Tennis Elbow

Tennis Elbow / Lateral Epicondylitis [Large Guide - 2022]

Tennis elbow / lateral epicondylitis is due to overload of the wrist stretching muscles (wrist extensors).

Tennis elbow / lateral epicondylitis can greatly affect quality of life and work ability. The condition is characterized by pain on the outside of the elbow over the part we call the lateral epicondyle (hence the name). In addition to pain in the elbow, you can also have reduced grip strength or pain when using the forearm and hand.


Article: Tennis Elbow / Lateral Epicondylitis

Last updated: 22.03.2022



- At our interdisciplinary departments at Vondtklinikkene in Oslo (Lambert seats) and Viken (Eidsvoll Sound og Raw wood), our clinicians have a uniquely high professional competence in the assessment, treatment and rehabilitation training of tendon injuries in the elbow. Click on the links or here to read more about our departments.


In this article you will be able to learn more about:

  • Causes of Tennis Elbow (Lateral Epicondylitis)

Common Causal Mechanisms

+ Injury Tissue in Muscle Fasteners and Tendons (With Grading)

+ Why Not Heal My Tendon Injury?

  • 2. The definition of Lateral Epicondylitis
  • 3. Symptoms of Tennis Elbow

+ 5 Common Symptoms of Tennis Elbow

  • 4A. Treatment of Tennis Elbow

+ Evidence-Based Treatment Methods

  • 4B. Clinical Investigation of Tennis Elbow

+ Functional Examination

+ Imaging Diagnostic Investigation

  • 5. Self-measures and Self-treatment for Elbow Pain
  • 6. Exercises and Training against Tennis Elbow
  • 7. Contact Us: Our Clinics


1. The cause of tennis elbow / lateral epicondylitis?

Tennis elbow / lateral epicondylitis is often due to repetitive movements over a long period of time. Examples can be painting, computer work and sports. What we do know is that there has been an overload on the tendon attachment in the area - also known as one tendinosis. Here it is important to mention that there may also be involvement from other muscles in the forearm, including the pronator teres.


Treatment of tennis elbow / lateral epicondylitis involves relief from the causative cause, eccentric training of the muscles involved, physical treatment (often sports acupuncture), as well as any pressure wave and / or laser treatment. We go into more detail on documented treatment methods later in the article. It is the wrist extensors that cause the condition tennis elbow / lateral epicondylitis (including musculus extensor carpi radialis or extensor carpi ulnaris myalgi / myosis).


Lateral epicondylite - tennis elbow - Photo Wikimedia

[Figure 1: Lateral epicondylitis - tennis elbow. Here you see which tendon attachments from the forearm muscles are involved. Image: Wikimedia]

The image above illustrates a lateral epicondylitis damage. In the muscle / tendon attachment to the lateral epicondyle (which you find on the outside of the elbow), small micro-tears can occur, which can worsen if the symptoms and pain are not taken into account. So that it becomes harder and harder for the body's own healing process to do something about. In such cases, external help from a physiotherapist, chiropractor or manual therapist is often required. The treatment will usually consist of eccentric training in combination, muscular techniques (often sports acupuncture), with pressure wave and / or laser treatment, as well as relief from the causes that started the problem.


Common Causes of Tennis Elbow:

  • Sports Injuries (Like holding a tennis racket hard over time)
  • Sudden error load (Fall where the person touches or grabs something to avoid falling)
  • Repetitive movements (Factory work or repeated daily computer use)


- To Understand the Cause of Tennis Elbow We Must Understand Injury Tissue in Soft Tissue and Tendon Tissue

[Figure 2: Injury tissue in 3 different phases. Picture: Eidsvoll Healthy Chiropractor Center and Physiotherapy]

Over time, there may be a gradual build-up of damaged tissue in soft tissue and tendon tissue. This damaged tissue has reduced elasticity, less load-bearing capacity and poorer function than normal healthy tissue. In figure 2 you can see an illustration that shows how soft tissue and tendon tissue can be damaged over time. We like to divide it into three phases.


The 3 Phases in Soft Tissue and Tendon Tissue
  1. Normal tissue: Normal function. Painless.
  2. Damaged tissue: In the case of damage mechanisms in soft tissue and tendon tissue, we can change the structure, and this can occur 'crossed fibers'- that is, the tissue fibers are not in their normal position. One can divide damaged tissue further into 3 grades; mild, moderate and significant. In this phase of the problem, it is important to make arrangements to avoid incorrect loading while stimulating healing. Injury tissue has higher pain sensitivity and poorer functioning.
  3. Scar tissue: If we continue to repeat the misloading mechanisms, damaged tissue will not be able to heal itself. Over time, what we call scar tissue can occur. This grading of damaged tissue has significantly reduced functional ability and healing ability. Often the pain at this level has also become significantly worse.


«- The key often lies in acknowledging the pain and disability. Those who continue as before, even with obvious pain, run a high risk of further aggravation - often with the excuse that they do not have 'time to do anything about it'. The irony of this is that they will be able to spend even significantly more time on the ailments, and that there is a risk of chronicity. "


- Why does not my elbow get good?

If a damage mechanism is not healed, it is important to take a step back and get a better overview. If you have not already done so, you should seek professional advice for help with treatment and rehabilitation exercises. When injuries and pain persist, this indicates that we have damaged tissue that does not have the right access to nutrients and function.


By breaking down the damaged tissue, for example with treatment techniques such as pressure wave treatment and intramuscular acupuncture, one will be able to give an increased healing response in the area. This will also be able to help reverse the evil trend you are in. Time does not heal all wounds if you go in the red - then on the contrary, it could get worse and worse.



2. The definition of Lateral Epicondylitis

So how do you define tennis elbow? You get the answer here.


Lateral epicondylitis: An extra-articular overload condition located at the origin of the wrist stretching muscles or tendons on the outside of the elbow. Repeated full extension (backward bending) of the wrist in the working day is the most common cause. An example may involve sitting in a poor ergonomic position when working on a PC.


3. Symptoms of Tennis Elbow / Lateral Epicondylitis

Here we go through some common symptoms you may experience with tennis elbow. One of the most characteristic is that the pain is located locally on the outside of the elbow above the anatomical landmark lateral epicondyle. In addition to this, the pain can often be of an aching nature which is especially aggravated immediately after activity.


5 Common Symptoms of Tennis Elbow

Pain and tenderness towards the outside of the elbow

[Figure 3: Referred Pain Patterns from the Wrist Extensors]

The basis for the pain and tenderness on the outside of the elbow is that this is the elbow attachment for the wrist extensors. That is, the muscles that are responsible for bending the wrist backwards. The pain can also go down to the forearm, as well as the wrist, and can be aggravated by certain movements. In the picture we show two of the most common pain patterns that can occur with tennis elbow. Many people will also recognize themselves in how they can cause pain down the wrist.


2. Stiffness in the elbow

The elbow can feel stiff and it can be painful to tie the hand to a fist. It can also feel painful and 'tough' to straighten the arm out after having it in a bent position. The feeling of stiffness is due to damage to the tissue in the tendon attachment in the elbow and in the forearm muscles. Injury tissue is, as we showed in Figure 2, less elastic and has reduced mobility. The tendon fibers will thus not move like fresh tissue and you can therefore experience a feeling of stiffness in the elbow.


3. Cracking of the elbow

There may be a cracking sound in the elbow at the tennis elbow. Again, the cause lies in the damaged tendon tissue that does not have the same mobility as before. When moving, the tendon can thus «miss over» and form a cracking sound. Another possible cause is that the malfunction in the tendon and muscles leads to reduced function in the elbow joint and thus gives a higher joint pressure there.


Weakness in the hands or fingers

Occasionally, tennis elbow can give weakness in the hand on the affected side. Many people may experience that the forearm or grip almost 'gives in' to certain loads and movements. This is due to a built-in defense mechanism in the body that is there to prevent further damage. The brain subconsciously overrides you and forces you


5. Iling down towards the hand and wrist

If we take a closer look at Figure 3 again, we will be able to see that tennis elbow can cause referred pain to the wrist. Others may experience increased pain at the base of the thumb or in the wrist below the little finger. In addition to this, we must keep in mind that reduced function in the elbow and forearm can be a risk factor for getting nerve irritation in the wrist (carpal tunnel syndrome).


4A. Treatment of Tennis Elbow / Lateral Epicondylitis

Fortunately, there are well-documented treatment methods for tennis elbow and other tendon injuries. Among the best documented we find pressure wave treatment, laser therapy, intramuscular acupuncture, elbow mobilization and adapted rehabilitation exercises (preferably eccentric training). The treatment is usually performed by a modern chiropractor or physiotherapist.


- 4 Main Objectives in the Treatment of Tendon Injury in the Elbow

A course of treatment against tennis elbow would like to have the following 4 main goals:

  1. Break down damaged tissue and stimulate healing
  2. Normalize function in elbow joints and forearms
  3. Address possible associated causes in the shoulder and upper arm
  4. Reduce the risk of relapse with customized rehabilitation exercises


What has the best evidence for the treatment of lateral epicondylitis is pressure wave therapy, eccentric training (see exercises here ), preferably in combination with laser therapy and elbow mobilization / joint manipulation. Studies have shown that pressure wave therapy can provide pain reduction and improved grip strength (3).


Standard protocol for treatment of tennis elbow with Shockwave Therapy is about 5-7 treatments, with about 5-7 days in between the treatments so that the recovery / rest period will be optimal. What is interesting about the pressure wave is that it facilitates long-term improvement - thus many will experience a significant improvement in the 4-6 weeks after the last treatment in the course.


- Combination of Different Treatment Techniques for Optimal Effect

For optimal treatment effect, it is often advantageous to combine several different treatment methods. At our departments in the Pain Clinics, both in Oslo and Viken, a normal course of treatment can include a pressure wave, sports acupuncture, laser therapy and rehabilitation exercises. See an overview of our clinics here (the clinic overview opens in a new browser window).


Evidence for Chiropractic Elbow Joint Mobilization in Tennis Elbow / Lateral Epicondylitis

A larger RCT (Bisset 2006) - also known as a randomized controlled trial - published in the British Medical Journal (BMJ), showed that physical treatment of lateral epicondylitis consisting of elbow joint manipulation and specific training had a significantly greater effectt in the form of pain relief and functional improvementcompared to waiting and watching in the short term, and also in the long term compared to cortisone injections. The same study also showed that cortisone has a short-term effect, but that, paradoxically, in the long term it increases the chance of relapse / ruptures and leads to slower healing of the damage. Another study (Smidt 2002) also supports these findings.


- VIDEO: Intramuscular Acupuncture at Tennis Elbow

Intramuscular acupuncture (needle treatment) is used regularly for elbow pain. It can be effective against conditions such as tennis elbow (lateral epicondylitis), golf elbow (medial epicondylitis) and general muscular dysfunction (myalgia). Here you can see a video of an acupuncture treatment for tennis elbow.

(This is one of our older videos. Feel free to subscribe for free on our Youtube channel to stay up to date with exercise programs and health knowledge)


List of Other Treatment Techniques:

- Acupuncture / needle treatment

- Soft tissue work / massage

- Electrotherapy / current therapy

- Laser treatment

- Joint corrective treatment

- Muscle knot treatment / trigger point therapy

- Ultrasound

- Heat treatment


Invasive treatment of tennis elbow

- Surgery / surgery

- Pain injection


Tennis elbow / lateral epicondylitis surgery

Rare and less frequent operations are performed on the tennis elbow. This is because recent research has shown that conservative treatment usually has a better effect, and does not entail the risks that an operation does. But in extreme cases, it may still be relevant. However, you will try injection therapy before going to this step.


Pain injection against Tennis Elbow / Lateral Epicondylitis

A treatment option that can be tested before surgery, if conservative treatment is fully tested and the pain only persists, then it may be relevant to have an injection in the treatment of tennis elbow / lateral epicondylitis. Normally, cortisone injection is performed. Unfortunately, cortisone injections can lead to worsening pain in the long run, as it also increases the risk of impaired tendon health and tendon ruptures.


4B. Clinical Investigation of Tennis Elbow

The symptoms and clinical signs of tennis elbow are usually so characteristic that the caregiver suspects early. A first-time examination usually begins with a history-taking followed by a functional examination. Imaging tests are usually not necessary, but this may be indicated by the lack of effect of conservative treatment.


Imaging Diagnosis of Tennis Elbow / Lateral Epicondylitis

An MRI examination is preferred for examination at the tennis elbow. The reason why it is preferred over diagnostic ultrasound is that the latter can not see what is on the other side of the bone or in the elbow joint itself (as sound waves do not pass through bone tissue). Normally, one will manage without performing such imaging tests, as the diagnosis and symptoms are usually very clear to a clinician. However, it may be relevant if the cause of the debut was a trauma or similar.


MRI Examination: Image of tennis elbow / lateral epicondylitis

MR image of lateral epicondylitis - tennis elbow

Here we see an MRI image of tennis elbow / lateral epicondylitis. We can see clear signal changes and reactions around the lateral epicondyle.


Diagnostic ultrasound examination: Picture of Tennis Elbow / Lateral Epicondylitis

Ultrasound of tennis elbow

On this ultrasound image, one can see a thickened muscle attachment to the lateral epicondyle on the outside of the elbow.


- At Vondtklinikkene, our publicly authorized clinicians have the right to be referred for an imaging examination if this should be medically indicated.


5. Self-measures and Self-treatment for Tennis Elbow / Lateral Epicondylitis

Many of our patients ask questions about how they themselves can contribute to healing healing in tennis elbow. Here we are happy to give individual advice, but on a general basis there are two common self-measures in particular. The first involves the use of compression support for the elbow, and the other is the use of trigger point ball which one rolls in towards the musculature and tendon attachment. Others experience that reusable heat pack or application of heat conditioner has a soothing effect. The links to the tips below open in a new browser window.


Recommendation: Compression support for the elbow (The link opens in a new window)

elbow pad

Our clear first recommendation for lateral epicondylitis is the use of compression support for the elbow.

Such supports have a well-documented effect in research - and can point to a reduction in elbow pain (4). The basis for compression clothing lies in both extra stability to the area, but also increased blood circulation to the injured area. The measure is simple and easy to use. Touch the image or link here to read more about our recommended compression support, as well as see purchase options. Use the support daily and in situations where you feel that your elbow may be exposed to incorrect loading.


Ergonomic Advice against Tennis Elbow / Lateral Epicondylitis

One of the most important things about congestion injuries is that you simply and easily cut down on the activity that has irritated the muscle and tendon attachment, this can be done by making ergonomic changes in the workplace or taking a break from the painful movements. However, it is important not to stop completely, as this hurts more than good in the long run.



6. Exercise and Exercises for Tennis Elbow / Lateral Epicondylitis

We have already mentioned how eccentric training is often recommended for tennis elbow. So this is a training exercise, you can see it in the video below, where you train in the extended longitudinal direction of the tendon tissue and muscle fibers. In this part of the article, we will also take a closer look at several strength and stretching exercises that can be beneficial.


Something many people forget is the importance of good function also higher up in the arm and shoulder. Precisely for this reason, training with elastic can be an excellent training method for you with elbow pain and tennis elbow. Improved shoulder functionality will in fact only lead to more correct use of the elbow and forearm.


Strength training against Tennis elbow / Lateral Epicondylitis

Grip Training: Press a soft ball and hold for 5 seconds. Perform 2 sets of 15 reps.

Forearm pronation and supination strengthening: Hold a soup box or similar in your hand and bend your elbow 90 degrees. Slowly turn the hand so that the hand is facing upwards and slowly turn back to face down. Repeat 2 sets of 15 reps.

Resistance training for elbow flexion and extension: Hold a light exercise manual or similar with your hand facing up. Bend your elbow so that your hand is facing your shoulder. Then lower your arm until it is fully extended. Do 2 sets of 15 reps. Gradually increase your resistance as you get stronger.


Stretching of tennis elbow / lateral epicondylitis

Wrist mobilization in flexion and extension: Bend your wrist into flexion (forward bend) and extension (back bend) as far as you can get. Do 2 sets of 15 repetitions.

Wrist extension: Press the back of your hand with your other hand to get a bend in your wrist. Hold with custom pressure for 15 to 30 seconds. Then change movement and stretch by pushing the front of the hand backwards. Hold this position for 15 to 30 seconds. Keep in mind that the arm should be straight when performing these stretching exercises. Perform 3 sets.

Forearm pronation and supination: Bend the elbow on the aching arm 90 degrees while holding the elbow to the body. Turn the palm up and hold this position for 5 seconds. Then slowly lower your palm down and hold this position for 5 seconds. Do this in 2 sets of 15 repetitions in each set.


VIDEO: Eccentric Exercise against Tennis Elbow

In the video below, we show you the eccentric training exercise you use against tennis elbow / lateral epicondylitis. Remember to take into account daily form and your own medical history.


VIDEO: Strength training with elastic for the shoulders and arms

As mentioned earlier, we are preoccupied with long-term improvement. A good way to ensure better function in both shoulders and arms is strength exercises with elastic. In the video below, chiropractor Alexander Andorff shows v / Lambertseter Chiropractor Center and Physiotherapy develop a recommended exercise program. The exercises can be done 3-4 times a week if desired, but you can also go a long way with doing them twice a week.

Feel free to subscribe for free our Youtube channel if you want. Here you get a number of free exercise programs and useful health knowledge.

7. Contact Us: Our Clinics

We offer modern assessment, treatment and training for elbow problems and tendon injuries.

Feel free to contact us via one of our specialized clinics (the clinic overview opens in a new window) or on vår Facebook-side (Vondtklinikkene - Health and Exercise) if you have any questions. For appointments, we have XNUMX-hour online booking at the various clinics so that you can find the consultation time that suits you best. You can also call us within the clinic's opening hours. We have interdisciplinary departments in Oslo (included Lambert seats) and Viken (Raw wood og Eidsvoll). Our skilled therapists look forward to hearing from you.


Sources and Research:

  1. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilization with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomized trial. BMJ. 2006 Nov 4; 333 (7575): 939. Epub 2006 Sep 29.
  2. 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: a randomized controlled trial. Lancet. 2002 Feb 23; 359 (9307): 657-62.
  3. Zheng et al, 2020. Effectiveness of extracorporeal shock wave therapy in patients with tennis elbow: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020 Jul 24; 99 (30): e21189. [Meta-analysis]
  4. Sadeghi-Demneh et al, 2013. The Immediate Effects of Orthoses on Pain in People with Lateral Epicondylalgia. Pain Res Treat. 2013; 2013: 353597.


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FAQ: Frequently asked questions regarding tennis elbow / lateral epicondylitis


Should I get treatment for tennis elbow / lateral epicondylitis?

Yes, in most cases you should. If you do not take any action, the condition will most likely only get worse. Seek help for the problem today, so that you do not have to carry it with you for the rest of your life. If you can not afford treatment, then it is at least okay to start with relief measures (elbow support) and adapted exercises (see earlier in the article).


A first-time examination may not cost the whole world. Here you will be able to get specific information about the condition, as well as recommended measures further. Be open with your clinician if you have poor financial advice, and ask for a long-term exercise plan, for example.


Should I ice down tennis elbow / lateral epicondylitis?

Yes, in situations where it is clear that the attachments to the lateral epicondyle are irritated and perhaps even swollen, then icing should be used according to the usual icing protocol. Be careful not to damage the tissue with too much cold. We usually only recommend cold treatment in case of acute overloads or in case of clear heat development and swelling.


3. What are the best painkillers or muscle relaxants for tennis elbow / lateral epicondylitis?

If you are going to take over-the-counter painkillers then they should be anti-inflammatory, e.g. ibuprofen or voltaren. It is not recommended to go on painkillers without addressing the actual cause of the problem, as this will most likely only mask the pain temporarily without there being anything particularly better towards the elbow attachment. The doctor may prescribe muscle relaxants as needed; then most likely tramadol or brexidol. Always consult a doctor or pharmacist before taking painkillers.


Craftsman, 4 years. It hurts in the elbow when I lift something. What could be the cause?

The cause is most likely tennis elbow (lateral epicondylitis) or golf elbow (medial epicondylitis) which can both occur due to repetitive strain (eg carpentry). Tears can occur in the muscle attachment to the outside or inside of the elbow - both of which can cause pain when using the hand and wrist. This can also lead to reduced grip strength.


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