Improper form or movement allows for power in a swing to rotate through and around the wrist—creating a moment on that joint instead of the elbow joint or rotator cuff. This moment causes pressure to build impact forces to act on the tendon causing <a href="/enwiki/wiki/Irritation" title="Irritation">irritation</a> and inflammation.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">&#91;<i><a href="/enwiki/wiki/Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (October 2020)">citation needed</span></a></i>&#93;</sup> </p><p>At least one author questions that lateral epicondylitis is caused by repetitive <a href="/enwiki/wiki/Microtrauma" title="Microtrauma">microtrauma</a>/overuse, maintaining the theory is likely overstated and lacks scientific support.<sup id="cite_ref-boyer_26-1" class="reference"><a href="#cite_note-boyer-26">&#91;26&#93;</a></sup> </p><p>Other speculative risk factors for lateral epicondylitis include taking up tennis later in life, unaccustomed strenuous activity, decreased <a href="/enwiki/wiki/Mental_chronometry" title="Mental chronometry">mental chronometry</a> and speed and repetitive <a href="/enwiki/wiki/Eccentric_contraction" class="mw-redirect" title="Eccentric contraction">eccentric contraction</a> of muscle (controlled lengthening of a muscle group). </p> <h2><span class="mw-headline" id="Diagnosis">Diagnosis</span></h2> <h3><span class="mw-headline" id="Physical_examination">Physical examination</span></h3> <p>To diagnose tennis elbow, <a href="/enwiki/wiki/Physician" title="Physician">physicians</a> perform a battery of tests in which they place pressure on the affected area while asking the patient to move the elbow, wrist, and fingers. Diagnosis is made by clinical signs and symptoms that are discrete and characteristic. For example, when the elbow fully extended, the patient feels points of tenderness over the affected point on the elbow. The most common location of tenderness is at the origin of the <a href="/enwiki/wiki/Extensor_carpi_radialis_brevis_muscle" title="Extensor carpi radialis brevis muscle">extensor carpi radialis brevis muscle</a> from the lateral epicondyle (extensor carpi radialis brevis origin), 1&#160;cm <a href="/enwiki/wiki/Anatomical_terms_of_location" title="Anatomical terms of location">distal</a> and slightly <a href="/enwiki/wiki/Anatomical_terms_of_location" title="Anatomical terms of location">anterior</a> to the lateral epicondyle.<sup id="cite_ref-:0_11-1" class="reference"><a href="#cite_note-:0-11">&#91;11&#93;</a></sup> There is also pain with passive wrist <a href="/enwiki/wiki/Flexion" class="mw-redirect" title="Flexion">flexion</a> and resistive wrist <a href="/enwiki/wiki/Extension_(kinesiology)" class="mw-redirect" title="Extension (kinesiology)">extension</a> (<a href="/enwiki/wiki/Cozen%27s_test" title="Cozen&#39;s test">Cozen's test</a>).<sup id="cite_ref-nihgov_27-0" class="reference"><a href="#cite_note-nihgov-27">&#91;27&#93;</a></sup> </p> <h3><span class="mw-headline" id="Medical_imaging">Medical imaging</span></h3> <p>X-rays can confirm and distinguish possibilities of existing causes of pain that are unrelated to tennis elbow, such as <a href="/enwiki/wiki/Fracture" title="Fracture">fracture</a> or <a href="/enwiki/wiki/Arthritis" title="Arthritis">arthritis</a>. Rarely, calcification can be found where the extensor muscles attach to the lateral epicondyle.<sup id="cite_ref-:0_11-2" class="reference"><a href="#cite_note-:0-11">&#91;11&#93;</a></sup> <a href="/enwiki/wiki/Medical_ultrasonography" class="mw-redirect" title="Medical ultrasonography">Medical ultrasonography</a> and <a href="/enwiki/wiki/Magnetic_resonance_imaging" title="Magnetic resonance imaging">magnetic resonance imaging</a> (MRI) are other valuable tools for diagnosis but are frequently avoided due to the high cost.<sup id="cite_ref-mayoclinic.com_13-1" class="reference"><a href="#cite_note-mayoclinic.com-13">&#91;13&#93;</a></sup> <a href="/enwiki/wiki/MRI" class="mw-redirect" title="MRI">MRI</a> screening can confirm excess fluid and swelling in the affected region in the elbow, such as the connecting point between the forearm bone and the extensor carpi radialis brevis muscle. </p> <h2><span class="mw-headline" id="Prevention">Prevention</span></h2> <p>Where lateral epicondylitis is caused by playing tennis, another factor of tennis elbow injury is experience and ability. The proportion of players who reported a history of tennis elbow had an increased number of playing years. As for ability, poor technique increases the chance for injury much like any sport. Therefore, an individual must learn proper technique for all aspects of their sport. The competitive level of the athlete also affects the incidence of tennis elbow. Class A and B players had a significantly higher rate of tennis elbow occurrence compared to class C and novice players. However, an opposite, but not statistically significant, trend is observed for the recurrence of previous cases, with an increasingly higher rate as ability level decreases.<sup id="cite_ref-mayoclinic.com_13-2" class="reference"><a href="#cite_note-mayoclinic.com-13">&#91;13&#93;</a></sup> </p><p>Other ways to prevent tennis elbow: </p> <ul><li>Decrease the amount of playing time if already injured or feeling pain in outside part of the elbow.</li> <li>Stay in overall good physical shape.</li> <li>Strengthen the muscles of the forearm: (<a href="/enwiki/wiki/Pronator_quadratus" class="mw-redirect" title="Pronator quadratus">pronator quadratus</a>, <a href="/enwiki/wiki/Pronator_teres" class="mw-redirect" title="Pronator teres">pronator teres</a>, <a href="/enwiki/wiki/Supinator_muscle" title="Supinator muscle">supinator muscle</a>) and Extensor Carpi Radialis Longus and Brevis<sup id="cite_ref-28" class="reference"><a href="#cite_note-28">&#91;28&#93;</a></sup>—the upper arm: (<a href="/enwiki/wiki/Biceps" title="Biceps">biceps</a>, <a href="/enwiki/wiki/Triceps" title="Triceps">triceps</a>)—and the <a href="/enwiki/wiki/Shoulder" title="Shoulder">shoulder</a> (<a href="/enwiki/wiki/Deltoid_muscle" title="Deltoid muscle">deltoid muscle</a>) and upper back (<a href="/enwiki/wiki/Trapezius" title="Trapezius">trapezius</a>). Increased muscular strength increases stability of joints such as the elbow.</li> <li>Like other sports, use equipment appropriate to your ability, body size, and muscular strength.<sup id="cite_ref-mayoclinic.com_13-3" class="reference"><a href="#cite_note-mayoclinic.com-13">&#91;13&#93;</a></sup></li> <li>Avoid any repetitive lifting or pulling of heavy objects (especially over your head)<sup id="cite_ref-29" class="reference"><a href="#cite_note-29">&#91;29&#93;</a></sup></li></ul> <p>Vibration dampers (otherwise known as "gummies") are not believed to be a reliable preventative measure. Rather, proper weight distribution in the racket is thought to be a more viable option in negating shock.<sup id="cite_ref-30" class="reference"><a href="#cite_note-30">&#91;30&#93;</a></sup> </p> <h2><span class="mw-headline" id="Treatment">Treatment</span></h2> <p>Evidence for the treatment of lateral epicondylitis before 2010 was poor.<sup id="cite_ref-BrJSportsMed2005-Bisset_31-0" class="reference"><a href="#cite_note-BrJSportsMed2005-Bisset-31">&#91;31&#93;</a></sup> There were clinical trials addressing many proposed treatments, but the trials were of poor quality.<sup id="cite_ref-32" class="reference"><a href="#cite_note-32">&#91;32&#93;</a></sup> </p><p>In some cases, severity of tennis elbow symptoms mend without any treatment, within six to 24 months. Tennis elbow left untreated can lead to chronic pain that degrades quality of daily living.<sup id="cite_ref-mayoclinic.com_13-4" class="reference"><a href="#cite_note-mayoclinic.com-13">&#91;13&#93;</a></sup> </p> <h3><span class="mw-headline" id="Physical_therapy">Physical therapy</span></h3> <p>There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including stretches and progressive strengthening exercises to prevent re-irritation of the tendon<sup id="cite_ref-BrJSportsMed2005-Stasinopoulos_33-0" class="reference"><a href="#cite_note-BrJSportsMed2005-Stasinopoulos-33">&#91;33&#93;</a></sup> and other exercise measures.<sup id="cite_ref-34" class="reference"><a href="#cite_note-34">&#91;34&#93;</a></sup> </p><p>One way to help treat minor cases of tennis elbow is simply to relax the affected arm. The rest lets stress and tightness within the forearm slowly relax and eventually have the arm in working condition—in a day or two, depending on the case. </p><p>Eccentric exercise using a rubber bar is highly effective at eliminating pain and increasing strength.<sup id="cite_ref-Tyler_35-0" class="reference"><a href="#cite_note-Tyler-35">&#91;35&#93;</a></sup><sup id="cite_ref-Reynolds_36-0" class="reference"><a href="#cite_note-Reynolds-36">&#91;36&#93;</a></sup> The exercise involves grasping a rubber bar, twisting it, then slowly untwisting it.<sup id="cite_ref-Tyler_35-1" class="reference"><a href="#cite_note-Tyler-35">&#91;35&#93;</a></sup><sup id="cite_ref-37" class="reference"><a href="#cite_note-37">&#91;37&#93;</a></sup> Although it can be considered an evidence-based practice, long-term results have not yet been determined.<sup id="cite_ref-38" class="reference"><a href="#cite_note-38">&#91;38&#93;</a></sup> </p><p>There are differences in opinions on whether it is okay if pain occurs during these exercises.<sup id="cite_ref-Coom2015_39-0" class="reference"><a href="#cite_note-Coom2015-39">&#91;39&#93;</a></sup> Some suggest pain of less than 5/10 is okay.<sup id="cite_ref-Coom2015_39-1" class="reference"><a href="#cite_note-Coom2015-39">&#91;39&#93;</a></sup> </p><p>Moderate evidence exists demonstrating that <a href="/enwiki/wiki/Joint_manipulation" title="Joint manipulation">joint manipulation</a> directed at the elbow and wrist and <a href="/enwiki/wiki/Spinal_manipulation" title="Spinal manipulation">spinal manipulation</a> directed at the cervical and thoracic spinal regions results in clinical changes to pain and function.<sup id="cite_ref-40" class="reference"><a href="#cite_note-40">&#91;40&#93;</a></sup><sup id="cite_ref-41" class="reference"><a href="#cite_note-41">&#91;41&#93;</a></sup> There is also moderate evidence for short-term and mid-term effectiveness of cervical and thoracic spine manipulation as an add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. Although not yet conclusive, the short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises, resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.<sup id="cite_ref-42" class="reference"><a href="#cite_note-42">&#91;42&#93;</a></sup> </p><p>Low level laser therapy, administered at specific doses and wavelengths directly to the lateral elbow tendon insertions, may result in short-term pain relief and less disability.<sup id="cite_ref-43" class="reference"><a href="#cite_note-43">&#91;43&#93;</a></sup> </p><p>Extracorporeal shockwave therapy, while safe, is of unclear benefit.<sup id="cite_ref-44" class="reference"><a href="#cite_note-44">&#91;44&#93;</a></sup><sup id="cite_ref-45" class="reference"><a href="#cite_note-45">&#91;45&#93;</a></sup> </p> <h3><span class="mw-headline" id="Orthotic_devices">Orthotic devices</span></h3> <div class="thumb tright"><div class="thumbinner" style="width:222px;"><a href="/enwiki/wiki/File:Counterforce_brace_YM.jpg" class="image"><img alt="" src="/upwiki/wikipedia/commons/thumb/e/e4/Counterforce_brace_YM.jpg/220px-Counterforce_brace_YM.jpg" decoding="async" width="220" height="165" class="thumbimage" data-file-width="1024" data-file-height="768" /></a> <div class="thumbcaption"><div class="magnify"><a href="/enwiki/wiki/File:Counterforce_brace_YM.jpg" class="internal" title="Enlarge"></a></div>Counterforce orthosis reduces the elongation within the musculotendinous fibers</div></div></div> <div class="thumb tright"><div class="thumbinner" style="width:222px;"><a href="/enwiki/wiki/File:Wrist_brace.jpg" class="image"><img alt="" src="/upwiki/wikipedia/commons/thumb/b/b1/Wrist_brace.jpg/220px-Wrist_brace.jpg" decoding="async" width="220" height="165" class="thumbimage" data-file-width="2199" data-file-height="1649" /></a> <div class="thumbcaption"><div class="magnify"><a href="/enwiki/wiki/File:Wrist_brace.jpg" class="internal" title="Enlarge"></a></div>Wrist extensor orthosis reduces the overloading strain at the lesion area</div></div></div> <p>Orthosis is a device externally used on the limb to improve the function or reduce the pain. Orthotics may be useful in tennis elbow, however long-term effects are unknown.<sup id="cite_ref-46" class="reference"><a href="#cite_note-46">&#91;46&#93;</a></sup> There are two main types of orthoses prescribed for this problem: counterforce elbow orthoses and wrist extension orthoses. Counterforce orthosis has a circumferential structure surrounding the arm. This orthosis usually has a strap which applies a binding force over the origin of the wrist extensors. The applied force by orthosis reduces the elongation within the musculotendinous fibers. Wrist extensor orthosis maintains the wrist in the slight extension. This position reduces the overloading strain at the lesion area.<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">&#91;<i><a href="/enwiki/wiki/Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (October 2020)">citation needed</span></a></i>&#93;</sup> </p><p>Studies indicated both type of orthoses improve the hand function<sup id="cite_ref-pmid19487823_47-0" class="reference"><a href="#cite_note-pmid19487823-47">&#91;47&#93;</a></sup> and reduce the pain<sup id="cite_ref-48" class="reference"><a href="#cite_note-48">&#91;48&#93;</a></sup> in people with tennis elbow. </p> <h3><span class="mw-headline" id="Medication">Medication</span></h3> <p>Although anti-inflammatories are a commonly prescribed treatment for tennis elbow, the evidence for their effect is usually anecdotal with only limited studies showing a benefit.<sup id="cite_ref-uptodate_49-0" class="reference"><a href="#cite_note-uptodate-49">&#91;49&#93;</a></sup> A systematic review found that topical <a href="/enwiki/wiki/Non-steroidal_anti-inflammatory_drug" class="mw-redirect" title="Non-steroidal anti-inflammatory drug">non-steroidal anti-inflammatory drugs</a> (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues.<sup id="cite_ref-Patt2013_50-0" class="reference"><a href="#cite_note-Patt2013-50">&#91;50&#93;</a></sup> Evidence for oral NSAIDs is mixed.<sup id="cite_ref-Patt2013_50-1" class="reference"><a href="#cite_note-Patt2013-50">&#91;50&#93;</a></sup> </p><p>Evidence is poor for long term improvement from injections of any type, whether <a href="/enwiki/wiki/Corticosteroids" class="mw-redirect" title="Corticosteroids">corticosteroids</a>, <a href="/enwiki/wiki/Botulinum_toxin" title="Botulinum toxin">botulinum toxin</a>, <a href="/enwiki/wiki/Prolotherapy" title="Prolotherapy">prolotherapy</a> or other substances.<sup id="cite_ref-51" class="reference"><a href="#cite_note-51">&#91;51&#93;</a></sup> Corticosteroid injection may be effective in the short term<sup id="cite_ref-&#80;MID20970844_52-0" class="reference"><a href="#cite_note-PMID20970844-52">&#91;52&#93;</a></sup> however are of little benefit after a year, compared to a wait-and-see approach.<sup id="cite_ref-53" class="reference"><a href="#cite_note-53">&#91;53&#93;</a></sup> A recent <a href="/enwiki/wiki/Randomized_control_trial" class="mw-redirect" title="Randomized control trial">randomized control trial</a> comparing the effect of <a href="/enwiki/wiki/Corticosteroid" title="Corticosteroid">corticosteroid</a> injection, <a href="/enwiki/wiki/Physiotherapy" class="mw-redirect" title="Physiotherapy">physiotherapy</a>, or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year (<a href="/enwiki/wiki/Relative_risk" title="Relative risk">Relative risk</a> 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23).<sup id="cite_ref-54" class="reference"><a href="#cite_note-54">&#91;54&#93;</a></sup> Complications from repeated steroid injections include skin problems such as <a href="/enwiki/wiki/Hypopigmentation" title="Hypopigmentation">hypopigmentation</a> and fat atrophy leading to indentation of the skin around the injection site.<sup id="cite_ref-&#80;MID20970844_52-1" class="reference"><a href="#cite_note-PMID20970844-52">&#91;52&#93;</a></sup> Steroid injections against appear to be more effective than shock wave therapy.<sup id="cite_ref-55" class="reference"><a href="#cite_note-55">&#91;55&#93;</a></sup> <a href="/enwiki/wiki/Botulinum_toxin" title="Botulinum toxin">Botulinum toxin</a> type A to paralyze the forearm extensor muscles in those with chronic tennis elbow that has not improved with conservative measures may be viable.<sup id="cite_ref-56" class="reference"><a href="#cite_note-56">&#91;56&#93;</a></sup> </p> <h3><span class="mw-headline" id="Surgery">Surgery</span></h3> <p>In recalcitrant cases <a href="/enwiki/wiki/Surgery" title="Surgery">surgery</a> may be an option.<sup id="cite_ref-57" class="reference"><a href="#cite_note-57">&#91;57&#93;</a></sup><sup id="cite_ref-pmi17632419_58-0" class="reference"><a href="#cite_note-pmi17632419-58">&#91;58&#93;</a></sup><sup id="cite_ref-pmid23388420_59-0" class="reference"><a href="#cite_note-pmid23388420-59">&#91;59&#93;</a></sup> Surgical methods include:<sup id="cite_ref-FaroWolf2007_60-0" class="reference"><a href="#cite_note-FaroWolf2007-60">&#91;60&#93;</a></sup> </p> <ul><li>Lengthening, release, debridement, or repair of the origin of the <a href="/enwiki/wiki/Extrinsic_extensor_muscles_of_the_hand" title="Extrinsic extensor muscles of the hand">extrinsic extensor muscles of the hand</a> at the <a href="/enwiki/wiki/Lateral_epicondyle_of_the_humerus" title="Lateral epicondyle of the humerus">lateral epicondyle</a></li> <li>Rotation of the <a href="/enwiki/wiki/Anconeus_muscle" title="Anconeus muscle">anconeus muscle</a></li> <li>Denervation of the <a href="/enwiki/wiki/Lateral_epicondyle_of_the_humerus" title="Lateral epicondyle of the humerus">lateral epicondyle</a></li> <li>Decompression of the <a href="/enwiki/wiki/Posterior_interosseous_nerve" title="Posterior interosseous nerve">posterior interosseous nerve</a></li></ul> <p>Surgical techniques for lateral epicondylitis can be done by <a href="/enwiki/wiki/Open_surgery" class="mw-redirect" title="Open surgery">open surgery</a>, <a href="/enwiki/w/index.php?title=Percutaneous_surgery&amp;action=edit&amp;redlink=1" class="new" title="Percutaneous surgery (page does not exist)">percutaneous surgery</a> or <a href="/enwiki/wiki/Arthroscopic_surgery" class="mw-redirect" title="Arthroscopic surgery">arthroscopic surgery</a>, with no high-quality evidence that any particular type is better or worse than another.<sup id="cite_ref-:1_61-0" class="reference"><a href="#cite_note-:1-61">&#91;61&#93;</a></sup><sup id="cite_ref-pmi17632419_58-1" class="reference"><a href="#cite_note-pmi17632419-58">&#91;58&#93;</a></sup> Side effects include infection, damage to nerves and inability to straighten the arm.<sup id="cite_ref-62" class="reference"><a href="#cite_note-62">&#91;62&#93;</a></sup> A review of the evidence related to surgery found that published studies were of low quality and did not show that surgery was any more effective than other treatments.<sup id="cite_ref-:1_61-1" class="reference"><a href="#cite_note-:1-61">&#91;61&#93;</a></sup> A subsequent research trial showed that surgery was no more effective than sham surgery, where patients only received a skin incision, although the trial was limited by a small number of patients.<sup id="cite_ref-63" class="reference"><a href="#cite_note-63">&#91;63&#93;</a></sup> </p> <h2><span class="mw-headline" id="Prognosis">Prognosis</span></h2> <p>Response to initial therapy is common, but so is relapse (25% to 50%) and/or prolonged, moderate discomfort (40%).<sup class="noprint Inline-Template Template-Fact" style="white-space:nowrap;">&#91;<i><a href="/enwiki/wiki/Wikipedia:Citation_needed" title="Wikipedia:Citation needed"><span title="This claim needs references to reliable sources. (October 2020)">citation needed</span></a></i>&#93;</sup> </p><p>Depending upon severity and quantity of multiple tendon injuries that have built up, the extensor carpi radialis brevis may not be fully healed by conservative treatment. Nirschl defines four stages of lateral epicondylitis, showing the introduction of permanent damage beginning at Stage 2. </p> <ol><li>Inflammatory changes that are reversible</li> <li>Nonreversible pathologic changes to origin of the extensor carpi radialis brevis muscle</li> <li>Rupture of ECRB muscle origin</li> <li>Secondary changes such as fibrosis or calcification.<sup id="cite_ref-Lateral_Epicondylitis:_Workup_64-0" class="reference"><a href="#cite_note-Lateral_Epicondylitis:_Workup-64">&#91;64&#93;</a></sup></li></ol> <h2><span class="mw-headline" id="Epidemiology">Epidemiology</span></h2> <p>In tennis players, about 39.7% have reported current or previous problems with their elbow. Less than one quarter (24%) of these athletes under the age of 50 reported that the tennis elbow symptoms were "severe" and "disabling," while 42% over the age of 50 did. More women (36%) than men (24%) considered their symptoms severe and disabling. Tennis elbow is more prevalent in individuals over 40, where there is about a four-fold increase among men and two-fold increase among women. Tennis elbow equally affects both sexes and, although men have a marginally higher overall prevalence rate as compared to women, this is not consistent within each age group, nor is it a statistically significant difference.<sup id="cite_ref-65" class="reference"><a href="#cite_note-65">&#91;65&#93;</a></sup> </p><p>Playing time is a significant factor in tennis elbow occurrence, with increased incidence with increased playing time being greater for respondents under 40. Individuals over 40 who played over two hours doubled their chance of injury. Those under 40 increased it 3.5 fold compared to those who played less than two hours per day.<sup id="cite_ref-mayoclinic.com_13-5" class="reference"><a href="#cite_note-mayoclinic.com-13">&#91;13&#93;</a></sup> </p> <h2><span class="mw-headline" id="History">History</span></h2> <p>German physician F. Runge<sup id="cite_ref-66" class="reference"><a href="#cite_note-66">&#91;66&#93;</a></sup> is usually credited for the first description of the condition, calling it "writer's cramp" (<i>Schreibekrampf</i>) in 1873.<sup id="cite_ref-67" class="reference"><a href="#cite_note-67">&#91;67&#93;</a></sup> Later, it was called "washer women's elbow".<sup id="cite_ref-68" class="reference"><a href="#cite_note-68">&#91;68&#93;</a></sup> British surgeon Henry Morris published an article in <i><a href="/enwiki/wiki/The_Lancet" title="The Lancet">The Lancet</a></i> describing "lawn tennis arm" in 1883.<sup id="cite_ref-69" class="reference"><a href="#cite_note-69">&#91;69&#93;</a></sup><sup id="cite_ref-70" class="reference"><a href="#cite_note-70">&#91;70&#93;</a></sup> The popular term "tennis elbow" first appeared the same year in a paper by H. P. Major, described as "lawn-tennis elbow".<sup id="cite_ref-71" class="reference"><a href="#cite_note-71">&#91;71&#93;</a></sup><sup id="cite_ref-TechHandUpExtremSurg2003-Kaminsky_72-0" class="reference"><a href="#cite_note-TechHandUpExtremSurg2003-Kaminsky-72">&#91;72&#93;</a></sup> </p> <h2><span class="mw-headline" id="See_also">See also</span></h2> <style data-mw-deduplicate="TemplateStyles:r936637989">.mw-parser-output .portal{border:solid #aaa 1px;padding:0}.mw-parser-output .portal.tleft{margin:0.5em 1em 0.5em 0}.mw-parser-output .portal.tright{margin:0.5em 0 0.5em 1em}.mw-parser-output .portal>ul{display:table;box-sizing:border-box;padding:0.1em;max-width:175px;background:#f9f9f9;font-size:85%;line-height:110%;font-style:italic;font-weight:bold}.mw-parser-output .portal>ul>li{display:table-row}.mw-parser-output .portal>ul>li>span:first-child{display:table-cell;padding:0.2em;vertical-align:middle;text-align:center}.mw-parser-output .portal>ul>li>span:last-child{display:table-cell;padding:0.2em 0.2em 0.2em 0.3em;vertical-align:middle}</style><div role="navigation" aria-label="Portals" class="noprint portal plainlist tright"> <ul> <li><span><a href="/enwiki/wiki/File:Tennis_ball.svg" class="image"><img alt="icon" src="/upwiki/wikipedia/commons/thumb/c/c4/Tennis_ball.svg/28px-Tennis_ball.svg.png" decoding="async" width="28" height="28" class="noviewer" srcset="/upwiki/wikipedia/commons/thumb/c/c4/Tennis_ball.svg/42px-Tennis_ball.svg.png 1.5x, /upwiki/wikipedia/commons/thumb/c/c4/Tennis_ball.svg/56px-Tennis_ball.svg.png 2x" data-file-width="263" data-file-height="263" /></a></span><span><a href="/enwiki/wiki/Portal:Tennis" title="Portal:Tennis">Tennis portal</a></span></li></ul></div> <ul><li><a href="/enwiki/wiki/Olecranon_bursitis" title="Olecranon bursitis">Olecranon bursitis</a></li> <li><a href="/enwiki/wiki/Repetitive_strain_injury" title="Repetitive strain injury">Repetitive strain injury</a></li> <li><a href="/enwiki/wiki/Radial_tunnel_syndrome" title="Radial tunnel syndrome">Radial tunnel syndrome</a></li></ul> <h2><span class="mw-headline" id="References">References</span></h2> <div class="reflist" style="list-style-type: decimal;"> <div class="mw-references-wrap mw-references-columns"><ol class="references"> <li id="cite_note-Hub2018-1"><span class="mw-cite-backlink">^ <a href="#cite_ref-Hub2018_1-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-Hub2018_1-1"><sup><i><b>b</b></i></sup></a> <a href="#cite_ref-Hub2018_1-2"><sup><i><b>c</b></i></sup></a> <a href="#cite_ref-Hub2018_1-3"><sup><i><b>d</b></i></sup></a> <a href="#cite_ref-Hub2018_1-4"><sup><i><b>e</b></i></sup></a> <a href="#cite_ref-Hub2018_1-5"><sup><i><b>f</b></i></sup></a> <a href="#cite_ref-Hub2018_1-6"><sup><i><b>g</b></i></sup></a> <a href="#cite_ref-Hub2018_1-7"><sup><i><b>h</b></i></sup></a> <a href="#cite_ref-Hub2018_1-8"><sup><i><b>i</b></i></sup></a> <a href="#cite_ref-Hub2018_1-9"><sup><i><b>j</b></i></sup></a> <a href="#cite_ref-Hub2018_1-10"><sup><i><b>k</b></i></sup></a></span> <span class="reference-text"><style data-mw-deduplicate="TemplateStyles:r999302996">.mw-parser-output cite.citation{font-style:inherit}.mw-parser-output .citation q{quotes:"\"""\"""'""'"}.mw-parser-output .id-lock-free a,.mw-parser-output .citation .cs1-lock-free a{background:linear-gradient(transparent,transparent),url("/upwiki/wikipedia/commons/6/65/Lock-green.svg")right 0.1em center/9px no-repeat}.mw-parser-output .id-lock-limited a,.mw-parser-output .id-lock-registration a,.mw-parser-output .citation .cs1-lock-limited a,.mw-parser-output .citation .cs1-lock-registration a{background:linear-gradient(transparent,transparent),url("/upwiki/wikipedia/commons/d/d6/Lock-gray-alt-2.svg")right 0.1em center/9px no-repeat}.mw-parser-output .id-lock-subscription a,.mw-parser-output .citation .cs1-lock-subscription 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Reilly, M. Hughes and A.Lees. Published by E &amp; FN Spon <link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r999302996"/><a href="/enwiki/wiki/ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a>&#160;<a href="/enwiki/wiki/Special:BookSources/0-419-18500-3" title="Special:BookSources/0-419-18500-3">0-419-18500-3</a>.</span> </li> <li id="cite_note-69"><span class="mw-cite-backlink"><b><a href="#cite_ref-69">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r999302996"/><cite id="CITEREFFlatt_Adrian_E2008" class="citation journal cs1">Flatt Adrian E (Oct 2008). <a rel="nofollow" class="external text" href="/enwiki//www.ncbi.nlm.nih.gov/pmc/articles/PMC2566914">"Tennis elbow"</a>. <i>Proc (Bayl Univ Med Cent)</i>. <b>21</b> (4): 400–402. <a href="/enwiki/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1080%2F08998280.2008.11928437">10.1080/08998280.2008.11928437</a>. <a href="/enwiki/wiki/PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a>&#160;<span class="cs1-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="/enwiki//www.ncbi.nlm.nih.gov/pmc/articles/PMC2566914">2566914</a></span>. <a href="/enwiki/wiki/PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a>&#160;<a rel="nofollow" class="external text" href="/enwiki//pubmed.ncbi.nlm.nih.gov/18982084">18982084</a>.</cite><span title="ctx_ver=Z39.88-2004&amp;rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&amp;rft.genre=article&amp;rft.jtitle=Proc+%28Bayl+Univ+Med+Cent%29.&amp;rft.atitle=Tennis+elbow&amp;rft.volume=21&amp;rft.issue=4&amp;rft.pages=400-402&amp;rft.date=2008-10&amp;rft_id=%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC2566914%23id-name%3DPMC&amp;rft_id=info%3Apmid%2F18982084&amp;rft_id=info%3Adoi%2F10.1080%2F08998280.2008.11928437&amp;rft.au=Flatt+Adrian+E&amp;rft_id=%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC2566914&amp;rfr_id=info%3Asid%2Fen.wikipedia.org%3ATennis+elbow" class="Z3988"></span></span> </li> <li id="cite_note-70"><span class="mw-cite-backlink"><b><a href="#cite_ref-70">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r999302996"/><cite class="citation journal cs1"><a rel="nofollow" class="external text" href="http://www.thelancet.com/action/doSearch?journalCode=lancet&amp;searchText1=tennis&amp;occurrences1=all&amp;op1=and&amp;searchText2=&amp;occurrences2=all&amp;seriesISSNFltraddfilter=0140-6736&amp;date=custom&amp;fMonth=1&amp;fYear=1800&amp;lMonth=1&amp;lYear=1900&amp;searchAttempt=&amp;searchType=advanced&amp;doSearch=Search">"Tennis Elbow-Cap"</a>. <i>The Lancet</i>. <b>128</b> (3301): 1083. 1886. <a href="/enwiki/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1016%2Fs0140-6736%2800%2949587-5">10.1016/s0140-6736(00)49587-5</a>.</cite><span title="ctx_ver=Z39.88-2004&amp;rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&amp;rft.genre=article&amp;rft.jtitle=The+Lancet&amp;rft.atitle=Tennis+Elbow-Cap&amp;rft.volume=128&amp;rft.issue=3301&amp;rft.pages=1083&amp;rft.date=1886&amp;rft_id=info%3Adoi%2F10.1016%2Fs0140-6736%2800%2949587-5&amp;rft_id=http%3A%2F%2Fwww.thelancet.com%2Faction%2FdoSearch%3FjournalCode%3Dlancet%26searchText1%3Dtennis%26occurrences1%3Dall%26op1%3Dand%26searchText2%3D%26occurrences2%3Dall%26seriesISSNFltraddfilter%3D0140-6736%26date%3Dcustom%26fMonth%3D1%26fYear%3D1800%26lMonth%3D1%26lYear%3D1900%26searchAttempt%3D%26searchType%3Dadvanced%26doSearch%3DSearch&amp;rfr_id=info%3Asid%2Fen.wikipedia.org%3ATennis+elbow" class="Z3988"></span></span> </li> <li id="cite_note-71"><span class="mw-cite-backlink"><b><a href="#cite_ref-71">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r999302996"/><cite id="CITEREFMajor_HP1883" class="citation journal cs1">Major HP (1883). <a rel="nofollow" class="external text" href="/enwiki//www.ncbi.nlm.nih.gov/pmc/articles/PMC2372911">"Lawn-tennis elbow"</a>. <i>BMJ</i>. <b>2</b> (1185): 556–558. <a href="/enwiki/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1136%2Fbmj.2.1185.556">10.1136/bmj.2.1185.556</a>. <a href="/enwiki/wiki/PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a>&#160;<span class="cs1-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="/enwiki//www.ncbi.nlm.nih.gov/pmc/articles/PMC2372911">2372911</a></span>.</cite><span title="ctx_ver=Z39.88-2004&amp;rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&amp;rft.genre=article&amp;rft.jtitle=BMJ&amp;rft.atitle=Lawn-tennis+elbow&amp;rft.volume=2&amp;rft.issue=1185&amp;rft.pages=556-558&amp;rft.date=1883&amp;rft_id=%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC2372911%23id-name%3DPMC&amp;rft_id=info%3Adoi%2F10.1136%2Fbmj.2.1185.556&amp;rft.au=Major+HP&amp;rft_id=%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC2372911&amp;rfr_id=info%3Asid%2Fen.wikipedia.org%3ATennis+elbow" class="Z3988"></span></span> </li> <li id="cite_note-TechHandUpExtremSurg2003-Kaminsky-72"><span class="mw-cite-backlink"><b><a href="#cite_ref-TechHandUpExtremSurg2003-Kaminsky_72-0">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r999302996"/><cite id="CITEREFKaminsky_SB,_Baker_CLBaker2003" class="citation journal cs1">Kaminsky SB, Baker CL; Baker (December 2003). "Lateral epicondylitis of the elbow". <i>Techniques in Hand &amp; Upper Limb Surgery</i>. <b>7</b> (4): 179–89. <a href="/enwiki/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1097%2F00130911-200312000-00009">10.1097/00130911-200312000-00009</a>. <a href="/enwiki/wiki/PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a>&#160;<a rel="nofollow" class="external text" href="/enwiki//pubmed.ncbi.nlm.nih.gov/16518219">16518219</a>. <a href="/enwiki/wiki/S2CID_(identifier)" class="mw-redirect" title="S2CID (identifier)">S2CID</a>&#160;<a rel="nofollow" class="external text" href="https://api.semanticscholar.org/CorpusID:128648">128648</a>.</cite><span title="ctx_ver=Z39.88-2004&amp;rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&amp;rft.genre=article&amp;rft.jtitle=Techniques+in+Hand+%26+Upper+Limb+Surgery&amp;rft.atitle=Lateral+epicondylitis+of+the+elbow&amp;rft.volume=7&amp;rft.issue=4&amp;rft.pages=179-89&amp;rft.date=2003-12&amp;rft_id=https%3A%2F%2Fapi.semanticscholar.org%2FCorpusID%3A128648%23id-name%3DS2CID&amp;rft_id=info%3Apmid%2F16518219&amp;rft_id=info%3Adoi%2F10.1097%2F00130911-200312000-00009&amp;rft.au=Kaminsky+SB%2C+Baker+CL&amp;rft.au=Baker&amp;rfr_id=info%3Asid%2Fen.wikipedia.org%3ATennis+elbow" class="Z3988"></span></span> </li> </ol></div></div> <h2><span class="mw-headline" id="External_links">External links</span></h2> <ul><li><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r999302996"/><cite id="CITEREFWilsonBest2005" class="citation journal cs1">Wilson JJ, Best TM (September 2005). <a rel="nofollow" class="external text" href="http://www.aafp.org/afp/20050901/811.html">"Common overuse tendon problems: A review and recommendations for treatment"</a>. <i>American Family Physician</i>. <b>72</b> (5): 811–8. <a href="/enwiki/wiki/PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a>&#160;<a rel="nofollow" class="external text" href="/enwiki//pubmed.ncbi.nlm.nih.gov/16156339">16156339</a>.</cite><span title="ctx_ver=Z39.88-2004&amp;rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&amp;rft.genre=article&amp;rft.jtitle=American+Family+Physician&amp;rft.atitle=Common+overuse+tendon+problems%3A+A+review+and+recommendations+for+treatment&amp;rft.volume=72&amp;rft.issue=5&amp;rft.pages=811-8&amp;rft.date=2005-09&amp;rft_id=info%3Apmid%2F16156339&amp;rft.aulast=Wilson&amp;rft.aufirst=JJ&amp;rft.au=Best%2C+TM&amp;rft_id=http%3A%2F%2Fwww.aafp.org%2Fafp%2F20050901%2F811.html&amp;rfr_id=info%3Asid%2Fen.wikipedia.org%3ATennis+elbow" class="Z3988"></span></li></ul> <table class="infobox" style="width:22em;width:100%; margin:0.5em 0 0.5em 0;"><tbody><tr><th scope="row">Classification</th><td style="text-align:left;"><div style="position:relative; float:right; font-size:0.8em;"><a href="https://www.wikidata.org/wiki/Q736776" class="extiw" title="d:Q736776">D</a></div><div class="hlist hlist-separated" style="text-align:left;"><ul><li><b><a href="/enwiki/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problems" class="mw-redirect" title="International Statistical Classification of Diseases and Related Health Problems">ICD</a>-<a href="/enwiki/wiki/ICD-10" title="ICD-10">10</a></b>: <a rel="nofollow" class="external text" href="https://icd.who.int/browse10/2019/en#/M77.1">M77.1</a></li><li><b><a href="/enwiki/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problems" class="mw-redirect" title="International Statistical Classification of Diseases and Related Health Problems">ICD</a>-<a href="/enwiki/wiki/List_of_ICD-9_codes" title="List of ICD-9 codes">9-CM</a></b>: <a rel="nofollow" class="external text" href="http://www.icd9data.com/getICD9Code.ashx?icd9=726.32">726.32</a></li><li><b><a href="/enwiki/wiki/Medical_Subject_Headings" title="Medical Subject Headings">MeSH</a></b>: <a rel="nofollow" class="external text" href="https://www.nlm.nih.gov/cgi/mesh/2015/MB_cgi?field=uid&amp;term=D013716">D013716</a></li><li><b><a href="/enwiki/wiki/Diseases_Database" title="Diseases Database">DiseasesDB</a></b>: <a rel="nofollow" class="external text" href="http://www.diseasesdatabase.com/ddb12950.htm">12950</a></li></ul></div></td></tr><tr><th scope="row">External resources</th><td style="text-align:left;"><div class="hlist hlist-separated" style="text-align:left;"><ul><li><b><a href="/enwiki/wiki/MedlinePlus" title="MedlinePlus">MedlinePlus</a></b>: <a rel="nofollow" class="external text" href="https://www.nlm.nih.gov/medlineplus/ency/article/000449.htm">000449</a></li><li><b><a href="/enwiki/wiki/EMedicine" title="EMedicine">eMedicine</a></b>: <a rel="nofollow" class="external text" href="https://emedicine.medscape.com/orthoped/510-overview">orthoped/510</a> <a rel="nofollow" class="external text" href="http://www.emedicine.com/pmr/topic64.htm#">pmr/64</a> <a rel="nofollow" class="external text" href="http://www.emedicine.com/sports/topic59.htm#">sports/59</a></li><li><b><a href="/enwiki/wiki/Patient_UK" title="Patient UK">Patient UK</a></b>: <a rel="nofollow" class="external text" href="https://patient.info/doctor/epicondylitis-lateral-and-medial">Tennis elbow</a></li></ul></div></td></tr></tbody></table> <div role="navigation" class="navbox" aria-labelledby="Soft_tissue_disorders" style="padding:3px"><table class="nowraplinks mw-collapsible autocollapse navbox-inner" style="border-spacing:0;background:transparent;color:inherit"><tbody><tr><th scope="col" class="navbox-title" colspan="2"><style data-mw-deduplicate="TemplateStyles:r992953826">.mw-parser-output .navbar{display:inline;font-size:88%;font-weight:normal}.mw-parser-output .navbar-collapse{float:left;text-align:left}.mw-parser-output .navbar-boxtext{word-spacing:0}.mw-parser-output .navbar ul{display:inline-block;white-space:nowrap;line-height:inherit}.mw-parser-output .navbar-brackets::before{margin-right:-0.125em;content:"[ "}.mw-parser-output .navbar-brackets::after{margin-left:-0.125em;content:" ]"}.mw-parser-output .navbar li{word-spacing:-0.125em}.mw-parser-output .navbar-mini abbr{font-variant:small-caps;border-bottom:none;text-decoration:none;cursor:inherit}.mw-parser-output .navbar-ct-full{font-size:114%;margin:0 7em}.mw-parser-output .navbar-ct-mini{font-size:114%;margin:0 4em}.mw-parser-output .infobox .navbar{font-size:100%}.mw-parser-output .navbox .navbar{display:block;font-size:100%}.mw-parser-output .navbox-title .navbar{float:left;text-align:left;margin-right:0.5em}</style><div class="navbar plainlinks hlist navbar-mini"><ul><li class="nv-view"><a href="/enwiki/wiki/Template:Soft_tissue_disorders" title="Template:Soft tissue disorders"><abbr title="View this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">v</abbr></a></li><li class="nv-talk"><a href="/enwiki/wiki/Template_talk:Soft_tissue_disorders" title="Template talk:Soft tissue disorders"><abbr title="Discuss this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">t</abbr></a></li><li class="nv-edit"><a class="external text" href="https://en.wikipedia.org/enwiki/w/index.php?title=Template:Soft_tissue_disorders&amp;action=edit"><abbr title="Edit this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">e</abbr></a></li></ul></div><div id="Soft_tissue_disorders" style="font-size:114%;margin:0 4em"><a href="/enwiki/wiki/Soft_tissue_disorder" class="mw-redirect" title="Soft tissue disorder">Soft tissue disorders</a></div></th></tr><tr><th scope="row" class="navbox-group" style="width:1%">Capsular joint</th><td class="navbox-list navbox-odd hlist" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Synovial_membrane" title="Synovial membrane">Synoviopathy</a></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Synovitis" title="Synovitis">Synovitis</a>/<a href="/enwiki/wiki/Tenosynovitis" title="Tenosynovitis">Tenosynovitis</a> <ul><li><a href="/enwiki/wiki/Calcific_tendinitis" title="Calcific tendinitis">Calcific tendinitis</a></li> <li><a href="/enwiki/wiki/Stenosing_tenosynovitis" class="mw-redirect" title="Stenosing tenosynovitis">Stenosing tenosynovitis</a></li> <li><a href="/enwiki/wiki/Trigger_finger" title="Trigger finger">Trigger finger</a></li> <li><a href="/enwiki/wiki/De_Quervain_syndrome" title="De Quervain syndrome">De Quervain syndrome</a></li></ul></li> <li><a href="/enwiki/wiki/Transient_synovitis" title="Transient synovitis">Transient synovitis</a></li> <li><a href="/enwiki/wiki/Ganglion_cyst" title="Ganglion cyst">Ganglion cyst</a></li></ul> <ul><li><i><a href="/enwiki/wiki/Osteochondromatosis" title="Osteochondromatosis">osteochondromatosis</a></i> <ul><li><a href="/enwiki/wiki/Synovial_osteochondromatosis" title="Synovial osteochondromatosis">Synovial osteochondromatosis</a></li></ul></li> <li><a href="/enwiki/wiki/Plica_syndrome" title="Plica syndrome">Plica syndrome</a></li></ul> <ul><li><i><a href="/enwiki/wiki/Villonodular_synovitis" title="Villonodular synovitis">villonodular synovitis</a></i> <ul><li><a href="/enwiki/wiki/Giant-cell_tumor_of_the_tendon_sheath" class="mw-redirect" title="Giant-cell tumor of the tendon sheath">Giant-cell tumor of the tendon sheath</a></li></ul></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Synovial_bursa" title="Synovial bursa">Bursopathy</a></th><td class="navbox-list navbox-even" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Bursitis" title="Bursitis">Bursitis</a> <ul><li><a href="/enwiki/wiki/Olecranon_bursitis" title="Olecranon bursitis">Olecranon</a></li> <li><a href="/enwiki/wiki/Prepatellar_bursitis" title="Prepatellar bursitis">Prepatellar</a></li> <li><a href="/enwiki/wiki/Greater_trochanteric_pain_syndrome" title="Greater trochanteric pain syndrome">Trochanteric</a></li> <li><a href="/enwiki/wiki/Subacromial_bursitis" title="Subacromial bursitis">Subacromial</a></li> <li><a href="/enwiki/wiki/Achilles_bursitis" title="Achilles bursitis">Achilles</a></li> <li><a href="/enwiki/wiki/Retrocalcaneal_bursitis" title="Retrocalcaneal bursitis">Retrocalcaneal</a></li> <li><a href="/enwiki/wiki/Ischial_bursitis" title="Ischial bursitis">Ischial</a></li> <li><a href="/enwiki/wiki/Iliopsoas_bursitis" title="Iliopsoas bursitis">Iliopsoas</a></li></ul></li> <li><a href="/enwiki/wiki/Ganglion_cyst" title="Ganglion cyst">Synovial cyst</a> <ul><li><a href="/enwiki/wiki/Baker%27s_cyst" title="Baker&#39;s cyst">Baker's cyst</a></li></ul></li> <li><a href="/enwiki/wiki/Calcific_bursitis" title="Calcific bursitis">Calcific bursitis</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Noncapsular joint</th><td class="navbox-list navbox-odd hlist" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%">Symptoms</th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Ligamentous_laxity" title="Ligamentous laxity">Ligamentous laxity</a></li> <li><a href="/enwiki/wiki/Hypermobility_(joints)" title="Hypermobility (joints)">Hypermobility</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Enthesopathy" title="Enthesopathy">Enthesopathy</a>/<a href="/enwiki/wiki/Enthesitis" title="Enthesitis">Enthesitis</a>/<a href="/enwiki/wiki/Tendinopathy" title="Tendinopathy">Tendinopathy</a></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><style data-mw-deduplicate="TemplateStyles:r886047488">.mw-parser-output .nobold{font-weight:normal}</style><span class="nobold"><i>upper limb</i></span></th><td class="navbox-list navbox-even" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Adhesive_capsulitis_of_shoulder" class="mw-redirect" title="Adhesive capsulitis of shoulder">Adhesive capsulitis of shoulder</a></li> <li><a href="/enwiki/wiki/Impingement_syndrome" class="mw-redirect" title="Impingement syndrome">Impingement syndrome</a></li> <li><a href="/enwiki/wiki/Rotator_cuff_tear" title="Rotator cuff tear">Rotator cuff tear</a></li> <li><a href="/enwiki/wiki/Golfer%27s_elbow" title="Golfer&#39;s elbow">Golfer's elbow</a></li> <li><a class="mw-selflink selflink">Tennis elbow</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r886047488"/><span class="nobold"><i>lower limb</i></span></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Iliotibial_band_syndrome" title="Iliotibial band syndrome">Iliotibial band syndrome</a></li> <li><a href="/enwiki/wiki/Patellar_tendinitis" title="Patellar tendinitis">Patellar tendinitis</a></li> <li><a href="/enwiki/wiki/Achilles_tendinitis" title="Achilles tendinitis">Achilles tendinitis</a></li> <li><a href="/enwiki/wiki/Calcaneal_spur" title="Calcaneal spur">Calcaneal spur</a></li> <li><a href="/enwiki/wiki/Metatarsalgia" title="Metatarsalgia">Metatarsalgia</a></li> <li><a href="/enwiki/wiki/Osteophyte" title="Osteophyte">Bone spur</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r886047488"/><span class="nobold"><i>other/general:</i></span></th><td class="navbox-list navbox-even" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Tendinitis" class="mw-redirect" title="Tendinitis">Tendinitis</a>/<a href="/enwiki/wiki/Tendinosis" class="mw-redirect" title="Tendinosis">Tendinosis</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Nonjoint</th><td class="navbox-list navbox-odd hlist" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Fascia" title="Fascia">Fasciopathy</a></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Fasciitis" title="Fasciitis">Fasciitis</a>: <a href="/enwiki/wiki/Plantar_fasciitis" title="Plantar fasciitis">Plantar</a></li> <li><a href="/enwiki/wiki/Nodular_fasciitis" title="Nodular fasciitis">Nodular</a></li> <li><a href="/enwiki/wiki/Necrotizing_fasciitis" title="Necrotizing fasciitis">Necrotizing</a></li> <li><a href="/enwiki/wiki/Eosinophilic_fasciitis" title="Eosinophilic fasciitis">Eosinophilic</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Fibromatosis" title="Fibromatosis">Fibromatosis</a>/<a href="/enwiki/wiki/Contracture" title="Contracture">contracture</a></th><td class="navbox-list navbox-even" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Dupuytren%27s_contracture" title="Dupuytren&#39;s contracture">Dupuytren's contracture</a></li> <li><a href="/enwiki/wiki/Plantar_fibromatosis" title="Plantar fibromatosis">Plantar fibromatosis</a></li> <li><a href="/enwiki/wiki/Aggressive_fibromatosis" title="Aggressive fibromatosis">Aggressive fibromatosis</a></li> <li><a href="/enwiki/wiki/Knuckle_pads" title="Knuckle pads">Knuckle pads</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr></tbody></table></div> <div role="navigation" class="navbox" aria-labelledby="Inflammation" style="padding:3px"><table class="nowraplinks mw-collapsible autocollapse navbox-inner" style="border-spacing:0;background:transparent;color:inherit"><tbody><tr><th scope="col" class="navbox-title" colspan="2"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r992953826"/><div class="navbar plainlinks hlist navbar-mini"><ul><li class="nv-view"><a href="/enwiki/wiki/Template:Inflammation" title="Template:Inflammation"><abbr title="View this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">v</abbr></a></li><li class="nv-talk"><a href="/enwiki/wiki/Template_talk:Inflammation" title="Template talk:Inflammation"><abbr title="Discuss this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">t</abbr></a></li><li class="nv-edit"><a class="external text" href="https://en.wikipedia.org/enwiki/w/index.php?title=Template:Inflammation&amp;action=edit"><abbr title="Edit this template" style=";;background:none transparent;border:none;box-shadow:none;padding:0;">e</abbr></a></li></ul></div><div id="Inflammation" style="font-size:114%;margin:0 4em"><a href="/enwiki/wiki/Inflammation" title="Inflammation">Inflammation</a></div></th></tr><tr><th scope="row" class="navbox-group" style="width:1%">Symptoms</th><td class="navbox-list navbox-odd hlist" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Flushing_(physiology)" title="Flushing (physiology)">Flushing (Rubor)</a></li> <li><a href="/enwiki/wiki/Fever" title="Fever">Fever (Calor)</a></li> <li><a href="/enwiki/wiki/Swelling_(medical)" class="mw-redirect" title="Swelling (medical)">Swelling (Tumor)</a></li> <li><a href="/enwiki/wiki/Pain" title="Pain">Pain (Dolor)</a></li> <li><a href="/enwiki/wiki/Functio_laesa" title="Functio laesa">Malaise</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Mechanism</th><td class="navbox-list navbox-odd hlist" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Inflammation#Acute_inflammation" title="Inflammation">Acute</a></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Inflammation#Plasma-derived_mediators" title="Inflammation">Plasma-derived mediators</a></th><td class="navbox-list navbox-even" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Bradykinin" title="Bradykinin">Bradykinin</a></li> <li><i><a href="/enwiki/wiki/Complement_system" title="Complement system">complement</a></i> <ul><li><a href="/enwiki/wiki/Complement_component_3" title="Complement component 3">C3</a></li> <li><a href="/enwiki/wiki/Complement_component_5a" title="Complement component 5a">C5a</a></li> <li><a href="/enwiki/wiki/Complement_membrane_attack_complex" title="Complement membrane attack complex">MAC</a></li></ul></li> <li><i><a href="/enwiki/wiki/Coagulation" title="Coagulation">coagulation</a></i> <ul><li><a href="/enwiki/wiki/Factor_XII" title="Factor XII">Factor XII</a></li> <li><a href="/enwiki/wiki/Plasmin" title="Plasmin">Plasmin</a></li> <li><a href="/enwiki/wiki/Thrombin" title="Thrombin">Thrombin</a></li></ul></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Inflammation#Cell-derived_mediators" title="Inflammation">Cell-derived mediators</a></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"></div><table class="nowraplinks navbox-subgroup" style="border-spacing:0"><tbody><tr><th scope="row" class="navbox-group" style="width:1%"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r886047488"/><span class="nobold"><i>preformed:</i></span></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Granule_(cell_biology)" title="Granule (cell biology)">Lysosome granules</a></li> <li><i><a href="/enwiki/wiki/Biogenic_amine" title="Biogenic amine">biogenic amines</a></i> <ul><li><a href="/enwiki/wiki/Histamine" title="Histamine">Histamine</a></li> <li><a href="/enwiki/wiki/Serotonin" title="Serotonin">Serotonin</a></li></ul></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r886047488"/><span class="nobold"><i>synthesized on demand:</i></span></th><td class="navbox-list navbox-even" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><i><a href="/enwiki/wiki/Cytokine" title="Cytokine">cytokines</a></i> <ul><li><a href="/enwiki/wiki/Interferon_gamma" title="Interferon gamma">IFN-γ</a></li> <li><a href="/enwiki/wiki/Interleukin_8" title="Interleukin 8">IL-8</a></li> <li><a href="/enwiki/wiki/Tumor_necrosis_factor_alpha" class="mw-redirect" title="Tumor necrosis factor alpha">TNF-α</a></li> <li><a href="/enwiki/wiki/IL1A" title="IL1A">IL-1</a></li></ul></li> <li><i><a href="/enwiki/wiki/Eicosanoid" title="Eicosanoid">eicosanoids</a></i> <ul><li><a href="/enwiki/wiki/Leukotriene_B4" title="Leukotriene B4">Leukotriene B4</a></li> <li><a href="/enwiki/wiki/Prostaglandin" title="Prostaglandin">Prostaglandins</a></li></ul></li> <li><a href="/enwiki/wiki/Nitric_oxide" title="Nitric oxide">Nitric oxide</a></li> <li><a href="/enwiki/wiki/Kinin" title="Kinin">Kinins</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="/enwiki/wiki/Chronic_inflammation" class="mw-redirect" title="Chronic inflammation">Chronic</a></th><td class="navbox-list navbox-odd" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Macrophage" title="Macrophage">Macrophage</a></li> <li><a href="/enwiki/wiki/Epithelioid_cell" title="Epithelioid cell">Epithelioid cell</a></li> <li><a href="/enwiki/wiki/Giant_cell" title="Giant cell">Giant cell</a></li> <li><a href="/enwiki/wiki/Granuloma" title="Granuloma">Granuloma</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Other</th><td class="navbox-list navbox-even" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Acute-phase_protein" title="Acute-phase protein">Acute-phase reaction</a></li> <li><a href="/enwiki/wiki/Vasodilation" title="Vasodilation">Vasodilation</a></li> <li><a href="/enwiki/wiki/Vascular_permeability" title="Vascular permeability">Increased vascular permeability</a></li> <li><a href="/enwiki/wiki/Exudate" title="Exudate">Exudate</a></li> <li><a href="/enwiki/wiki/Leukocyte_extravasation" title="Leukocyte extravasation">Leukocyte extravasation</a></li> <li><a href="/enwiki/wiki/Chemotaxis" title="Chemotaxis">Chemotaxis</a></li></ul> </div></td></tr></tbody></table><div></div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Tests</th><td class="navbox-list navbox-odd hlist" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Full_blood_count" class="mw-redirect" title="Full blood count">Full blood count</a> <ul><li><a href="/enwiki/wiki/Leukocytosis" title="Leukocytosis">Leukocytosis</a></li></ul></li> <li><a href="/enwiki/wiki/C-reactive_protein" title="C-reactive protein">C-reactive protein</a></li> <li><a href="/enwiki/wiki/Erythrocyte_sedimentation_rate" title="Erythrocyte sedimentation rate">Erythrocyte sedimentation rate</a></li></ul> </div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">General</th><td class="navbox-list navbox-even hlist" style="text-align:left;border-left-width:2px;border-left-style:solid;width:100%;padding:0px"><div style="padding:0em 0.25em"> <ul><li><a href="/enwiki/wiki/Lymphadenopathy" title="Lymphadenopathy">Lymphadenopathy</a></li> <li><a href="/enwiki/wiki/List_of_inflammed_body_part_states" class="mw-redirect" title="List of inflammed body part states">List of inflammed body part states</a></li></ul> </div></td></tr></tbody></table></div> '
Whether or not the change was made through a Tor exit node (tor_exit_node)
false
Unix timestamp of change (timestamp)
1613615162