Tennis Elbow Not Getting Better? This Could Be Why.

18 June 2021

Tennis elbow is a condition that can happen to anyone who repeatedly uses their elbow, wrist, and hands in their daily activities for work or leisure.

What is Tennis Elbow?

Lateral epicondylalgia, commonly known as “Tennis Elbow”, refers to elbow pain located at the outer aspect of the elbow.

There are many structures at the elbow that can contribute to pain in the outer part of the elbow. Hence, it is important to find out specifically where the pain is coming from so that the right treatment can be applied.

Tennis Elbow Pain
Physiotherapy treating patient elbow pain

Is there more than one type of “Tennis Elbow”?

Yes, there are 2 types:

True Tennis Elbow

True Tennis Elbow can arise as a result of tendon dysfunction. Tendon is a fibrous connective tissue that connects both muscles to bone and essential for controlling joint movement.

False Tennis Elbow

False Tennis Elbow further categorised into;

  • Cervical radiculopathy (Cervical referred pain)
  • Ligamentous instability (Ligament laxity)
  • Intra-articular pathology (Elbow joint movement dysfunction)
  • Posterior interosseous nerve entrapment (Nerve is pinched by surrounding structures of the elbow)

How can I tell which type of I am having?

True Tennis Elbow caused by two types of tendon dysfunction in either case of inflammatory or non-inflammatory.

Meanwhile, normal healing of soft tissue like tendon takes 72 hours to eight weeks to recover.

In most cases, true tennis elbow which does not heal after 6 to 8 weeks is due to a non-inflammatory issue.

80% of these cases do not recover, as the tendon matrix compromised by inappropriate loading; such as the overuse of the tendon.

This may lead to early wear and tear of the tendon matrix.

Both True and False tennis elbow is usually recognised by ruling in and out certain factors as follows.

To Rule In for True Tennis Elbow

To rule in if it is a true tennis elbow, we need to test or check for the following signs.

1. Inflammatory

  • Complaints of intermittent or constant pain started after sudden trauma or injury,
  • Presence of swelling and warmth;
  • Tenderness at the outer aspect of the elbow specifically located at the lateral epicondyle
  • Pain worsens with a load into wrist extension (wrist extensors) and resisted into 3rd finger extension (ECRB)

2. Non- inflammatory

  • Complaints of intermittent pain after repetitive usage of the tendon
  • Tenderness reported at the outer aspect of the elbow specifically located at the lateral epicondyle
  • Pain elicited with repetitive loading of the tendon into wrist extension (wrist extensors) and resisted into 3rd finger extension (ECRB)

Basically, false tennis elbow mimics pain at the outer aspect of the elbow and could be attributing to;

3. Cervical radiculopathy (Cervical referred pain) 

The cervical spine can refer to pain down to the outer aspect of the elbow (at both C5 and C6 nerve root). Which may be mistaken as Tennis elbow.

4. Ligamentous instability

Ligaments located at the outer aspect of the elbow called the Lateral collateral ligament and Annular ligament. Which stabilise the elbow joint that basically loose and cause increased movement to the elbow joint.

Therefore, this can also lead to pain at the outer aspect of the elbow.

5. Intra-articular pathology (elbow joint movement dysfunction)

In essence, joints are an interaction of two bones and the joints at the elbow; consist of the radioulnar joint, humeroulnar and radiohumeral joint.

6. Posterior interosseous nerve entrapment where the nerve is pinched by surrounding structures of the elbow

The posterior interosseous nerve that lies close to the elbow can be compressed by tight muscles at the outer aspect of the elbow. When it is irritated, it can contribute to pain at the outer aspect of the elbow.

Therefore, it is important to differentiate which type of tennis elbow because treatments are different among them.

To Rule Out for False Tennis elbow

To rule out for a false tennis elbow we need to check the following signs or symptoms

1. Cervical radiculopathy (Cervical referred pain)

Firstly, an assessment of the neck spine is carried out to see if there is any referral of pain to the elbow.

2. Ligamentous instability

Secondly, assess the ligaments with tests to check if there is an increase in laxity and stability that causes pain around the elbow but not at the tendon at the lateral epicondyle.

3. Intra-articular pathology (Elbow joint movement dysfunction)

Thirdly, assess the movement of the elbow joint like the radioulnar joint, humeroulnar and radiohumeral joint to see if there is any increased stiffness that may contribute to the outer aspect of the elbow.

4. Posterior interosseous nerve entrapment where the nerve is pinched by surrounding structures of the elbow

Lastly, assess if any tenderness of the posterior interosseous nerve and feel the muscles around the area, which may contribute to the nerve referring to the outer aspect of the elbow.

It is important to differentiate which type of Tennis Elbow you are experiencing because treatments will differ accordingly.

What are the specific treatments that would help my type of Tennis Elbow?

True Tennis Elbow

Inflammatory Type Tennis Elbow

The treatments include rest, applying an ice pack, adding compression and lastly rehabilitation to stretch and strengthen the tendons involved (R.I.C.E.R).

Other treatment methods can include ultrasound therapy, as well as sports taping to reduce swelling or offload the tendon.

Non- inflammatory Type Tennis Elbow

The rehabilitation is targeted to stretch or massage the tendon if it is tight, also to strengthen the tendons to allow more efficient loading of the tendons.

This will prepare the tendons to withstand load during functional activities such as carrying weight without discomfort.

False Tennis Elbow

Treatments for false Tennis Elbow will depend on the source of the problem. For example, if the elbow pain is referred from the neck, it is important to target the neck.

Therefore, it is important to differentiate the type of Tennis Elbow with a thorough assessment before the right treatment can be given for a speedy recovery.

In summary, this video below gives a good explanation of what are tendons and what happens in tendonitis (inflammation of the tendon).

Experiencing elbow or wrist pain? Click here to find out more about physiotherapy for elbow or wrist pain relief and how Core Concepts manage effective pain relief.