The most common cause of pain in the elbow is lateral epicondylitis, which is also known as Tennis elbow. Tennis elbow effects 1-3% of the general population, and 15-30% of the workforce. 80% of those effected recover within one year. As per it’s name, a high percentage of tennis players are effected by this condition (40-50%). However, it is actually more common in amateur golfers than golfer’s elbow.1

Lateral epicondylitis is the result of repetitive activity or overuse of the extensor tendons of the forearm, which attach their associated muscle to the outside of the elbow (at the lateral epicondyle of the humerus).

Tendons normally adapt and become more resilient when an optimal amount of tension is applied to them. When the tension applied to a tendon exceeds its tolerance, often due to repetitive loading, micro tears can occur. These cumulative micro tears lead to tendinosis, a symptomatic degenerative process to the tendon.

These degenerative changes to the tendon can occur over time from actions such as repetitive gripping, extending the wrist or rotating the wrist and forearm. Activities that may bring on symptoms of tennis elbow include using tools or manual work, prolonged typing, playing an instrument, or from sports such as golf or tennis which require gripping with a stable wrist position. Elbow pain will often lead to underuse or resting the affected limb, which can result in even further weakening of the tendon making it more susceptible to further injury, and lowering the threshold for tendon tears to occur.8,11,12,13

Symptoms of tennis elbow commonly include pain over the bony prominence at the outside of the elbow, known as the lateral epicondyle, and/or pain to the surrounding tissue. Pain can often radiate into the forearm. This area may also be tender to touch. Pain is exacerbated with the activities mentioned above.

There are many other contributing factors that can make you more susceptible to experiencing this condition, including poor posture, poor scapular stability, rotator cuff pathology, nerve impingement, history of smoking, manual labour type jobs, and obesity.1,7,8

Tips for a successful recovery

Modify your activity but stay active! Initially, take aggravating activities out of your daily routine, or modify the way you perform a task to keep them pain-free. This may include: taking breaks from typing throughout your work day, adjusting your work station, golfing less days per week or less holes per round, wearing a counterforce brace (tennis elbow brace) to offload your elbow, and even simple activities such as lifting a 4 L milk jug with your other hand.8,12

Posture: Working on your posture and your postural endurance/stability can help offload the elbow during aggravating activities. Don’t slouch. By mindful of your posture throughout the day, and change positions often. Ensure you have good desk ergonomics if you work at a computer. Your wrists should be supported on a pad (or rolled up towel), and placed in a neutral position versus extended.8,12

Counterforce brace: The use of a counterforce brace (tennis elbow brace) which when worn correctly applies compression just below the tender area of your forearm, can reduce the load to the tendons that attach at your elbow, therefore reducing pain during aggravating activities.8,12,13

Physiotherapy: A physiotherapist will perform an examination, help determine a correct diagnosis, and guide you through the proper rehabilitation process specific to you and your goals. Treatment should include a gradual and progressive exercise program, education and strategies for self-management, activity modifications, and may also include dry needling/acupuncture to change muscle tension, manual therapy, and taping to offload the painful area.

A gradual progressive home exercise program to build up strength in your forearm muscles, and making their associated tendons more resilient, as prescribed by your physiotherapist, is a key component to treating this condition. Working on posture, core, and scapular stability is also as important part of the process.7,8,9,11,12,13

Injections
Research has shown that PRP and prolotherapy injections may to beneficial in treating lateral epicondylitis in addition to a good progressive exercise rehabilitation program. One study showed that physiotherapy and physiotherapy plus prolotherapy are optimal over prolotherapy alone at 12 weeks. Cortisone injections, although good for relieving pain in the short term, are actually worse for pain at 3 months and beyond compared to physiotherapy and a wait and see approach.7,8,9,10,11

Final thoughts
This post is a small generalized glimpse into this common condition. Remember, this is just one of the many conditions that causes lateral (outside) elbow pain. If you are experiencing any pain with life, please see a health professional, such as a physiotherapist, to better assess and help guide your care.

Kayla Eagle, PT, MScPT, BKin

References
1. Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006 Dec 1;164(11):1065-74. doi: 10.1093/aje/kwj325. Epub 2006 Sep 12. PMID: 16968862.
2. Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum. 2004 Aug 15;51(4):642-51. doi: 10.1002/art.20535. PMID: 15334439.
3. Ranney D, Wells R, Moore A. Upper limb musculoskeletal disorders in highly repetitive industries: precise anatomical physical findings. Ergonomics. 1995 Jul;38(7):1408-23. doi: 10.1080/00140139508925198. PMID: 7635130.
4. Stockard AR. Elbow injuries in golf. J Am Osteopath Assoc. 2001 Sep;101(9):509-16. PMID: 11575037.
5. McCarroll JR. The frequency of golf injuries. Clin Sports Med. 1996 Jan;15(1):1-7. PMID: 8903705.
6. Gosheger G, Liem D, Ludwig K, Greshake O, Winkelmann W. Injuries and overuse syndromes in golf. Am J Sports Med. 2003 May-Jun;31(3):438-43. doi: 10.1177/03635465030310031901. PMID: 12750140.
7. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4;333(7575):939. doi: 10.1136/bmj.38961.584653.AE. Epub 2006 Sep 29. PMID: 17012266; PMCID: PMC1633771.
8. Cutts S, Gangoo S, Modi N, Pasapula C. Tennis elbow: A clinical review article. J Orthop. 2019 Aug 10;17:203-207. doi: 10.1016/j.jor.2019.08.005. PMID: 31889742; PMCID: PMC6926298.
9. Bot SD, van der Waal JM, Terwee CB, van der Windt DA, Bouter LM, Dekker J. Course and prognosis of elbow complaints: a cohort study in general practice. Ann Rheum Dis. 2005 Sep;64(9):1331-6. doi: 10.1136/ard.2004.030320. Epub 2005 Feb 11. PMID: 15708885; PMCID: PMC1755654.
10. Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013 Feb 6;309(5):461-9. doi: 10.1001/jama.2013.129. PMID: 23385272.
11. Bisset LM, Vicenzino B. Physiotherapy management of lateral epicondylalgia. J Physiother. 2015 Oct;61(4):174-81. doi: 10.1016/j.jphys.2015.07.015. Epub 2015 Sep 8. PMID: 26361816.
12. Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391- 397. DOI: 10.1302/2058-5241.1.000049.
13. Ma KL, Wang HQ. Management of Lateral Epicondylitis: A Narrative Literature Review. Pain Res Manag. 2020 May 5;2020:6965381. doi: 10.1155/2020/6965381. PMID: 32454922; PMCID: PMC7222600.