Though there are MANY causes of elbow pain, the most common cause of pain to the elbow is lateral epicondylitis, commonly known as Tennis elbow. Tennis elbow effects about 1-3% of the general population, and 15-30% of the workforce. 80% of those effected recover within one year. Based on its 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. And hey, now that the greens are covered with snow, it’s time to talk about getting a plan in place for next season and living pain-free. ^{1,2,3,4,5,6,8,12.}

Those who develop this condition will experience symptoms that 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 radiate into the forearm. This area may also be tender to touch. Pain is often exacerbated or made worse by gripping, twisting, lifting, or repetitive activities such as the use of tools or typing.

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 or stress is applied to them. When the tension applied to a tendon exceeds it’s tolerance, often due to repetitive loading, micro tears occurs. These cumulative micro tears lead to tendinosis, which is essentially a symptomatic degenerative process to the tendon.

These degenerative changes to the tendon can occur over time from repetitive gripping, extending of the wrist, rotating the wrist and forearm, or from activities such as using tools/manual work, prolonged typing, playing an instrument, or from sports such as golf or tennis which require gripping with a stable wrist position. Generally, individuals with painful lateral elbow symptoms tend to underuse or rest their painful arm, which can result in further weakening of the tendon, making it more susceptible to injury, and lowering the threshold for tendon micro tears to occur. ^7,11,12,13

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, a labour type job, and obesity. ^1,8,12

So now what? A few helpful tips for success:

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 to offload your elbow, or even simple activities such as lifting a milk jugs with your other hand. ^{7, 12}

Posture, posture, posture: Have you ever heard the phrase “Sh$t flows downhill? Well this is VERY true for not only sh$t but also for pain in your elbow. Working on your posture and your postural and scapular 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. ^7,12

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. ^7,12,13

Physiotherapy: A physiotherapist will perform an examination, help determine a correct diagnosis (remember, MANY causes of elbow pain, and not just local to the elbow), and guide you through the proper rehabilitation process specific to you, your lifestyle, 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 topic is SO complex, and this is just a small generalized glimpse into this common condition without mucking the waters. 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. The above is just a starting place.

Stay healthy, Stay active, Stay kind.

Regards,

Kayla Eagle, PT, MScPT, Bkin

References

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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.

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8. 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.

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.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.

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.