Lateral epicondylitis results from inflammation and microtearing of fibers in the extensor tendons of the forearm. Symptoms include pain at the lateral epicondyle of the elbow, which can radiate into the forearm. Diagnosis is by examination and provocative testing. Treatment is with rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy.
Theories about the pathophysiology of lateral epicondylitis include nonathletic and occupational activities that require repetitive and forceful forearm supination and pronation, as well as overuse or weakness (or both) of the extensor carpi radialis brevis and longus muscles of the forearm, which originate from the lateral epicondyle of the elbow. For example, during a backhand return in racket sports such as tennis, the elbow and wrist are extended, and the extensor tendons, particularly the extensor carpi radialis brevis, can be damaged when they roll over the lateral epicondyle and radial head. Contributing factors include weak shoulder and wrist muscles, a racket strung too tightly, an undersized grip, hitting heavy wet balls, and hitting off-center on the racket.
In resistance training, injuries often are caused by overuse (too much activity or performing the same movements too often) or by muscle imbalance between the forearm extensors and flexors. Nonathletic activities that can cause or contribute to lateral epicondylitis include those involving repetitive grasping and twisting the elbow (eg, turning a screwdriver, perhaps typing).
With continued forearm supination and pronation, subperiosteal hemorrhage; calcification; spur formation on the lateral epicondyle; and, most importantly; tendon degeneration can occur.
Symptoms and Signs of Lateral Epicondylitis
Pain initially occurs in the extensor tendons of the forearm and around the lateral elbow when the wrist is extended against resistance (eg, as in using a manual screwdriver or hitting a backhand shot with a racket). In resistance training, lateral epicondylitis is most noticeable during various rowing and chin-up exercises for the back muscles, particularly when the hands are pronated. Pain can extend from the lateral epicondyle to the mid forearm.
Diagnosis of Lateral Epicondylitis
Primarily history and physical examination
Provocative testing
Pain along the common extensor tendon when the third digit is extended against resistance and the elbow is held straight is diagnostic. Alternatively, the diagnosis is confirmed if the same pain occurs during the following maneuver: The patient sits on a chair with the forearm on the examination table and the elbow held flexed (bent) and the hand held palm downward; the examiner places a hand firmly on top of that of the patient, who tries to raise the hand by extending the wrist (see also How to Examine the Elbow).
Treatment of Lateral Epicondylitis
Rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), extensor muscle stretches
Modification of activity
Tennis elbow (counterforce) brace
Later, resistive exercises
Initially, rest, ice, NSAIDs, and stretching of the extensor muscles are used (1). Occasionally a glucocorticoid injection into the painful area around the tendon may be administered for short-term pain relief. When the pain subsides, gentle resistive exercises of the extensor and flexor muscles in the forearm are performed followed by eccentric and concentric resistive exercises. Activity that hurts when the wrist is extended or supinated should be avoided. Use of a tennis elbow (counter force) brace around the forearm is often advised. Adjusting the fit and type of racket used can also help prevent further injury.
Although surgery is not usually needed, surgical techniques to treat lateral epicondylitis involve removing scar and degenerative tissue from the involved extensor tendons at the elbow. Surgery is usually considered only after at least 1 year of unsuccessful conservative treatment; patients should be advised that surgery may not provide satisfactory relief of symptoms.
1. Flatten putty on table.
2. Flex (curl) fingers and place on putty.
3. Extend and abduct (spread) fingers.
4. Perform
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Grasp and gently squeeze towel roll with both hands.
2. Twist towel in alternating directions.
3. Perform 3 sets of
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Place forearm on table with the hand palm down, off the edge of the table.
2. Move wrist up into extension.
3. Slowl
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Place forearm on table with the hand palm up, off the edge of the table.
2. Curl wrist up into flexion.
3. Slowly lo
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Position involved hand palm up.
2. Grasp fingers on involved hand with the other hand.
3. Keep elbow straight on inv
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Begin with the elbow straight.
2. With the uninvolved hand, grasp thumb side of hand and bend wrist downward into wr
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Flatten putty on table.
2. Flex (curl) fingers and place on putty.
3. Extend and abduct (spread) fingers.
4. Perform 3 sets of 10 repetitions, 1 time a day.
5. Special Instructions
a. Start with least resistance putty (ie, yellow).
b. Can also perform exercise using rubber band for resistance around fingers.
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Grasp and gently squeeze towel roll with both hands.
2. Twist towel in alternating directions.
3. Perform 3 sets of 10 repetitions, 1 time a day.
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Place forearm on table with the hand palm down, off the edge of the table.
2. Move wrist up into extension.
3. Slowly flex wrist down to starting position.
4. Perform 3 sets of 10 repetitions, 1 time a day.
5. Special Instructions
a. Focus on lowering (eccentric) phase with a count of 4 to flex wrist down to starting position and a count of 2 up for wrist extension.
b. Start with least resistance (ie, a soup can) or simply against gravity.
c. Can also perform exercise with band resistance.
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Place forearm on table with the hand palm up, off the edge of the table.
2. Curl wrist up into flexion.
3. Slowly lower and extend wrist to starting position.
4. Perform 3 sets of 10 repetitions, 1 time a day.
5. Special Instructions
a. Focus on lowering (eccentric) phase with a count of 4 to extend wrist down to starting position and a count of 2 up for wrist flexion.
b. Start with light resistance (ie, a soup can) or simply against gravity.
c. Can also perform exercise with band resistance.
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Position involved hand palm up.
2. Grasp fingers on involved hand with the other hand.
3. Keep elbow straight on involved arm.
4. Pull hand and fingers gently into extension.
5. Hold exercise for 30 seconds.
6. Perform 1 set of 4 repetitions, 3 times a day.
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
1. Begin with the elbow straight.
2. With the uninvolved hand, grasp thumb side of hand and bend wrist downward into wrist flexion.
3. To increase the stretch, bend wrist toward small finger and pull, curling fingers into more flexion.
4. Hold each exercise for 30 seconds.
5. Perform 1 set of 4 repetitions, 3 times a day.
Courtesy of Tomah Memorial Hospital, Department of Physical Therapy, Tomah, WI; Elizabeth C.K. Bender, MSPT, ATC, CSCS; and Whitney Gnewikow, DPT, ATC.
Treatment reference
1. Wolf JM. Lateral Epicondylitis. N Engl J Med. 2023;388(25):2371-2377. doi:10.1056/NEJMcp2216734
Key Points
Lateral epicondylitis can result from repetitive and forceful forearm supination and pronation, and/or extension of the forearm and wrist; such motions involve the extensor carpi radialis brevis and longus muscles of the forearm, which originate from the lateral epicondyle of the elbow.
Typical activities that involve such motions include a backhand return in racket sports (eg, tennis) and using a screwdriver.
Pain along the common extensor tendon when the long finger is extended against resistance and the elbow is held straight is diagnostic.
Treat initially with rest, ice, NSAIDs, and stretching of the extensor muscles, followed by exercises to strengthen wrist extensors and flexors.
Occasionally glucocorticoid injections and rarely surgery may help.
