A Physical Therapy Guide to Tennis Elbow (Lateral Epicodylitis)
Elbow pain can happen even if you do not play sports. Your elbow anatomically lies in a very important spot of your body, between your shoulder and hand. This hinge joint is necessary to be in optimal shape to be functional. For example, reaching for items in a cabinet, scratching the back of your neck, or driving your car all require the surprisingly intricate movements of your elbow and forearm.
The elbow pain caused by lateral epicondylitis prevents you from being able to pick up even the lightest objects, like a fork to feed yourself, due to pain. Lateral epicondylitis is often referred to as tennis elbow, although this is a misconception because lateral epicondylitis is found in people who have never picked up a tennis racket.
Lateral epicondylitis has a prevalance of 1-3% in the adult population. While it tends to be self-limiting (meaning it will resolve usually by 18 months from onset of symptoms), those who have it experience decreased quality of life and frustration. Luckily, conservative management through proper therapy is effective in improving your symptoms.1
This guide gives you in-depth information about lateral epicondylitis, its treatment, and how seeing a Certified Hand Therapist, physical or occupational therapist can help.
- Understanding Lateral Epicondylitis
- Symptoms of Lateral Epicondylitis
- What are the Most Common Causes of Lateral Epicondylitis?
- Diagnosing Lateral Epicondylitis
- What to Expect from Hand Therapy
- What If Conservative Treatment Doesn't Work?
- Preventing Lateral Epicondylitis
- Is It Time to Seek Treatment?
Your outer (or lateral) elbow is the origin of a group of muscles that work together to extend your wrist and fingers. This group of muscles originate on the outer part of your humerus bone (upper arm bone) and can often be referred to as your "wrist extensors."
This area notoriously does not have great blood flow which can cause the degeneration of the area leading to elbow pain. Sometimes this can be due to overuse or repetitive stress or have an onset that seems to have no cause.
Often, when you have lateral epicondylitis (epicondylosis), there is probably an underlying shoulder issue, as well. Studies are mixed on the root cause of lateral epicondylitis, but what we do know, is very often, the shoulder is involved.2
Lateral Epicondlytis vs Epicondylosis
For a long time, lateral epicondylitis was thought to be inflammatory in nature. However, after studying the fluid surrounding elbows with lateral epicondylitis, it has been noted that no inflammatory cells are there. Instead, it is thought to be degenerative changes. In other words, it is age-related. No underlying cause has been identified.
Since "-itis" usually indicates inflammation, the nomenclature is slowly changing to "-osis" for degenerative changes.
What are the symptoms of Lateral Epicondylitis? Let's review.
- Dull ache on outside (lateral) side of the elbow especially when lifting objects
- Can progress to sharp, shooting pains radiating from lateral elbow down or up the arm
- Decreased ability to perform daily tasks like lifting a coffee mug, opening containers, lifting a purse or groceries
- Tenderness to touch over the outside or lateral part of the elbow
- Decreased motion due to pain
- Swelling over lateral (outside) elbow
- Weakness or pain with decreased motion in the shoulder that is on the same side as your elbow pain
- Sharp, shooting pain with gripping, especially with the elbow straight
While many different types of folks can experience Lateral Epicondylitis, below are the most risk factors.3
- Repetitive stress on the tendons (like hammering, tennis, or moving boxes)
- Ages 30 - 50 years old
- Occupation with repetitive stress and loading like carpentry, plumbers, or butchers
- Participation in racket sports and using improper form during play
- Female gender
- Tobacco consumer
If you are experiencing lateral elbow pain, you will likely see your primary care doctor, orthopedic surgeon, or local Certified Hand Therapist (CHT) — physical or occupational therapist. To get the best conservative care with less need for pain medications, injections, or surgery, it's best to see a CHT for long-term relief and sustainable results.
In other words, proper diagnosis from a specialist like a CHT who is an occupational or physical therapist with additional specialty training, will help you get better quickly and return to those daily activities that are most meaningful to you, pain-free.
The sooner your elbow pain is properly diagnosed, the better the results will be. Diagnosis is usually clinical with no imaging necessary. However, occasionally, your doctor may have routine imaging done like X-ray or MRI to rule out other possibilities of elbow pain or if your symptoms last longer than a year. It's best to seek treatment as soon as possible.
Many folks are hesitant to seek medical care due to past traumatic experiences. We strive to make it more inviting by providing you with an idea of what you can expect at your evaluation.
Your therapist might ask you questions to get to know you to aid in shaping your recovery. The questions may be like:
- When did your elbow pain start?
- How did it start?
- What activities or positions make it better or worse?
- Do you have any medical conditions we should know about?
- What are three things you cannot do right now that you wish you could because of your wrist pain?
- What major life changes have you experienced in the last year?
Your therapist will also perform a thorough physical evaluation which may include:
- Differential diagnostic testing to evaluate tissue, joint, or muscle integrity
- Measuring range of motion and strength
- Testing functional abilities
- Noting sensory changes, like numbness or tingling
- Palpating areas of tenderness
- Observing swelling (edema)
Follow-up treatment may vary but likely to include the following:
- Manual therapy (hands on treatment)
- Custom splinting to reduce local tissue strain
- Dry needling to address underlying muscle tension (trigger points/knots)
- Taping for soft tissue support
- Education for activity modification and proper lifting techniques
- Re-education of movement patterns to correct and prevent further injury
- Approachable exercises to improve range of motion, strength, and endurance
Sometimes, despite best efforts, conservative management fails. This can be due to the duration of symptoms or in the specific case of Lateral Epicondylitis, some folks are unfortunate in the persistence of their symptoms. If you have tried conservative management and continue to experience pain and dysfunction, your therapist may refer you to your physician who may offer:
- Injections: Cortisone injections, while not always effective, can offer temporary relief from the pain to allow your body to heal itself.
- Surgery: When all else has failed, your physician may offer surgery to attempt to reduce your elbow pain. There are a variety of surgical approaches, all with mixed success rates. You will likely be referred to therapy post-operatively as well to ease you back into meaningful daily activities. Your hand therapist will help by addressing range of motion, functional adaptations, tendon gliding, swelling and scar management, and increased strength.
Whether you are a new racket sports player looking to prevent Lateral Epicondylitis or someone who might be experiencing intermittent pain on the outside of your elbow, here are some ideas to consider for prevention.
- Stay active: Motion is lotion. Moving is grooving. Gentle stretching and strengthening as part of an active lifestyle can reduce the likelihood of developing Lateral Epicondylitis. As we have already discussed, elbow tendons that start at the lateral part of the elbow often have less-than-ideal blood flow, so anything you can do to increase blood flow is great including brisk walking, jogging, or cycling.
- Focus on Shoulder and Core: Focusing on proximal strength and coordination can also help prevent the onset of Lateral Epicondylitis. Proximal strengthening means including your shoulder, scapular muscles (shoulder blades), and core into your workouts and functional tasks.
- Proper Technique If you are a racket sports player, consider a coach to teach you proper form to reduce the likelihood of developing elbow pain and dysfunction, sidelining you from your beloved sport.
- Make healthy lifestyle choices: Try to get enough sleep, stay hydrated, and eat nutrient dense foods. Practice healthy stress management. Do your best to stop tobacco use. Your whole body will thank you!
- Try splinting: Nighttime splinting in a wrist support splint can help position your wrist ergonomically while you sleep, giving your tendons a much needed break. There are also a variety of counterforce braces with mixed results that can off-load the lateral elbow during activities.
- Talk to a Certified Hand Therapist: If you have concerns or want professional advice on splinting, treatments at home, and functional adaptations, make an appointment!
If your symptoms are getting in the way of your daily independence or if you have already tried self-treatment but your symptoms persist — it may be time to seek professional help. Or, if you are not sure where to start, it may be time to see a hand expert. A Certified Hand Therapist can create a custom plan to ease your pain and help you return to your most meaningful daily activities.
Schedule an appointment with a CityPT hand expert. They'll work with you to find the root of your pain and improve your independence with daily activities, getting you on the path to recovery.
This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.
Sanders TL Jr, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey BF. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med. 2015 May;43(5):1066-71. doi: 10.1177/0363546514568087. Epub 2015 Feb 5. PMID: 25656546; PMCID: PMC4517446. https://pubmed.ncbi.nlm.nih.gov/25656546/ ↩
Park HB, Gwark J-Y, Im J-H, Na J-B. Factors Associated With Lateral Epicondylitis of the Elbow. Orthopaedic Journal of Sports Medicine. 2021;9(5). doi:10.1177/23259671211007734 https://pubmed.ncbi.nlm.nih.gov/34036114/ ↩
Andrew Arjun Sayampanathan, Masoodh Basha, Amit Kanta Mitra. Risk factors of lateral epicondylitis: A meta-analysis. The Surgeon. 2020; 18(20: 122-128. ISSN 1479-666X. https://doi.org/10.1016/j.surge.2019.08.003. Accessed November 17, 2022. ↩