Elbow pain when straightening your arm: the back of the elbow, tennis elbow, stiffness, what helps

After a fall, not being able to straighten fully mattersStrong evidence

In 1,740 people with an elbow injury in 5 English emergency departments, 46% of those who couldn't fully straighten the elbow had a fracture; of adults who could, 98.4% had none. The authors say people who can't fully straighten it after an injury "should be referred for radiography", and that those not X-rayed should come back if it hasn't settled within 7 to 10 days. This is a clinician's test after an injury, not a home test, and the NHS sends a very painful, swollen or stiff injured arm to NHS 111.

Sources 1, 2

Tennis elbow: a common cause, and it can stop the arm straighteningStrong evidence

The NHS lists "difficulty fully straightening your arm" among the symptoms of tennis elbow, and says it is worse lifting or bending the arm, gripping and moving the wrist. In a Finnish population study of 4,783 adults aged 30 to 64, 1.3% had it at any one time, most often at 45 to 54, as often in men as in women, and more often with forceful, repetitive arm work and in people who smoke. The NHS says it is "more common in people between 35 and 54 years of age", from computer work, manual tasks and leisure activities as well as tennis.

Gripping with the arm straight is weaker and more painful. In 81 people with tennis elbow, the sore arm had 50% of the other arm's grip strength with the elbow straight and 69% with it bent; in 21 people, pain-free grip was strongest with the elbow bent to a right angle and the thumb up. These are small clinic studies.

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

The back of the elbow: a bursa, the triceps tendon or a pinchEmerging evidence

A soft swelling on the point of the elbow is usually olecranon bursitis: at least 10 people per 100,000 a year, mostly men aged 40 to 60, and about a third infected in one review (24% in a large military study). The elbow usually still moves, unlike an infected joint, though Arthritis UK lists restricted movement among its symptoms.

Pain at the triceps tendon just above the point of the elbow, worse straightening against resistance (dips, skull crushers, press lockouts) with strength kept, is triceps tendinopathy, "the rarest of the tendinopathies around the elbow". A torn triceps tendon is rare: about 0.5% of tendon ruptures seen in US emergency departments, men about 12 times as often as women. It usually follows a heavy push or a fall onto an outstretched hand, with sudden pain, bruising, "A gap that you can feel in the back of the elbow" and weakness straightening, US orthopaedic surgeons (AAOS) say.

In throwers, the tip of the elbow can be driven into its socket at the end of the throw, causing pain, bone spurs and lost straightening; in 72 professional baseball players having elbow surgery, a spur there was the commonest finding. In 5 professional boxers, missed punches that forced the elbow past straight did the same. No study has looked at this in weightlifters or calisthenics, so linking it to lockouts in the gym is our inference.

Sources 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20

A stiff elbow after an injury, and arthritisEmerging evidence

Stiffness after an elbow injury is common, reported in up to 56%, and straightening is usually the movement lost. After a simple dislocation, 56% of 110 adults reported some stiffness about 7 years later, though most used the arm well. After surgery for elbow fractures, extra bone in the soft tissues (heterotopic ossification) showed on X-ray in 37% and limited movement in 20%.

Osteoarthritis of the elbow is uncommon unless the elbow was injured before, Arthritis UK says. Without an injury it mostly affects middle-aged men with heavy manual work or weightlifting, causes pain at the very end of straightening, and before surgery people lacked on average 22 to 29 degrees of straightening. "Occasionally, the elbow may lock in a fixed position", from a loose bit of bone or cartilage. Rheumatoid arthritis involves the elbow in 32% to 61% of people after 10 years, as one review reports.

Sources 21, 22, 23, 24, 25, 26, 27, 13, 28

Clicking is usually harmlessEmerging evidence

A fold of joint lining is "normal anatomic finding" in 86% to 100% of elbows and causes symptoms in only a few. The ulnar nerve slipped over the inner bump in 51% of 153 Japanese volunteers and 15.8% of 76 nerves in healthy Chinese adults, without symptoms. So painless clicking isn't a sign of damage or arthritis on its own; pain, swelling, locking or lost straightening are what matter.

Sources 29, 30, 31

Other causes, and how rare they areEmerging evidence

Elbow pain can come from the neck, "even when you don't feel pain in your neck", NHS inform says, often with pins and needles or burning. In young children, a pulled elbow is common at ages 1 to 4: "the child will hold the arm still at their side and refuse to bend or rotate the elbow or use the arm". A hot, swollen elbow can be an infection or gout. Tumours at the elbow are rare: it is the site of about 1% of bone tumours, and soft tissue lumps there are about 10 times more often harmless than not.

Sources 32, 33, 34, 35, 36

When an X-ray or scan helpsStrong evidence

After an injury, an X-ray if you can't fully straighten the elbow. A suspected triceps tear shows a fleck of bone on a side X-ray in 61% to 88% of operated cases, then an ultrasound or magnetic resonance imaging (MRI) scan confirms it. An X-ray shows arthritis, spurs and loose pieces. A hot, swollen bursa or joint may need a sample of fluid to test for infection and gout. Tennis elbow is diagnosed by examination; scans are for an uncertain diagnosis.

Sources 1, 37, 17, 13, 38, 9

How it usually goesStrong evidence

Tennis elbow gets better in most people: in the no-treatment groups of 24 trials, 89% had improved at a year. The NHS says physiotherapy may help if it hasn't improved after 6 weeks of home treatment, and mentions surgery only after 6 to 12 months. New elbow pain "should begin to settle within 6 weeks" in many cases, NHS inform says. Bursitis in soldiers lasted a mean of about 4 months. After a simple dislocation, function was good 14 to 25 years later, and a stiff elbow can keep improving for 6 to 12 months: "patience is warranted". No one can promise a date.

Sources 39, 3, 32, 11, 40, 41

Keep it moving, then use it moreStrong evidence

NHS inform says move the elbow gently for 10 to 20 seconds every hour in the first day or two, then "try to use your elbow more", and avoid sports or heavy lifting until you have less discomfort and good movement. The NHS suggests simple exercises "such as bending and straightening your arm". After a simple dislocation, early movement gave a faster recovery than 3 weeks in plaster (121 against 102 degrees of movement at 6 weeks, back to work in 10 against 18 days), with the same result at a year, in a trial of 100 adults.

Sources 32, 3, 42, 43

Tennis elbow: exercise helps early, most recover either way, and injections backfireStrong evidence

In 198 people, physiotherapy (8 sessions over 6 weeks, with home exercise) beat wait-and-see at 6 weeks (65% against 27% successful) and matched it at a year (94% against 90%). A steroid injection helped most at 6 weeks but did worse at a year (68%), and in another trial of 165 people it did worse than a placebo injection at a year (83% against 96% recovered, with 54% against 12% coming back). NHS inform says injections have "limited benefit" and "may be detrimental to the health of your tendon".

A UK physiotherapy consensus suggests still holds of up to 60 seconds, 5 times, once a day, then lifting and lowering in 3 sets of 10 to 15 once a day, and stretches held 30 seconds 3 times, with pain at a level the person finds acceptable. The plan uses these doses.

Sources 44, 45, 39, 46, 47

Grip and carrying with a bent elbow: our inference from small studiesEmerging evidence

NHS inform suggests changing how you grip or lift, reducing the weight you carry and taking regular breaks. Carrying with the elbow slightly bent and the thumb up, rather than hanging straight with the palm down, is our inference from small studies that found grip weakest and most painful with the arm straight; no trial has tested it. A counterforce strap eased pain at rest for some weeks against a placebo brace in 31 people, but NHS inform says the evidence for braces is limited.

Sources 6, 8, 47, 48

A stiff elbow: gentle work and time, splints for some, surgery rarelyEmerging evidence

Gentle stretching (contract and relax) helped early stiffness without harm in 3 small trials. For stiffness that lasts, splints worn in physiotherapy gained about 47 to 49 degrees over a year in 66 people, with no difference between dynamic and static types. In 30 people still stiff after 6 months, surgery to release the joint plus rehabilitation gained 41 degrees against 17 with rehabilitation alone. Never force it.

Most daily tasks need about 30 to 130 degrees of elbow movement; some modern tasks, like using a phone, need more bend, but no study showed daily tasks need full straightening. Sport, push-ups and pressing do (our reading).

Sources 21, 41, 49, 50, 51, 52, 53

Arthritis and loose pieces: exercise first, and NICE's position on keyhole clean-outsMixed evidence

The National Institute for Health and Care Excellence (NICE) says offer therapeutic exercise to everyone with osteoarthritis, that joint pain may increase when they start, and that steroid injections give short-term relief of 2 to 10 weeks. It also says: "Do not offer arthroscopic lavage or debridement to people with osteoarthritis"; its evidence wasn't specific to the elbow. Elbow case series report about 34 degrees more movement after removing spurs and loose pieces, with complications in 6% to 12%, and Arthritis UK says loose pieces that cause pain can be removed with keyhole surgery. So the evidence is mixed, and it is a decision to make with a specialist.

Sources 54, 25, 13

A torn triceps tendon: early assessment mattersEmerging evidence

In 22 people with a torn triceps tendon, 10 tears were missed at first, and a direct repair was always possible within 3 weeks of the injury; later, a more complex reconstruction was needed. Across 262 operated cases, 89% went back to their previous activity and about 6% tore again. These are case series, but they agree.

Sources 55, 37, 16

A pinch at the back of the elbow: rest from the provoking movement firstEmerging evidence

For throwers, care starts with a break from throwing, physiotherapy and a gradual return with technique checked. Keyhole removal of spurs, for those who don't settle, returned most athletes to sport in case series, but in professional baseball a third needed two or more operations. All 5 boxers in one series returned to boxing after keyhole surgery. No trial has compared treatments.

Sources 17, 56, 20, 18

Gripping, lifting and the gym for now (written steps)

Our 3D figure can't show these. They come from NHS inform, the NHS and US orthopaedic surgeons; where a step is our suggestion or our inference, it says so. No trial has tested a way of lifting or pressing for elbow pain.

• 1. Grip and carry: change how you grip or lift, reduce the weight you carry and take regular breaks (NHS inform). Carry with the elbow slightly bent and the thumb up, close to your side, and split loads between two bags (our inference from small grip studies).
• 2. Presses and push-ups: stop just short of snapping into a hard lockout, lower under control, and use a lighter load or a shorter range, such as a floor press (editorial; our inference from studies of throwers and boxers).
• 3. Dips and skull crushers: dips to about a right angle at the elbow; skull crushers and overhead extensions come back in the last stage, as our triceps guide says (editorial).
• 4. Sleep: if the elbow stiffens overnight, rest it nearly straight on a pillow rather than tightly bent (our suggestion).
• 5. The point of the elbow: avoid leaning on it, use padding, and "do not knock or bang your joints" (the NHS).
• 6. Throwing: a break from throwing, then a gradual throwing programme with your technique checked (a review for throwers).
• 7. Young children: "To safely lift a child, grasp gently under the arms. Do not lift children by holding their hands or arms" (AAOS).

Sources 47, 6, 8, 18, 38, 33, 17