• susanherdman

TENNIS ELBOW: A Look Inside

Updated: May 19

Believe it or not Tennis Elbow is not just caused by walloping a tennis ball around a court. Nor can you blame this outer elbow pain on two little mischievous gremlins playing tennis on your elbow.

Tennis elbow is essentially an OVERUSE injury (or in the “physio world” a “repetitive strain injury”) of the forearm muscles that support the back of the wrist and straighten the fingers. Almost all of those muscles attach onto one spot (yes, you guessed it!) – the outer bump (or lateral epicondyle) of your elbow.


Therefore, ANYONE who does a lot of repetitive gripping, holding, carrying, or wielding of tools (from a carpenter to a knight in shining armor) can get tennis elbow.


But the tissues can also be overworked if you hold a certain position for hours (remember the dreaded “wall sit” from PE class?). The elbow’s equivalent of this “wall sit” is holding your wrists, palm down, for hours…just like when using a computer or laptop. Which is why this condition is very common among those who spend hours working on the computer.


How do I know if I have it? / Common Symptoms:

  • Pain and tenderness over the boney bump on the outside of your elbow

  • Pain and/or difficulty with gripping or holding items (from using power tools or hammers, to even light items such as your morning cup of coffee!)

  • Pain is worse by the end of your day

  • Sometimes wrist & forearm feel “stiff”

  • No “nervey” symptoms (ie. tingling, numbness, or pins & needles) into hand, wrist, or forearm

  • If you do have “nervey” symptoms and they aren’t going away, there may be something else going on = get thyself to a physiotherapist and/or doctor!

So what exactly IS Tennis Elbow?

It goes by a lot of names: Lateral Epicondyl-itis, Lateral Epicondyl-algia, and Lateral Epicondyl-osis. Broken down into English, this means outer (lateral) elbow (epicondyle) – and then either: inflammation (-itis), pain (-algia), or degeneration/bad condition of (-osis).


Inflammation (red/hot/swollen), if any, usually only occurs up to the first week after injury. Therefore, it’s becoming more common in the medical field to call this condition the more encompassing “Lateral Elbow Tendinopathy” (LET) which means degenerative condition of the outer elbow tendons.


Under the microscope / Do I need an MRI or Ultrasound?

Normal healthy tendons (which connect muscles to bone – in this case at the elbow), are made of strong, stiff, & well organized bundles of collagen – similar to uncooked spaghetti in a box.

If the tendon undergoes too much force/stress for too long with not enough recovery time (ie. OVERUSE injury), this collagen starts to soften and become disorganized – like a bowl of cooked spaghetti. This allows for fat, nerve endings, and blood vessels to weave themselves into the tendon – which makes the tendon itself thicker and generally weaker.


HOWEVER, several studies looking at the ultrasounds of pain-free vs. painful elbows with LET – have found that anywhere from 15-55% of PAIN-FREE elbows can ALSO have this THICKENING!! So just because the thickened tendon is there, doesn’t mean that that is the root cause of your pain.


Long story short, ultrasounds or MRI’s can help rule out other causes, but shouldn’t be used to “rule in” or diagnose LET (because even non-painful elbows can have this thickness).




So WHY are there pain-free yet thick tendons?

Because pain is complicated…and there are a lot of other factors that affect tendon health – some of which include:

With all these factors above in play IN ADDITION to a sudden change in activity levels (ie. more force/stress and less rest/recovery time), it can be understandable why two different people, both with lateral elbow pain may not recover at the same rate.


What can I do about it? / Treatment:

The first and most important step is load management – balancing rest & loading/stress. We want to take the “Goldilocks” approach.

  • Too much (stress/loading) too soon, overloads the tendon, further progressing the degeneration.

  • With an OVERUSE injury, at least initially, we have to UNDER-USE it – to allow recovery.

  • "No pain, no gain” does NOT apply here.

  • However, too much rest doesn’t stress the tissue enough to stimulate rebuilding

  • ie. the “use it or lose it” principle.

Finding this balance and addressing any other tendon health factors is where a physiotherapist can come in handy – helping create a personalized treatment program that addresses YOUR current “Goldilocks” level! In addition to providing you with practical strategies to help manage your daily activities while you’re resting. Over time, we want to gradually increase the load and stress on the tendon. The key word here is “gradually”. Patience is vital as it can take weeks to months to fully recover!



If you have more questions about tennis elbow/lateral elbow tendinopathy or any hand, arm, or shoulder issue, feel free to book a Telehealth appointment with me at InReach Physiotherapy!

By: Susan Herdman, Registered Physiotherapist – Specializing in Upper Extremity and Hand Telerehabilitation

Susan provides online physio (aka telephysio, virtual physio, telerehab) to patients all over British Columbia including Haida Gwaii, Fort St James, Fraser Lake, Fort St John, Fort Nelson, Dease Lake, Dawson Creek, Hudson's Hope, Mackenzie and Stewart. She also collaborates with the First Nations Health Authority to provide service. Susan lives on beautiful Vancouver Island between Nanaimo and Victoria.

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