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How common is lateral elbow pain?
About 3 out of every 100 people develop Lateral Elbow Tendinopathy. As people get older, the rates increase to 7 to 10 out of every 100. In some jobs that involve a lot of wrist and hand movements, these rates are even higher, reaching up to 29 out of every 100.
Among those affected, around 30 out of 100 people with Lateral Elbow Tendinopathy need to take about 12 weeks off work due to their symptoms. Lateral elbow pain is difficult to treat, both with and without surgery. Even after treatment, 20 to 38 out of 100 people still have symptoms after 6 to 12 months. Often, symptoms return, and up to 54 out of 100 people may experience them again two years later.
Anatomy of Lateral Elbow Pain
The lateral epicondyle is a bony area on the outer side of the elbow, just above the elbow joint. This is where the muscles that help straighten and rotate the arm are attached. It is also the most common site for problems related to elbow pain. The reason this area is so prone to pain is that the fibers of the main tendon—the extensor carpi radialis brevis (ECRB)—are connected to the ligaments and joint capsule of the elbow. This connection helps distribute the stress from movements of the elbow, which may explain why pain is often felt over a large area around the outside of the elbow.
The common tendon that attaches here helps move the wrist and fingers. It can get injured by repeated pulling or rubbing against the edge of the elbow joint during arm movements. This tendon is positioned in a way that makes it easy to get hurt when the forearm rotates.
It also has a lower blood supply, which could make it more prone to injury and slow down the healing process. Other nearby tendons can be affected as well. This may be why repetitive movements of the elbow, forearm, wrist, or fingers during work or sports increase the risk of developing Lateral Elbow Tendinopathy. However, similar stresses can also damage nearby structures, so it is important for doctors to carefully examine the area to determine if the pain is coming from the tendons, muscles, joints, or nerves.
The term "tendinopathy" is used to describe an injury to a tendon that is not torn but worsens with physical activity. "Tendinitis" refers to a sudden injury that involves inflammation, while "tendinosis" describes a long-term tendon problem where there is an increase in cells and blood vessels and disorganized collagen fibers. Over time, the term "tendinopathy" has become more common because it covers a wide range of possible changes in the tendon, including pain and muscle issues, regardless of whether the condition is sudden or long-lasting.
Symptoms of Lateral Elbow Tendinopathy
People with Lateral Elbow Tendinopathy may have a combination of sudden and long-term symptoms that can come and go during treatment. Sometimes, mild inflammation can occur after intense use of the tendon, especially in chronic cases, creating what is known as an "acute-on-chronic" condition. Some researchers think that Lateral Elbow Tendinopathy begins with irritation in the low-blood-supply area of the common extensor tendon where it attaches to the lateral epicondyle. This irritation can lead to the formation of new blood vessels and changes in the tissue. Chronic Lateral Elbow Tendinopathy is often identified by disorganized collagen fibers, increased blood vessels and nerves, and areas with low cell activity or a fibroblast response.
Although there is no consistent evidence on whether inflammation is always present in this area, other inflammatory chemicals like cytokines, growth factors, prostaglandins, and neuropeptides have been found in chronic tendinopathy cases. These chemicals play a key role in controlling the blood supply to the tendon and may also cause nerve-related inflammation. Changes in how the nervous system processes pain might also contribute to the ongoing pain seen with Lateral Elbow Tendinopathy. Some early research suggests that the nervous system may become more sensitive in people with chronic tendinopathy, affecting both the tendon itself and how the nervous system responds to pain.
The complex processes involved in Lateral Elbow Tendinopathy could explain why it is challenging to classify and treat this condition using a straightforward approach. It also might help explain why these symptoms can be difficult to completely resolve.
There is a strong link between certain wrist and elbow movements and the development of Lateral Elbow Tendinopathy. Women who handle tools weighing more than 1 kilogram and people who frequently lift loads greater than 20 kilograms, at least 10 times a day for over 20 years, are at higher risk.
Tasks that involve bending and twisting the wrist or rotating the forearm also increase the likelihood of developing this condition. Both men and women who bend their wrists for more than 2 hours a day, as well as those who perform repetitive hand or wrist movements for at least 2 hours daily for many years, are particularly vulnerable.
Engaging in manual labor and having rotator cuff injuries are also associated with a higher risk of Lateral Elbow Tendinopathy. Additionally, people who have low control over their work or receive low social support are more likely to develop this condition.
Long-Term Impact and Progression of Lateral Elbow Tendinopathy
Lateral elbow tendinopathy can cause long-lasting pain and disability for many people. How the condition progresses largely depends on how much the affected area is repeatedly irritated. Some people fully recover quickly with nonsurgical treatments, but more than half of those who seek general medical care still report symptoms after a year. Even after receiving treatment, up to 20% of people may continue to experience pain for 3 to 5 years.
Certain activities, like specific jobs or sports such as tennis, can worsen the condition and lead to lost work time due to injury. Around 55% of people with lateral elbow tendinopathy may have ongoing pain and loss of function for more than two years after their symptoms start. This means that the condition does not always follow the typical healing process. Often, by the time someone seeks medical help, the inflammation has gone away, but the symptoms remain.
The way the condition progresses can vary. It might be a single, isolated event, it might come back again, or it could be a persistent issue that flares up occasionally. In cases where the condition becomes chronic, flare-ups are usually linked to certain activities, and these can sometimes be predicted based on the type and amount of activity. Understanding how irritable the condition is by assessing pain levels, where the pain is located, and how much it affects daily life can help guide treatment.
Effective Classification Systems for Lateral Elbow Tendinopathy (LET)
Classification systems for lateral elbow tendinopathy are usually meant to describe the condition, but ideally, they would also help in choosing the best treatment or predicting outcomes. However, there is limited research supporting the use of these classification systems for tendinopathy in general, and LET in particular. Most systems classify LET based on how severe it is, how irritable it is, and how long it has lasted. People with different jobs or sports activities, or those who have had multiple recurrences, might respond differently to treatments.
One proposed classification system takes into account six factors:
how irritable the condition is
where the symptoms are located
general context (like if the person is an athlete or a worker)
how recent the condition is
what the likely underlying pathology is (usually determined by imaging)
whether the condition is recurrent or persistent.
This system can give healthcare providers a comprehensive view of the patient’s condition and help in tracking progress and guiding treatment. For example, pain intensity can be classified as mild, moderate, or severe.
The location of symptoms can be classified as:
unilateral and localized (type 1)
bilateral and localized (type 2)
diffuse with additional pain or neuropathic symptoms (type 3).
Assessing how symptom irritability affects daily function can also help in determining the level of disability, which can be mild, moderate, or severe.
Differential Diagnosis
Physical therapists should be able to recognize other conditions that mimic LET and refer patients to other healthcare professionals if needed. Developing a differential diagnosis involves taking a medical history, conducting a physical examination (including special tests), and possibly using imaging. Conditions that should be considered in a differential diagnosis of lateral elbow pain include:
Cervical radiculopathy
Radial tunnel syndrome
Posterior interosseous syndrome
Plica syndrome
Radio-capitellar chondromalacia
Posterolateral rotatory instability
Myofascial trigger points in the wrist extensors
The best way to confirm a diagnosis is through a detailed history and physical exam. Imaging can be helpful in evaluating the severity of the disease, identifying associated conditions, and ruling out other causes of elbow pain, especially if nonsurgical treatments do not work. For stubborn cases of LET, initial imaging might include X-rays, which are usually negative but can show calcium deposits near the lateral epicondyle or rule out other issues. Magnetic resonance imaging (MRI) is commonly used, as it has high sensitivity and specificity for detecting LET. Typical MRI findings include increased signals within or around the common extensor tendon, fluid collections, and tendon thickening. Ultrasound can also be used and is less expensive than MRI, but its accuracy depends on factors like operator experience, equipment, and the stage of the condition. Electrodiagnostic studies, such as electromyography and nerve conduction studies, might also be used to rule out radial nerve compressions as a cause of lateral elbow pain.
Optimizing Exercise for Managing Lateral Elbow Tendinopathy: What Works Best?
An unsupervised isometric exercise group reported less pain and disability after eight weeks, but there were no significant changes in overall improvement or grip strength. Eccentric exercises, which involve lengthening muscles while they contract, were found to be effective in reducing pain and improving muscle strength.
Exercise was also shown to be better than corticosteroid injections for improving grip strength, reducing pain, and lowering disability in the long term. However, the best type of exercise, the specific muscles to target, and the optimal exercise dosage are still not fully understood. Strengthening exercises for the wrist extensors, combined with other therapies like joint mobilization and manual therapy, can lead to better short-term outcomes. Additionally, including exercises for the shoulder and scapular muscles may provide further benefits.
Manual Therapy Techniques for Lateral Elbow Tendinopathy
Manual therapy techniques can be effective in managing Lateral Elbow Tendinopathy by reducing pain and improving grip strength and function. Lateral glide mobilization with movement (MWM) to the elbow has been shown to have a positive effect on both pain and grip strength. Mill's manipulation also helps alleviate pain, but it does not significantly impact grip strength.
Manipulations of the cervical spine (neck), thoracic spine (upper back), and wrist have demonstrated short-term improvements in pain, grip strength, and overall function. Myofascial release therapy (MRT) is useful in relieving chronic musculoskeletal pain, improving joint movement, and enhancing quality of life. MRT involves various techniques, such as applying direct pressure, stretching, or self-administered methods, and can help reduce pain and improve function.
Deep friction massage (DFM), when combined with a lidocaine injection, has shown improvements in pain, grip strength, and function. Similarly, eccentric exercises for the wrist, combined with instrument-assisted soft tissue mobilization, have been effective in enhancing grip strength and overall function.
The Benefits of Dry Needling for Lateral Elbow Tendinopathy
Dry needling (DN) near the lateral epicondyle and along the extensor carpi radialis brevis (ECRB) muscle has been found to be more effective than corticosteroid injections for reducing pain and improving function, both at 3-week and 6-month follow-ups. When comparing trigger point dry needling (TDN) with percutaneous electrolysis (PE)—a technique that uses a small electric current on the common extensor tendon at the elbow—PE was found to be more effective in reducing pain and increasing the pressure pain threshold (PPT). Overall, dry needling has been shown to significantly reduce pain and disability, increase the pressure pain threshold, and improve grip strength for those suffering from Lateral Elbow Tendinopathy.
Effectiveness of Orthoses in Managing Pain and Improving Function
A lateral counterforce orthosis did not significantly reduce pain compared to other physical therapy treatments. For younger patients under 45, the orthosis also did not have a significant effect on pain. In the long term, other physical therapy treatments seemed to be more effective than using the counterforce orthosis alone. However, forearm counterforce and wrist support orthoses could reduce pain and improve strength, but they might also decrease the ability to grip objects effectively. The use of a forearm counterforce orthosis was shown to help people with lateral epicondylitis (LET) perform daily activities more comfortably.
Benefits of Elastic and Rigid Taping in Pain Management and Muscle Support
Elastic tape, such as kinesiology tape, is believed to help reduce pain by stimulating the skin and potentially improving movement awareness, or proprioception. Kinesiology tape has been shown to reduce pain, improve grip strength, and enhance function, with noticeable improvements in grip strength after eight weeks. Rigid tape, which does not stretch, is primarily used to support and off-load tissues, particularly the wrist extensor muscles. The rigid diamond-deloading taping technique significantly improved pain-free grip strength and pain sensitivity both immediately and shortly after application. Rigid taping often provided better immediate and short-term improvements in pain and grip strength compared to other methods.
Overview of Pain Relief and Rehabilitation Modalities
Cryotherapy (cold therapy) and heat have long been used to help with pain relief and healing. Cold therapy is primarily used to reduce pain and inflammation, while heat therapy is thought to make soft tissues more flexible for stretching and increase blood flow to promote healing.
Therapeutic ultrasound has not shown a significant difference in overall improvement but may be more effective in reducing pain and improving function in the short term compared to treatments like chiropractic care and exercise.
Phonophoresis, which uses ultrasound waves to deliver anti-inflammatory medications through the skin, may not be more effective than other treatments.
Iontophoresis, a method that uses a mild electrical current to deliver anti-inflammatory medication directly to the affected area, resulted in significantly less pain at rest and with exertion compared to other treatments, though there was no significant difference in grip strength between groups.
Transcutaneous Electrical Nerve Stimulation (TENS) is another therapy used for pain management by applying electrical currents through the skin. The use of burst TENS alone, cryotherapy alone, or a combination of both significantly improved pain thresholds and tolerance, with the combination being particularly effective. TENS applied to acupuncture points also reduced pain over a two-week period. Low-intensity laser therapy (LILT) had a moderate positive effect on pain and grip strength.
Ergonomic training, including the use of forearm supports, ergonomic keyboards and mice, and taking frequent breaks, can help reduce symptoms in the upper extremities for people who work with computers, especially those with cumulative trauma disorders. Adjusting activities to reduce stress on the wrist extensors and minimizing repetitive motions of the elbow, forearm, wrist, and hand that worsen symptoms, as well as avoiding lifting objects with the forearm rotated downward, are important aspects of treatment.
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