Tennis Elbow Doesn't Require Playing Tennis

Tennis Elbow Doesn't Require Playing Tennis

Lateral epicondylalgia — commonly called tennis elbow — affects roughly 1–3% of the general population and is seen far more often in tradespeople, office workers, and recreational athletes than on a tennis court.¹ The name is a historical artefact. The condition is defined by pain and tenderness at the lateral epicondyle of the humerus (the bony prominence on the outside of the elbow) and provoked by gripping, lifting, or any activity that loads the wrist extensor tendons.

Like most tendon problems, lateral epicondylalgia is now understood as a load tolerance issue rather than a classic inflammatory condition. The tissue at the common extensor tendon origin undergoes degenerative changes — a tendinopathy — in response to accumulated overload without sufficient recovery. Anti-inflammatory strategies alone don't address this, which is why the condition is notorious for recurring when treated only with rest and corticosteroid injection.

What's Actually Happening in the Tendon

Tendon tissue is highly responsive to mechanical load. Under appropriate loading, tendons remodel toward a stronger, more organized structure. Under excessive or repetitive loading without recovery, the collagen matrix becomes disorganized, neovascularization occurs, and the tendon loses its mechanical properties — the degenerative picture of tendinopathy.²

At the elbow, this process most commonly affects the extensor carpi radialis brevis (ECRB), which originates at the lateral epicondyle and is under significant tension during gripping and wrist extension activities. Repetitive use — whether from a racquet, a screwdriver, a keyboard, or a barbell — gradually exceeds the tendon's capacity to recover between loading bouts, and the pain begins.

The Kinetic Chain Above the Elbow

The elbow doesn't work independently. Cervical spine and shoulder function significantly influence the loading patterns at the elbow, and a thorough assessment of lateral epicondylalgia includes examining both. Cervical radiculopathy at C6 can refer pain to the lateral elbow and mimic or coexist with local tendinopathy. Reduced shoulder mobility can alter arm mechanics during overhead and reaching activities, shifting load distally to the elbow structures.

Grip strength and motor control also involve the entire upper limb chain, and weakness or altered recruitment proximally can increase the relative demand on the wrist extensors during functional tasks.

What the Evidence Supports for Treatment

Exercise therapy is the cornerstone of evidence-based management for lateral epicondylalgia. Progressive tendon loading — starting with isometric wrist extension holds and advancing to eccentric and heavy slow resistance exercises — builds the tendon's capacity to handle the demands that provoked it.² Improvements in pain and function with a consistent loading program typically take six to twelve weeks, which is a timeline that most patients underestimate.

Corticosteroid injection can provide short-term pain relief, but trials comparing it to physiotherapy show that injection-managed cases have significantly worse outcomes at 12 months — likely because the temporary pain relief leads to return of the provocative loading before the tendon has rebuilt its capacity.¹ If injection is used, it should be an adjunct to a structured loading program, not a replacement for it.

There are no exercises that are inherently harmful for the elbow tendon — only progressions introduced too quickly for the current tissue tolerance.³ Starting with sub-maximal isometric loading and progressing systematically over weeks is the approach backed by the best available evidence.

Modifying the Load

Identifying and modifying the tasks driving the overload is equally important. This might mean adjusting technique, changing equipment (grip size, racquet string tension, tool handle diameter), distributing tasks differently across a work day, or temporarily reducing volume of the most provocative activities while the tendon loading program builds capacity. Complete avoidance isn't usually necessary — but unmanaged continuation of the provocative load while doing rehabilitation is a reliable way to prolong recovery.

At Boreal Spine & Sport, lateral elbow assessments include a full upper limb kinetic chain examination alongside local tendon assessment — ensuring that cervical, shoulder, and movement pattern contributions are identified and addressed alongside the local loading program.

References

1. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751–1767.
2. Vicenzino B, Cleland JA, Bisset L. Joint manipulation in the management of lateral epicondylalgia: a clinical commentary. J Man Manip Ther. 2007;15(1):50–56.
3. Gabbett TJ. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med. 2016;50(5):273–280.
4. Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis. Lancet. 2002;359(9307):657–662.