Elbow pain when gripping: tennis and golfer's elbow, the nerves, tools, the gym and what helps

Why gripping hurts at the elbow, and who gets itStrong evidence

Every firm grip makes the muscles on the back of the forearm hold the wrist steady while the muscles on the front close the hand, and both groups start from the bony bumps at the elbow. Tennis elbow (the outer bump) is worse "gripping objects", the NHS says, and NHS inform lists "difficulty with gripping" and "difficulty with twisting movements such as opening jars" for both tennis and golfer's elbow (the inner bump). NHS Lothian adds: "Your grip may feel weak".

In 4,783 Finnish adults aged 30 to 64, 1.3% had tennis elbow at the time and 0.4% golfer's elbow, most often at 45 to 54 and as often in men as women; in 6,038 English adults aged 25 to 64, 0.7% and 0.6%. Most cases come from work and home, not sport: forceful, repetitive gripping, tools over 1 kg, heavy loads, long spells of repetitive movement and smoking each went with about 2 to 5 times the odds in population and worker studies. "Most people who develop it don't play tennis", NHS Lothian says.

Sources 1, 2, 3, 4, 5, 6, 7, 8, 9

The nerves, the biceps tendon and the neckEmerging evidence

The ulnar nerve at the inner elbow (cubital tunnel syndrome) is the second commonest trapped nerve in the arm: in UK general practice, about 25 men and 19 women in every 100,000 a year see their GP with a trapped ulnar nerve. It starts with numbness or tingling in the ring and little fingers, brought on by leaning on the elbow or keeping it bent, and in more severe cases weakens grip. Reviews of surgical series report that about 20% to 45% of people having an operation for golfer's elbow also had an irritated ulnar nerve; how often that happens in everyday golfer's elbow isn't known.

Radial tunnel syndrome, an ache below the outer bump, is rare (about 9 new cases per 100,000 a year in one large US database). A torn biceps tendon at the front is rarer still (3 to 5 per 100,000 a year) and comes with a pop. Elbow arthritis is uncommon unless the elbow was injured, though a review found it in 31% of workers exposed to vibration and 20% of manual workers, on very weak evidence. A nerve in the neck can cause elbow pain "even when you don't feel pain in your neck", NHS inform says, often with pins and needles or burning.

Sources 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22

Grip is weakest, and hurts most, with the arm straightMixed evidence

In 81 people with tennis elbow, grip on the sore side was 50% of the other side with the elbow straight and 69% with it bent; in 19 people, grip fell with the elbow straight while wrist strength on its own didn't. Before treatment, pain-free grip was about 43% of the other side in a trial of 198 people, and it came back with time and exercise.

Which way the palm should face is less clear. In one small study of 21 people, pain-free grip was highest with the elbow bent and the thumb up, and lower with the palm down; no study has tested palm-up gripping in tennis elbow. NHS Lothian suggests lifting and gripping "with your palm facing upwards" where possible, and in US workers forceful work was linked with tennis elbow with the palm turned either way. So bend the elbow, and use whichever of thumb up or palm up hurts less. Grip readings also vary by several kilograms from day to day, so one day's reading means little.

Sources 23, 24, 25, 4, 26, 27, 28, 29

What a scan or nerve test shows, and what it doesn'tStrong evidence

Tennis elbow is diagnosed by examination. UK elbow surgeons say an X-ray isn't essential and MRI or CT isn't needed in primary care, and NHS Lothian says scans "are rarely required, particularly if there has not been a fall or an injury". Tendon changes are common without pain: on MRI in 37% of 30 volunteers aged 35 to 65 with no elbow symptoms, and 67% of those aged 55 to 65. An X-ray helps after a fall, or to look for arthritis.

For the ulnar nerve, an NHS referral guide says no imaging is needed in primary care; in one trial 76% of people with typical symptoms had normal nerve tests. Nerve tests matter when a specialist is judging how severe it is or whether to operate.

Sources 30, 4, 31, 32, 33, 34, 13

How it usually goesStrong evidence

Tennis elbow gets better in most people. In the no-treatment groups of 24 trials, the share not yet better halved about every 2.5 to 3 months and 89% had improved at a year, however long it had lasted beforehand; with wait and see, 83% to 90% had succeeded at a year in two trials. Arthritis UK says tennis and golfer's elbow "can last between six months and two years. Most people get better within a year. Unfortunately, they can both return".

An expert review says non-surgical care "may improve nine out of ten" people with golfer's elbow. Mild ulnar nerve symptoms improved in 89.5% of 70 people at 6 months with advice alone. No one can promise a date.

Sources 35, 36, 28, 18, 1, 19, 34

Keep the arm working, and ease the grip that provokes itStrong evidence

NHS inform suggests "changing how you grip or lift an object. reducing the weight you are carrying. taking regular breaks while doing aggravating activities", and says "You don't need to be symptom free before you consider returning to work". The NHS says don't rest a repetitive strain injury for more than a few days, and NHS Lothian says "Continuing to use your arm will not cause long term damage".

The NHS tennis elbow page also says it "usually gets better after resting your arm for a few weeks", so health-service wording on rest is mixed. The fair summary is to ease off the grip that brings it on and keep the arm working.

Sources 2, 37, 4, 1

Handles, tools and the desk: sensible advice, not tested for elbow painEmerging evidence

NHS Lothian: "Try to use the minimal amount of force to grip objects", increase the grip size or reduce the weight of tools, and "Use a different mouse (e.g. a thumb mouse)". The Health and Safety Executive (HSE) recommends a power grip with the wrist near the handshake position, "a screwdriver handle with a flexible grip requires less force", handles long enough for the whole hand, and no narrow handles. Thicker helps only up to a point: in 61 healthy workers, grip force was highest with a handle about 3.8 cm across and fell with thicker ones, and a thin screwdriver handle made the wrist bend more.

For vibrating tools, the HSE says use low-vibration tools, shorter spells and no more grip than you need, and that vibration damage "is preventable, but once the damage is done it is permanent". No trial has tested handle or tool changes in people with elbow pain, and a review found no good evidence for workplace changes for tennis elbow.

Sources 4, 38, 39, 40, 41, 42, 7

Loading exercise is the main treatment, though the gains are smallMixed evidence

UK elbow surgeons say physiotherapy should be offered. A UK consensus suggests held contractions of up to 60 s, 5 times, once a day, and slow lifting and lowering, 3 sets of 10 to 15 once a day, for at least 6 weeks. Across 30 trials of 2,123 people, exercise did better than a steroid injection for pain-free grip at every time point, on low-certainty evidence.

Against waiting it out, the gains are small: across 23 trials of manual therapy and exercise, benefits were small and didn't last, and in two trials people who had physiotherapy did no better at a year than those who didn't. NHS leaflets follow the same pattern: an NHS Scotland booklet's slow lowering, 3 sets of 15, and an NHS Borders leaflet's ball squeezes and hammer turns. Slow lowering eased pain a little faster than lifting in 120 people, home holds improved disability but not overall success in 40, and in one trial most people gave up heavy slow loading because it hurt. Stretching alone did about as well as stretching plus strengthening at 6 weeks in 94 people, so no single exercise has been shown to beat another.

Sources 30, 43, 44, 45, 28, 46, 50, 51, 47, 48, 49, 64

Golfer's elbow and the ulnar nerve: thinner evidenceEmerging evidence

For golfer's elbow, a review found 5 small studies of slow-lowering exercise in 143 people, with one trial showing a clear advantage. NHS leaflets use slow-lowering wrist curls (NHS inform: "Do 3 sets of 12, once a day") and stretches.

For the ulnar nerve, information about which positions to avoid comes first: in 70 people, 89.5% improved at 6 months, and a night splint or nerve glides added nothing to advice alone. UK hand surgeons suggest a headset for calls and pads or nothing under the inner elbow, and US orthopaedic surgeons say don't drive with the arm on the open window. Surgery is mainly to stop weakness and muscle wasting getting worse.

Sources 52, 53, 9, 34, 11, 12, 13

Steroid injections, platelet-rich plasma and shockwave: not recommendedStrong evidence

In a trial of 165 people with tennis elbow, 83% had recovered a year after a steroid injection against 96% after a placebo injection, and the pain came back in 54% against 12%. UK elbow surgeons say a steroid injection "should not be used" for tennis elbow, and NHS inform says it has "limited benefit" and "may be detrimental to the health of your tendon". For golfer's elbow, an injection helped at 6 weeks but not at 3 months or a year; for radial tunnel syndrome it was no better than salt water.

Platelet-rich plasma (PRP) and blood injections probably don't help more than a placebo injection (32 studies, 2,337 people, moderate certainty), and UK elbow surgeons say shockwave "should not be used".

Sources 46, 30, 2, 54, 15, 55, 13

Straps and braces: optional, and a placebo brace group improved tooMixed evidence

In a trial of 31 people with tennis elbow, a counterforce strap eased pain at rest more than a placebo strap at 2 to 12 weeks, and people rated their elbow function a little better at 26 weeks, but the placebo brace group also improved over time: pain, grip and function were better in both groups at 6 months and 3 years. Across 7 small crossover trials, a forearm strap eased pain while gripping straight away; wrist splints didn't.

UK elbow surgeons say braces "may not give benefit", and NHS Lothian says they are "usually only worn when carrying out activities that cause pain". For golfer's elbow, US orthopaedic surgeons say a strap "may occasionally cause more forearm pain" and suggest a wrist brace as an alternative.

Sources 56, 57, 58, 30, 2, 4, 59

Surgery: no better than a sham operation in one small trialEmerging evidence

In 26 people with tennis elbow followed for about 2.5 years, surgery did no better than a sham operation. UK elbow surgeons say people should know "there is no evidence of benefit compared to a placebo", and suggest referral if tennis elbow hasn't improved after 12 to 24 weeks of good care; the NHS mentions surgery after 6 to 12 months.

Sources 60, 30, 1

Racquets and clubs: expert advice and old studiesMixed evidence

US orthopaedic surgeons say "stiffer racquets and looser-strung racquets often can reduce the stress on the forearm", and suggest a smaller head if yours is oversized. In 16 players, a grip a quarter of an inch (about 6 mm) bigger or smaller than recommended made no difference to forearm muscle activity. In a 1979 survey of club players, changes in stroke technique and racquet helped stop it coming back, and a brace least. NHS Fife suggests getting "some professional advice about your technique". None of this has been tested in a trial.

Sources 61, 62, 63, 9

Grip, handles, tools and the desk (written steps)

Our 3D figure can't show these. They come from NHS inform, NHS Lothian and the HSE; where a step is our suggestion, it says so. No trial has tested a way of gripping for elbow pain.

• 1. Grip lightly: "Try to use the minimal amount of force to grip objects" (NHS Lothian), carry less and take breaks (NHS inform).
• 2. Elbow bent: hold mugs, kettles, bags and tools with the elbow bent and close to your side. One small study found pain-free grip highest with the thumb up; NHS Lothian suggests palm up where possible. Use whichever hurts less (our reading).
• 3. Handles: wrap a bandage round a hammer or club handle (NHS Lothian), and choose soft, flexible handles long enough for the whole hand, not narrow ones (the HSE). Not as thick as possible: in one lab study grip force peaked at about 3.8 cm across.
• 4. Power tools: low-vibration tools, shorter spells with other jobs in between, trigger locks, and no more grip than the job needs (the HSE).
• 5. The desk: a thumb mouse or a different mouse, with the mouse and keyboard close to your body (NHS Lothian).
• 6. A strap, if you want one: worn for the jobs that hurt, not all day, alongside the exercises (NHS Lothian).

Sources 4, 2, 25, 38, 39, 42

Sport, the gym and tingling fingers (written steps)

Where a step is our suggestion, it says so. No study has tested gym changes for elbow pain.

• 1. Racquets: a stiffer, looser-strung racquet and a smaller head if yours is oversized (US orthopaedic surgeons), a coach's check of your technique (NHS Fife), and short sessions back (our suggestion).
• 2. The gym: straps for heavy deadlifts and rows once your back rather than your grip limits you, thumbs-up grips for rows and curls, and no thick-grip attachments, long hangs or heavy pinch work while it's sore (our suggestion; a thicker bar asks for more of your maximum grip).
• 3. Tingling in the ring and little fingers: a headset for calls, pads or nothing under the inner elbow, a towel wrapped round the elbow at night (UK hand surgeons), and not resting your arm on the open car window (US orthopaedic surgeons).

Sources 61, 9, 12, 13, 39