Taking the Mystery Out of Lateral Elbow Pain

You have a new patient who comes into the clinic with a three-month history of lateral elbow pain. Do you get excited… or do you secretly groan?

Knowing the approach to take, the right tests to assess and identify the cause of the pain, and an arsenal of treatment ideas will help you address elbow pain with confidence.

Taking a Systematic Approach

Using a manual therapy approach to evaluate and treat patients with tennis elbow can significantly improve your efficiency and increase your clinical confidence in determining the pain generator. Manual therapy is not necessarily what we do with our hands during a treatment session; it’s more a method of approaching our patient’s issues—a compass, of sorts, to guide our evaluation process so we can determine the pain generator.

Dr. James Cyriax gave us, as therapists, a systematic approach to gaining the most information with the smallest number of tests. This approach guides us to first identify issues at the joint, as opposed to in the soft tissue (for example, the musculotendinous unit versus the nerve).

Finding the Potential Pain Generators

At the lateral elbow, there may be issues at the humeroradial joint (HRJ), proximal attachment of the extensor carpi radialis brevis (ECRB) or extensor digitorum communis (EDC), or radial nerve.1

How can we provoke these to identify the pain generator?

Humeroradial joint (HRJ)

Patients can present with cartilage issues at the HRJ, which can be a potential cause of lateral elbow pain. A fascinating study evaluated 31 elbows undergoing surgery for lateral epicondylosis and found that 65% of these cases had cartilage injuries on the capitulum, and a whopping 81% of cases had cartilage injuries on the radial head.2

If testing of the ECRB and testing of the extensor carpi ulnaris (ECU) both provoke lateral elbow pain (due to loading of the HRJ), the patient may likely have joint involvement.


The proximal attachment of the ECRB is most commonly involved with tennis elbow and would be most painful with resisted testing.3 This could be differentiated from an issue at the HRJ, as resisted testing to the ECU would provoke little to no pain. The EDC is the second most commonly involved muscle with tennis elbow, in which resisted testing of the index, middle, ring, and small finger would provoke symptoms.4

Radial nerve

The radial nerve travels around the lateral elbow and pierces the supinator muscle at an area called the radial tunnel, approximately 5 cm distal to the lateral epicondyle. It is estimated that radial tunnel syndrome is present in 5% of patients with tennis elbow.5

For patients presenting with radial nerve issues, use of a tennis elbow strap can have adverse effects and should be avoided. Pain in the area of the radial tunnel with resisted middle finger extension and pain with resisted forearm supination can identify radial nerve involvement.6

Treatment Ideas

Using Cyriax’s approach, if it is determined in the examination that there is a problem with the joint, the joint should be treated first. Therefore, performing joint mobilization techniques to improve the HRJ capsular mobility would be beneficial.

When treating issues with the ECRB or EDC, soft tissue techniques such as transverse friction massage, instrument-assisted soft tissue mobilization, or dry needling can be beneficial in the initial stages, followed by initiation of strengthening once the patient’s pain begins to subside. For the radial nerve, addressing soft tissue restrictions and nerve gliding would be beneficial.

Ergonomic considerations such as performing activities in supination (versus pronation) and addressing scapular stabilizer strength and control can all play a critical role in addressing your patient’s impairments.

Understanding how to use a systematic approach to determine if the pain is arising from the joint, musculotendinous unit, or nerve in patients with tennis elbow can help take the “mystery” out of these patients and make treating them more fun!

For more information on using a systematic approach for a variety of upper extremity conditions, please see my MedBridge courses:

  1. Duparc, F., Putz, R., Michot, C., Muller, J. M., & Fréger, P. (2002). The synovial fold of the humeroradial joint: anatomical and histological features, and clinical relevance in lateral epicondylalgia of the elbow. Surgical and Radiological Anatomy, 24(5): 302-7.
  2. Sasaki, K., Onda, K., Ohki, G., Sonoda, T., Yamashita, T., & Wada, T. (2012). Radiocapitellar cartilage injuries associated with tennis elbow syndrome. The Journal of Hand Surgery, 37(4): 748-54.
  3. Walz, D. M., Newman, J. S., Konin, G. P., & Ross, G. (2010). Epicondylitis: pathogenesis, imaging, and treatment. Radiographics, 30(1): 167-84.
  4. Nirschl, R.P. (1995). Tennis elbow tendinosis: pathoanatomy, nonsurgical and surgical management. In S. L. Gordon, S. J. Blair, & L. J. Fine (Eds), Repetitive Motion Disorders of the Upper Extremity (pp. 467 – 478). Rosemont, IL: American Academy of Orthopaedic Surgeons.
  5. Lee, J. T., Azari, K., & Jones, N. F. (2008). Long term results of radial tunnel release—the effect of co-existing tennis elbow, multiple compression symptoms and workers’ compensation. Journal of Plastic, Reconstructive, and Aesthetic Surgery, 61(9): 1095-9.
  6. Moradi, A., Ebrahimzadeh, M. H., & Jupiter, J. B. (2015). Radial tunnel syndrome, diagnostic and treatment dilemma. The Archives of Bone and Joint Surgery, 3(3): 156-62.