Lateral Epicondylalgia (Tennis Elbow): Overview and Evidence Summary

Condition Overview

Lateral epicondylalgia—often called tennis elbow—is a common, sometimes stubborn condition affecting the tendinous origin of the wrist extensor muscles, particularly the extensor carpi radialis brevis (ECRB), at the lateral epicondyle of the humerus. Despite its famous association with tennis, the majority of people who experience it have never picked up a racquet. Instead, the condition typically emerges from repetitive gripping, lifting, twisting, or fine motor tasks—anything that loads the wrist extensors over time.

This is not simply an inflammatory problem as once believed. Modern understanding classifies lateral epicondylalgia as a mechanical tendinopathy, involving collagen disorganization, neovascularization, biochemical sensitization, and reduced load capacity of the tendon. People usually notice gradually increasing pain rather than a sudden onset—though acute flares can occur following an unusually demanding activity.

The hallmark symptom is pain on the outside of the elbow, often sharp with gripping or lifting, and more of an ache at rest. Patients may describe dropping objects unexpectedly or feeling that the forearm “has no strength.” Pain often radiates down the forearm, and simple tasks like shaking hands, opening jars, lifting a coffee cup, pouring a kettle, or using a mouse can provoke symptoms.

While the condition is highly treatable, lateral epicondylalgia can become chronic if the underlying load issue isn’t addressed. The tendon becomes less tolerant of repeated stress, and the nervous system may amplify pain responses. Many people experience a frustrating cycle of short-term relief followed by recurrence, particularly if treatment is passive-only or exercise is either too aggressive or too cautious.

Fortunately, strong evidence supports a combination of graded loading, education, manual therapy, and self-management strategies as the most robust approach. Tendon rehab is rarely linear, but with the right process, outcomes are excellent.

Summary of Current Evidence for Lateral Epicondylalgia

Evidence-Based Management Discussion

Why the Tendon Fails: Understanding the Biology of Lateral Epicondylalgia

Lateral epicondylalgia represents a mismatch between what the tendon is being asked to do and what it is currently capable of tolerating. Tendons adapt well to gradual increases in load, but they respond poorly to sudden spikes or repeated high-load tasks without recovery. People often develop symptoms after:

• A change in work tasks or workload

• Increased computer use or mouse gripping

• Starting a new exercise program that includes gripping or pulling

• DIY or gardening projects requiring repeated forearm effort

Microscopically, the tendon displays disorganized collagen fibers, increased vascularity, and altered tenocyte activity—not inflammation in the traditional sense. Therefore, anti-inflammatory treatments alone rarely solve the problem.

The nervous system also plays a role. Chronic tendon pain often involves increased sensitivity of the local tissue and sometimes the central nervous system, meaning that pain may persist even when structural healing is underway.

Clinical Presentation and Functional Impact

Patients frequently report:

• Sharp pain during gripping or lifting, especially with the elbow extended

• Pain radiating down the forearm

• Weakness when pouring, turning keys, or holding objects

• Difficulty with racquet sports, weightlifting, or manual tasks

The provocative tests are straightforward:

• Pain with resisted wrist extension

• Pain with resisted middle finger extension

• Pain with gripping dynamometer testing

Grip strength is often notably lower on the affected side.

Importantly, many people adapt by overusing the shoulder and upper trapezius or reducing movement through the wrist, creating secondary issues that therapists must identify and correct.

Exercise Therapy: The Foundation of Successful Treatment

Rehabilitation for lateral epicondylalgia centers on progressive loading. Tendons become stronger and more tolerant through consistent, appropriately dosed exercise—much like muscle or bone.

Phase 1: Pain Reduction and Capacity Building (Weeks 1–3)

Early goals include reducing irritability while maintaining stimulus:

• Isometric holds for wrist extensors (e.g., pain-modulating sustained extension holds)

• Gentle mobility exercises for the elbow, wrist, and shoulder

• Avoiding or modifying aggravating tasks (changing grip size, reducing lifting volume, adjusting computer setup)

Patients often experience immediate relief from isometrics, though responses vary.

Phase 2: Strengthening and Tendon Remodeling (Weeks 3–8)

As irritability decreases, eccentric and heavy slow resistance exercises become central:

• Eccentric wrist extension with dumbbell or band

• Concentric–eccentric wrist extension slow reps

• Grip strengthening using putty, grippers, or rolled towels

• Forearm rotation strengthening (supination/pronation)

The goal is to progressively challenge the tendon without provoking flare-ups.

Phase 3: Functional and Sport-Specific Loading (Weeks 8–12+)

Returning to meaningful tasks requires:

• Power-based tasks (for athletes)

• Sport-specific drills (e.g., racquet swings)

• Functional lifting patterns

• Work-specific tasks for tradespeople or office workers

Patients should feel confident lifting, gripping, twisting, and sustaining repetitive tasks without pain spikes.

Manual Therapy: A Helpful Adjunct

Manual therapy can be extremely useful early in treatment:

• Soft tissue mobilization reduces forearm tension

• Radial head mobilization improves joint mechanics

• Cervical or thoracic mobilizations help when symptoms radiate

• Mulligan mobilization-with-movement (MWM) has good clinical support for immediate improvement in pain and grip strength

While manual therapy does not “fix” tendons, it reduces pain and allows more productive exercise sessions.

Ergonomics and Activity Modification

Poor workplace or sport technique often contributes to tendon overload. Therapists should evaluate:

• Mouse size and grip

• Keyboard height and forearm support

• Grip technique in racquet sports or weightlifting

• Wrist position during lifting (neutral wrist reduces tendon strain)

• Frequency and duration of repetitive tasks

Small adjustments frequently have a huge impact on symptom reduction.

Pharmacological Interventions and Injections

NSAIDs may help early pain but do not alter long-term tendon health.

Corticosteroid injections provide notable short-term relief but have poor long-term outcomes, with recurrence rates higher than conservative care alone. They may be considered only when pain severely limits participation in rehab—and even then, used carefully.

Biologic treatments such as PRP have shown mixed results. Some studies suggest benefit in chronic cases; others show no meaningful difference compared with placebo. These interventions should not replace well-structured rehabilitation.

Surgical Considerations

Surgery is rarely necessary but may be considered after:

• 12 months of high-quality conservative rehab

• Persistent functional deficits affecting work or sport

• Confirmed degenerative tendon pathology on imaging

Surgical techniques typically involve debridement of pathological tissue and stimulation of healing. Outcomes are generally positive, but recovery still requires structured loading.

Clinical Considerations for Therapists

Therapists play a central role in recovery:

• Educating patients on tendon adaptation

• Reducing fear or frustration during prolonged rehabilitation

• Guiding progressive loading

• Addressing whole-chain contributors (scapular strength, thoracic mobility, shoulder posture)

• Optimizing ergonomics at work and home

Patients who understand the nature of tendinopathy are more likely to adhere to long-term loading strategies—and therefore more likely to recover fully.

References

Coombes, B., et al. “Management of Lateral Epicondylalgia: Clinical Framework and Evidence Review.” British Journal of Sports Medicine.

Vicenzino, B., et al. “Mobilization with Movement Techniques for Lateral Epicondylalgia.” Manual Therapy.

Karanasios, S., et al. “Effectiveness of Exercise Interventions for Lateral Elbow Tendinopathy.” Sports Medicine.

Khan, K., et al. “Tendon Pathology and Adaptation: The Continuum Model.” Journal of Sports Science & Medicine.

Bisset, L., et al. “Treatment of Lateral Epicondylalgia: Systematic Review of Clinical Trials.” Journal of Physiotherapy.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.