What is Lateral Epycondylalgia (Tennis Elbow)?

Lateral epicondylalgia, also commonly referred to as tennis elbow, is an overuse injury that causes pain on the outer side of the elbow. It affects the tendons of the forearm muscles that attach to the lateral epicondyle of the humerus bone in the elbow. These tendons and muscles are responsible for extending the wrist and stabilising the hand, especially the extensor carpi radialis brevis (ECRB). When these muscles become overloaded or subjected to repetitive movements, increased load is placed on the tendons. As a result of this, small tears and inflammation in the tendons at the attachment to the elbow occurs, causing pain and tenderness.

LATERAL EPICONDYLALGIA ANATOMY

The elbow is a complex hinge joint that is made up of 3 joints allowing the arm to move. These joints are the ulnohumeral joint (where the ulna meets the humerus), radiohumeral joint (where the radius and humerus bones meet) and the proximal radioulnar joint (where the radius and ulna bones meet)

The common extensor origin is the lateral epicondyle of the humerus where the common extensor tendons originate. The common extensor tendon is made up of several muscles:

• Extensor carpi radialis brevis 

• Extensor carpi radialis longus

• Extensor digitorum

• Extensor carpi ulnaris

• Extensor digit minimi

WHAT ARE THE CAUSES OF LATERAL EPICONDYLALGIA

Lateral epicondylalgia is commonly caused by repetitive activities that involve heavy gripping and the use of the wrist and hand. As the wrist extensor tendons are unable to tolerate the repetitive load it can become irritated and inflamed, which leads to pain.

• Sports activities – sports requiring gripping and forearm rotation can lead to lateral epicondylalgia such as tennis, badminton etc.

• Manual labour – jobs that require repetitive arm and wrist movements such as bricklaying, painting, carpentry, landscaping or similar can stress the forearm tendons. 

• Repetitive use – everyday activities such as typing, using a computer mouse, gaming or lifting heavy objects can contribute to the development of lateral epicondylalgia over time.

• Age and degeneration – as people age, the tendons in the elbow and other joints can become less flexible and weaker which can increase the risk of injury. Lateral epicondylalgia is commonly seen in people aged between 30 and 50.

There are various elements within the literature regarding the cause of lateral epicondylalgia such as the presence of inflammation, microscopic tearing in the tendons which increases the presence of fibroblasts (cells that look to form connective tissue). Therefore, the fibres around the lateral elbow have been shown to have a disorganised connective tissue matrix. Lateral epicondylalgia also has a degenerative process within the tendon as a result of the increased cell production around the lateral elbow in response to the pain and loading of the tendon. The tendinous region of the lateral elbow has a poor ability to respond and repair accordingly to the loads through the extensor muscles , resulting in a decrease in the tolerance of the muscles and tendons.

LATERAL EPICONDYLALGIA SYMPTOMS

• Pain over the outer side of the elbow – the pain can range from mild to severe and worsen with particular activities. The pain can also radiate down the forearm

• Tenderness on palpation – pain is often localised to the lateral epicondyle and can be tender to touch.

• Weak grip strength – pain and difficulty with gripping objects or performing fine motor skills (holding cups, turning doorknobs) is often a symptom of lateral epicondylalgia.

• Pain with specific movements – the pain generally increases when performing tasks involving wrist extension, forearm rotation and gripping.

• Stiffness and swelling – the elbow may feel stiff and feel better after it is warmed up. Some swelling around the elbow joint may also be present.

• Pain that worsens over time: If left untreated, the pain can become more persistent and limit a person’s ability to perform daily activities as it doesn’t ease much with rest.

LATERAL EPICONDYLALGIA TREATMENT

Treatment for lateral epicondylalgia should always begin with conservative, non-invasive approaches and in the large majority of cases heal well with no invasive therapy. 

Treatment often consists of activity modification to avoid aggravating activities such as reducing repetitive motions or ergonomic adjustments to prevent further strain on the elbow. Physiotherapy plays an important role as they can guide patients through some manual therapy techniques to decrease the pain and guide specific exercises for the forearm muscles. Manual therapy such as soft tissue massage, dry needling and lateral joint glides are effective approaches in the literature. Specific exercises such as isometric strengthening of the wrist extensors and then loading the muscles through range are recommended as part of a home exercise program.

Bracing or strapping the lateral elbow can help to alleviate stress on the tendons by distributing the forces that are applied during the movement. This can be a beneficial treatment option especially during activity or exercise.

There are other options to help with the pain on the lateral elbow such as nonsteroidal anti-inflammatories or a topical gel such as voltaren gel. This can help reduce the inflammation around the lateral elbow and then allow the muscles to be loaded more. If the lateral epicondylalgia is slow to settle and cause some persistent pain, a corticosteroid injection may be considered.

PREVENTION OF LATERAL EPICONDYLALGIA

It is not always possible to prevent lateral epicondylalgia but there are several strategies to reduce the risk of it occurring. These include:

• Ensuring a good warm up – before engaging in sport or physical activity having a good warm up

• Good technique – when playing sports or performing repetitive movements to minimise strain on the elbow

• Forearm strengthening – to help support the muscles and tendons and reduce the risk of injury

• Take frequent breaks – during repetitive tasks especially those with gripping and twisting, taking breaks to reduce the load on the muscles and tendons 

• Maintaining good posture – to reduce unnecessary stress on the elbow joint with good posture, such as when working at the desk.

CONCLUSION

Lateral epicondylalgia can be a frustrating condition that affects people of all ages and activity levels. While it’s often associated with tennis players, it can impact anyone who performs repetitive motions that strain the elbow. Lateral epicondylalgia responds well to conservative treatments like rest, physical therapy and strength exercises. However, it’s important to seek early treatment if symptoms persist to prevent the condition from becoming chronic. If you're dealing with elbow pain or suspect you might have lateral epicondylalgia, consult with a healthcare provider to develop a personalized treatment plan.

REFERENCES:

1. Bisset L., Paungmali A., Vicenzino B., & Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 2005 Jun; 39(7), 411–422. https://doi.org/10.1136/bjsm.2004.016170

2. Landesa-Martínez L., & Leirós-Rodríguez R. Physiotherapy treatment of lateral epicondylitis: A systematic review. Journal of Back and Musculoskeletal Rehabilitation. 2022 May; 35(3), 1–15. https://doi.org/10.3233/bmr-210053 

3. Vaquero-Picado A., Barco R., & Antuña S. A. (2016). Lateral epicondylitis of the elbow. EFORT Open Reviews. 2016 Nov; 1(11), 391–397. https://doi.org/10.1302/2058-5241.1.000049 

4. Uttamchandani S. R. & Phansopkar P. Conservative Management of Lateral Epicondylalgia: A Review. Cureus, 2024 May; 16(5). https://doi.org/10.7759/cureus.59875 

5. Ikonen J., Lähdeoja T., Ardern C. L., Buchbinder R., Reito A., & Karjalainen T. Persistent Tennis Elbow Symptoms Have Little Prognostic Value: A Systematic Review and Meta-analysis. Clinical Orthopaedics & Related Research. 2022 April 480(4), 647–660. https://doi.org/10.1097/corr.0000000000002058 

6. Chen Z., & Baker N. A. (2020). Effectiveness of eccentric strengthening in the treatment of lateral elbow tendinopathy: A systematic review with meta-analysis. Journal of Hand Therapy. 2020 April; 34(1). https://doi.org/10.1016/j.jht.2020.02.002 

7. Couppé C., Døssing, S., Bülow P. M., Siersma V. D., Zilmer C. K., Bang C. W., Høffner R., Kracht M., Hogg P., Edström G., Kjaer M. & Magnusson S. P. Effects of Heavy Slow Resistance Training Combined With Corticosteroid Injections or Tendon Needling in Patients With Lateral Elbow Tendinopathy: A 3-Arm Randomized Double-Blinded Placebo-Controlled Study. The American Journal of Sports Medicine. 2022 Aug. 50(10), 2787–2796. https://doi.org/10.1177/03635465221110214