Written By: Chloe Wilson BSc (Hons) Physiotherapy
Reviewed By: SPE Medical Review Board
Lateral epicondylitis is the most common cause of outer elbow pain and can also extend down the forearm.
Whilst commonly known as tennis elbow, less than 10% of people with lateral epicondylitis actually play tennis! It is just as likely to affect office workers and manual workers as it is sports players.
Lateral epicondylitis is caused by overuse of the extensor muscles in the forearm and hand, typically from repetitive gripping, forearm twisting, heavy lifting and computer work.
Repetitive overuse of the forearm muscles leads to tendon damage and degeneration on the outer elbow resulting in lateral elbow and forearm pain and weakness.
Most cases of lateral epicondylitis are self-limiting and will get better by themselves within 6 months to 2 years, but with the correct treatments, you can reduce the symptoms and speed up the recovery time.
Here we will look at the common causes, symptoms, diagnosis and treatment options for lateral epicondylitis and prevention strategies.
Lateral epicondylitis is an overuse injury of the forearm muscles, usually from occupational or sporting activities, and is the most common type of forearm tendonitis.
On the back of the forearm are a group of muscles that work together to extend the wrist and fingers, rotate the wrist and forearm, and help to control your grip:
These muscles join together near the elbow to form the common extensor tendon. Tendons are thick, cord-like structures that work like a bridge to connect muscles to bone. The common extensor tendon attaches the forearm extensor muscles to the lateral epicondyle of the humerus, the bony lump that you can feel on the outer side of the elbow.
Repetitive overuse of the forearm muscles overloads the tendon which leads to micro-tearing in the tendon fibres. Initially, this causes inflammation in the common extensor tendon which progresses to degeneration. Collagen fibres become disorganized resulting in fibrous scar tissue, calcification and thickening. The tendon has a relatively poor blood supply which slows the healing process leading to progressive weakening of the tendon.
90% of cases of lateral epicondylitis occur at the teno-osseous junction, where the tendon attaches to the bone. The other 10% occur elsewhere in the tendon or in the muscle belly.
Tennis elbow is the most common cause of persistent elbow pain and affects approximately 2-3% of the population. Lateral epicondylitis typically affects the dominant hand and is equally prevalent in men and women. The next most common cause of outer elbow pain is radial tunnel syndrome.
Lateral epicondylitis is similar to medial epicondylitis, aka golfers elbow, which causes similar symptoms on the inner elbow.
Lateral epicondylitis is typically caused by repetitive overuse and strain through the common extensor tendon from:
Certain factors can increase the risk of developing lateral epicondylitis:
Common symptoms of lateral epicondylitis are:
Tennis elbow pain is usually mild and intermittent in the early stages and only causes problems when doing certain activities. But over time, tennis elbow pain may become more intense and constant to the point where undemanding activities such as writing become difficult.
Range of motion at the elbow and wrist is not normally affected with tennis elbow except in severe cases where there may be discomfort with end range extension, particularly when the forearm is pronated (palm facing down).
Tendon damage in lateral epicondylitis typically progresses through four stages with different symptoms at each stage:
Stage 1: Inflammatory, reversible tendon damage resulting in mild pain a couple of hours after the provoking activity
Stage 2: Progressive tendon degeneration resulting in pain towards the end of or immediately after the provoking activity
Stage 3: Structural alteration and tendinosis resulting in pain during the provoking activity that increases temporarily when you stop
Stage 4: Fibrosis and calcification in the tendon leading to constant pain which starts to prohibit provoking and other activities
Most cases of lateral epicondylitis can be diagnosed by your doctor or physical therapist taking a thorough history and performing some simple tennis elbow tests.
They will start by take a full history to find out about your symptoms, the onset, aggravating and easing factors and your usual hobbies and activities.
They will then carry out a physical examination looking at the neck and upper limb including range of motion and strength. If they suspect lateral epicondylitis they will palpate over the lateral epicondyle to look for any tenderness and then perform special tennis elbow tests to confirm the diagnosis.
Common tennis elbow tests include:
In most cases, the examiner will be able to make an accurate diagnosis with these tests, but if necessary they may send you for further scans e.g. x-rays, EMG, MRI or CT scans or if they suspect possible joint damage or nerve compression.
Tennis elbow pain can often be misdiagnosed. If your pain is more than 3cm below the elbow, chances are you actually have radial tunnel syndrome rather than lateral epicondylitis - they present with similar symptoms but the location of the pain is slightly different.
And if your symptoms extend in to the back of your hand, it may actually be brachioradialis pain. If you need help working out what is causing your pain, visit the elbow pain diagnosis section.
Non-operative tennis elbow treatment is successful in around 90% of cases and involves a combination of:
Resting from aggravating activities is the best place to start with lateral epicondylitis treatment. You may be able to modify your technique with certain activities but some you may need to stop completely for a while. The tendon needs time to heal and failure to rest will lead to repeated overloading which will impeded the healing process.
Regularly applying ice to the outer elbow, particularly in the early stages of lateral epicondylitis, can help to reduce the pain and inflammation associated with tennis elbow. An ice pack should be wrapped in a towel and placed over the affected area for approximately 10 minute, regularly during the day.
Over-the-counter pain relief and non-steroidal anti-inflammatories can help to reduce pain and inflammation with lateral epicondylitis. Talk to your doctor or pharmacist about suitable medication for lateral epicondylitis.
Exercises are a really important part of tennis elbow treatment. Your physical therapist will give a set of progressive tennis elbow stretches and strengthening exercises for the forearm muscles. Tennis elbow exercises should not exacerbate your symptoms and should be done regularly.
Your physio may recommend a course of laser therapy, shockwave therapy or ultrasound treatment for tennis elbow. These can help to reduce inflammation and speed up tendon healing although further research is needed into their efficacy
Deep transverse friction massage, aka Cyriax physiotherapy, is a useful part of tennis elbow treatment. This is a special type of deep tissue massage carried out by a physical therapist where they rub over the affected tendon at a 90 degree angle, applying increasing pressure. This helps to reduce tennis elbow pain, increase blood flow to the tendon and realign the collagen fibres to ensure the tendon heals correctly and regains full strength.
Ideally deep transverse friction massage for lateral epicondylitis should be carried out at least three times a week for at least 4 weeks, but your physio should be able to teach your how to self-massage so that you can continue treatment at home.
Wearing a tennis elbow brace or strap, also known as a counterforce brace, helps to take the tension off the common extensor tendon. A tennis elbow strap wraps tightly around the upper forearm, just below the elbow, and directs the forces away from the lateral epicondyle
Some people prefer to use kt tape for tennis elbow rather than a strap to off-load the tendon.
There are various ways to apply KT tape for tennis elbow - you're physio will be able to show you the best method for you depending on your symptoms and activities
KT taping is more specific and can be tailored to you, but does need re-applying regularly, whereas tennis elbow straps are less specific, but easy to apply and reuse.
For office workers suffering from computer elbow or mouse elbow, small changes to your desk set-up can make a difference. Start by switching your mouse to the other hand. Using a wrist rest pad can also reduce tennis elbow pain as by raising your wrist, your hand rests in a less extended position which places less strain through the common extensor tendon.
Corticosteroid, hyaluronic acid or platelet-rich plasma injections can be helpful short-term tennis elbow treatment to reduce pain and inflammation. There is little evidence for medium or long-term benefit from injections.
Injections may temporarily increase symptoms for 1-2 days and steroid injections temporarily weaken the tendon so it is important not to overload the tendon for a couple of weeks.
90% of people with tennis elbow only need one injection and for the other 10%, two will suffice.
It is important to take things very gently when returning to aggravating sports/activities. With racket sports, practice gripping the racket first, then playing shadow strokes (without a ball) before playing fully again. Make sure you warm up with stretches, arm movements and shadow play before going on court. And if your tennis elbow pain returns, stop playing immediately and apply ice.
If tennis elbow pain continues after 6-12 months of persistent treatment then your doctor may advise surgery. There are various different surgical procedures including open, percutaneous and arthroscopic approaches to debride and realign the damaged tendon.
There are lots of things you can do to prevent tennis elbow developing or coming back:
Relapses of lateral epicondylitis are common so it is important to continue rehab until you have made a full recovery and then follow these prevention strategies to stop tennis elbow from returning
Page Last Updated: 12/08/2022
Next Review Due: 12/08/2024
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