Technique Geek: Tennis Elbow – Lateral Epicondylalgia

So it’s that time of year again when we start to turn our attentions to the Wimbledon tennis championship. This got us thinking of associated injuries and where better to start than Tennis Elbow?

Tennis elbow is one of the most common conditions seen within physiotherapy practices and is estimated to affect between 1-3% of the population. Far from being a condition associated with tennis players, this repetitive strain injury is most commonly seen in people whose jobs involve repetitive activities such as typing and manual work. Initial intermittent aching of the outer area of the elbow may develop in severity within weeks, reaching the point where everyday activity is affected and time-off work and sport is required.

A common approach is to take anti-inflammatory medications to try and combat the symptoms. However while it is possible that inflammation exists during the initial genesis of this condition, a look at the local tissues in patients with a developed lateral epicondylalgia, usually over 6 weeks, reveals a consistent lack of inflammation (Regan et al 1992, Alfredson et al 2000). So what is going on?

Well research now shows that lateral epicondylalgia is a product of 3 mechanisms (Coombes et al 2009):-

1) Local tendon pathology – there are changes within the tendon that reflect other
common ‘tendinopathies’ such as Achilles and Patellar Tendinopathy. These include a
change in the type of collagen being produced at the site of injury.

2) Alterations in pain mechanisms – It is increasingly accepted in modern neuroscience that many of the conditions we suffer from start as a local tissue problem causing pain, but
prolonged firing of the ‘pain signal’ leads to hypersensitivity of the nervous system, both
locally and centrally at the spinal cord, and this actually becomes the problem (Latremoliere & Woolfe 2009). Treatments may need to focus on neurologically-related structures such as the neck!

3) Muscular control deficits – Or ‘motor control deficits’. A growing body of evidence is showing changes in the structure of the muscles around the wrist, forearm and even the shoulder in people with lateral epicondylalgia (Vicenzino et al 2003). While these alterations may be associated with disuse due to the elbow pain, many believe that they may be a pre-cursor to the development of the problem. This is an area that needs to be addressed both during and after rehabilitation.

So, what do we do about it?

Well, your physiotherapist will assess you and sub-group your injury based on the percentage involvement of the 3 mechanisms. Treatment needs to be specific to achieve the best outcome as one size most certainly does not fit all in this instance. A structured program of manual therapy and home exercises will make all the difference.

If you’re worried about on-going elbow pain our therapists are available to discuss your concerns and treat you within the framework of the latest research. With honest, straight-forward advice and treatment, Make the Move!


Alfredson H, Ljung B, Thorsen K et al (2000) In vivo investigation of ECRB tendons with microdialysis technique – no signs of inflammation but high amounts of glutamate in tennis elbow. Acta Orthop Scand; 71:475-479

Coombes B, Bisset L, Vicenzino B (2009) A new integrative model of lateral epicondylalgia. British Journal of Sports Medicine; 43:252-258

Latremoliere A, Woolf C (2009) Central sensitization: a generator of pain hypersensitivity by central neural plasticity. The Journal of Pain; 10(9):895-926

Regan W, Wold L, Coonrad R et al (1992) Microscopic histopathology of chronic refractory lateral epicondylitis. American Journal of Sports Medicine; 20:746-749

Vicenzino B (2003) Lateral Epicondylalgia: a musculoskeletal physiotherapy perspective. Manual Therapy; 8:66-79