Physical Medicine and Rehabilitation for Lateral Epicondylitis

Updated: Sep 16, 2019
  • Author: John W Hawkins, DO; Chief Editor: Stephen Kishner, MD, MHA  more...
  • Print

Practice Essentials

Lateral epicondylitis, or tennis elbow, is the most common overuse injury of the elbow. It has an annual incidence of 3% in the general population [1]  and is responsible for 10 million visits to physicians every year in the United States. [2] Lateral epicondylitis is usually precipitated by repetitive contraction of the wrist extensors and is characterized by aching pain that is worsened with activity. It is most commonly attributed to pathology of the extensor carpi radialis brevis tendon. [3]

Early conservative management is the key to symptom resolution, which eventually allows return to vocational and avocational activities without restriction. Resistance exercise is a widely accepted nonoperative treatment option for lateral epicondylitis, but patients with symptoms that persist beyond 6 months may have a prolonged course that ultimately requires surgical intervention. [4, 5, 6, 7, 8, 9]

Signs and symptoms of lateral epicondylitis

The patient usually describes a gradual onset of lateral elbow pain, which is characterized as follows:

  • The aching pain generally increases with activity; the patient may describe symptoms occurring during simple activities of daily living (ADL), such as picking up a cup of coffee or a gallon of milk

  • Pain may be present at night

  • Symptoms are typically unilateral

Most commonly, a physical examination reveals localized tenderness to palpation just distal and anterior to the lateral epicondyle.

Workup of lateral epicondylitis

Imaging studies usually are not necessary in the workup of lateral epicondylitis, but tendinopathies can be visualized with magnetic resonance imaging (MRI) and with diagnostic ultrasonography. [10, 11]

Electrodiagnostic studies may help to determine whether other causes of lateral elbow pain, such as cervical radiculopathy or posterior interosseous nerve palsy, are present.

Histologic findings in lateral epicondylitis can include collagen disorientation, collagen disorganization, fiber separation by increased mucinoid substance, an increased prominence of cells and vascular spaces (with or without neovascularization), and focal necrosis or calcification. Superimposed evidence of a tear, including fibroblastic proliferation, hemorrhage, and organizing granulation tissue, may be revealed.


Anti-inflammatory modalities include ice, ultrasonography, and iontophoresis. Iontophoresis with topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to help reduce pain.

A wrist splint used during activities can be helpful because it places the extensor muscles in a position of rest and prevents maximal muscle contraction. Counterforce bracing (tennis elbow strap) is another orthotic alternative that can be used to unload the area of muscle origin at the elbow. A splint or brace should not be used in isolation but should be employed only as an adjunct to modalities and exercise/stretching. [12, 13]

In the subacute stage, emphasis is placed on the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group can be achieved through a graded program.

Resistance exercise is a widely accepted nonoperative treatment option for lateral epicondylitis.

If a patient does not seem to be responding to conservative care, a steroid injection about the lateral epicondyle using local anesthetic can be performed. [10, 14, 15, 16, 17, 18, 19] However, the role of corticosteroid injection in tendinopathy remains controversial.

For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis may be considered. [20, 21]

Related Medscape Drugs & Diseases topics:

Elbow and Forearm Overuse Injuries

Lateral Epicondylitis Surgery [Orthopedic Surgery]

Lateral Epicondylitis [Sports Medicine]

Overuse Injury




The etiology of chronic tendinopathy has been debated in the literature. Tendons are hypovascular, with some suggesting that they receive one third the blood flow of muscles. [22] Thus, once tendons are injured, healing times can be prolonged.

Most clinicians agree that lateral epicondylitis is a result of inflammation, or enthesitis, at the muscular origin of the extensor carpi radialis brevis (ECRB). This inflammation leads to microtears of the tendon, with subsequent fibrosis and, ultimately, tissue failure. Less commonly, the attachments of the extensor carpi radialis longus (ECRL), extensor digitorum communis (EDC), or extensor carpi ulnaris (ECU) are involved. [23, 24, 25]





Lateral epicondylitis is seen in up to 50% of tennis players. [26]


The condition affects men and women with equal frequency.


Lateral epicondylitis most often occurs between the third and fifth decades of life.