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Assessment of Tennis Elbow

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Jess Bell, Tony Lowe, Tarina van der Stockt, Nupur Smit Shah, Ewa Jaraczewska, Rachael Lowe, Simisola Ajeyalemi, Stacy Schiurring, Lucinda hampton, Olajumoke Ogunleye and Robin Tacchetti  

Introduction and Epidemiology

Tennis Elbow is described as pain and sensitivity over the lateral epicondyle of the humerus. [1][2] Tennis Elbow is the most common cause of lateral elbow pain [1] and occurs most often in the patient's dominant arm. It affects 1% to 10% of the population. Onset typically occurs between the ages of 30 and 50, with no reported sex difference. [3]

Terminology Update: "Lateral elbow tendinopathy" (LET) is now the preferred clinical term for this condition. "Epicondylitis" is inaccurate as histology consistently shows degenerative rather than inflammatory changes. "Epicondylalgia" describes a symptom only. LET correctly identifies the structure (common extensor tendon), the region, and the pathological process. "Tennis elbow" remains useful patient-facing language.[4][5]

Smoking, obesity, manual work requiring repetitive loading of wrist extensors and being a tennis player are considered to be risk factors of Tennis Elbow. [6]

Tennis Elbow has great effects on quality of life as well as participation in work, sports and leisure activities. Work absenteeism is documented in 30% of Tennis Elbow patients. [7]

Despite the fact that tennis players represent 5-10% of the represented cases, the term Tennis Elbow is more widely recognised among physiotherapists, general practitioners and patients than LET.[8]

Although up to 90% of presentations are self-limiting, not all experience full recovery and pain and discomfort can persist for up to a year. Recurrence is also common in Tennis Elbow, about 72% after receiving a corticosteroid injection compared to 9% with a ''wait and see'' approach[9], and around 5% need surgery. [6]

Pathophysiology

LET, characterised by pain and dysfunction at the lateral epicondyle of the humerus, is caused by a complex interplay of factors, including mechanical overuse and psychosocial influences like stress and anxiety.[10] [11] [12][13] A multifactorial model has been proposed by researchers to contribute to the related development of pain and disability with psychological factors, central sensitisation and/or other CNS-mediated factors potentially playing roles in the onset and prognosis of the condition. [6]

Coombes et al. [14] proposed a pathophysiological integrative model explaining the development of Tennis Elbow. The model hypothesises an integration of local tendon pathology, changes in the pain system, and impairment in the motor system as the factors behind Tennis Elbow. This could impact on the clinical decisions and research field to understand the nature of the condition and facilitate patients' sub-grouping.

From a histological point of view, increased cellularity, an accumulation of ground substance, collagen disorganisation, and neurovascular ingrowth are similar to those observed in any other tendinopathy. In the case of Tennis Elbow this was observed in the deep and anterior fibers of the extensor carpi radialis brevis (ECRB). In severe presentations, the ECRB is often merged with the lateral collateral ligament (LCL), which fuses with the annular ligament of the proximal radioulnar joint. These structural changes could be the result of overuse, underuse or a combination of different forces across the tendon insertion. Both very high strain and low strain levels predispose the tendon to structural changes. [14]

The presence of neurochemical pain mediators is evident and is believed to be one of the contributing factors to the reduced pain threshold in Tennis Elbow[14].

Muscle weakness is also found in Tennis Elbow. Pain free gripping was reduced by about 60% compared to non affected side[14], another study found bilateral weakness[11][15] and another reported weakness in the whole upper limb except for the metacarpophalangeal joint muscles. [16] The last finding suggests Tennis Elbow patients may maintain or increase strength of the finger extensors to compensate for weakness in the wrist extensors. [14] Tennis players with a Tennis Elbow had significantly less ECRB activities during the early acceleration phase, while greater at ball impact compared with uninjured players. ECRB also produced less activity in isometric wrist extension and gripping tasks which was reversed with the relief of symptoms suggesting a link between neuromuscular activity and symptoms. [17] Motor impairments, particularly reduced ECRB activity during isometric wrist extension and gripping tasks, have been shown to partially reverse with symptom resolution, suggesting a link between neuromuscular activity and pain rather than fixed structural deficit. However, the extent and consistency of this reversibility across all sensorimotor deficits associated with LET remains incompletely understood.

Tennis Elbow and Central Sensitisation

"Central sensitisation is the mechanism of nociplastic pain and leads to an overemphasized response to a painful stimulus (hyperalgesia) or pain to stimuli that do not otherwise cause pain (allodynia)."[18]

Mechanical hyperalgesia and cold hyperalgesia are evident in Tennis Elbow. [19] Clinical ice pain test, a simple test that allows clinicians to examine pain sensitivity. Pain intensity of more than 5/10, after 10 seconds of ice application indicates 90% likelihood of cold hyperalgesia. [20]

Central sensitisation (CS) is present in a subgroup of patients with LET and can significantly influence prognosis and treatment response.[20] CS should be suspected when the subjective history reveals features suggesting altered pain processing beyond local tendon pathology, including widespread or bilateral pain, pain disproportionate to the activity, hypersensitivity to stimuli such as touch, noise, or temperature at sites remote from the elbow, fatigue, sleep disturbance, or concentration difficulties.[20][21] [22]

The LANSS (Leeds Assessment of Neuropathic Symptoms and Signs) has been recommended for use in LET where central pain mechanisms are suspected.[20] A positive result directs further clinical investigation and informs management; it does not replace comprehensive clinical reasoning. Where the LANSS is not available, the Central Sensitisation Inventory (CSI) is an alternative 25-item self-report tool that has undergone more recent psychometric evaluation and is increasingly used in clinical and research settings.[22]

Examination

Pain provoking tests are the most utilised method of diagnosing Tennis Elbow. This could be through palpating the lateral epicondyle, resisted wrist extension, or resisted middle finger extension (Maudsley's test);[23] and having the patient grip an object. [6] Mill's Test and Cozen's test may also be included in the assessment, [6][24] however the diagnostic validity data for these tests is limit and a thorough patient history better contributes to a diagnosis than any single special test.[25]

ROM of elbow, wrist and forearm should also be examined along with the accessory motion of the radioulnar, radiohumeral, and humeroulnar joints to detect any underlying stiffness or restriction. During examination, signs of elbow instability should be noted, such as clicking, loss of control and difficulty with pushing up with the forearm supinated[6].

The posterolateral rotary drawer test can be used if instability was suspected which may need to be further examined by imaging[6].

In the presence of arm pain or neck pain, the cervical and thoracic spines and the radial nerve should all be examined[6].

Also, examination of posture and motor control should be considered to understand the kinematic influence and tackle any abnormalities in the rehabilitation[6].

Outcome Measures

Tennis elbow outcome measures can be patient-reported or performance-based.

The pain-free grip test is a reliable and sensitive performance-based outcome measure for monitoring recovery in LET.[26] It is important to distinguish between maximum grip strength and pain-free grip strength: maximum grip strength is not consistently impaired in LET and asking a patient to grip to their maximum risks exacerbating symptoms and may outlast the consultation if irritability is high. Pain-free grip strength (ie. the maximum force a patient can generate before the onset of pain) is the more clinically meaningful and consistently reduced measure in LET, and is recommended as the preferred performance-based outcome.[4]

Patient Rated Tennis Elbow Evaluation (PRTEE) is a condition-specific, patient-reported outcome measure recommended for assessing pain and disability in patients with tennis elbow. It is part of a core-outcome set for lateral elbow tendinopathy. [26][27][28]

The Patient-Specific Functional Scale (PSFS) is another patient-reported, validated and reliable measure that could measure disability in functional activities in general. [6] Patients are asked to rate (on an 11-point scale) the current level of difficulty associated with each activity. After the intervention, patients are asked again to rate the activities previously identified.

[29]

Differential Diagnosis

Diagnosing Tennis Elbow may be challenging for clinicians because it shares similar clinical presentations with other pathologies such as non specific arm pain, arthritis, radial tunnel syndrome and posterior interosseous nerve entrapment. Distinguishing Tennis Elbow from other conditions is crucial to prescribe the most appropriate treatment options or refer the patient to a relevant healthcare specialist[6].

Refer to the table in this research paper to learn about the key features of different upper limb conditions that should help in differential diagnosis.

Imaging

A literature review summarised the following: [6]

  • MRI is sensitive but not specific
  • A recent study by Jeon and colleagues found that when MRI is combined with clinical assessment, it can help to facilitate management planning for tennis elbow[30]
  • Ultrasonography detected tendopathic changes on 90% affected and 50% unaffected tendons. It also detects tendon tears, calcification and bony irregularity. However, in 2020, Krogh and colleagues found that outcomes such as pain, disability, Patient-Rated Tennis Elbow Evaluation score, and disease duration did not correlate with ultrasound techniques, such as tendon thickness, color Doppler activity, and bone spurs[31]
  • Musculoskeletal ultrasound (MSKUS) is a valuable diagnostic tool for lateral elbow pain, offering real-time, high-resolution imaging of soft tissues like tendons, ligaments, and nerves. It is cost-effective, accessible, and radiation-free, making it ideal for conditions such as lateral epicondylitis. MSKUS also guides interventions like corticosteroid and platelet-rich plasma injections, aiding in accurate diagnosis and rehabilitation.[32]
  • Negative Ultrasound, specifically the absence of both tendon neovascularity and grey-scale changes, can help rule out LET, but does not rule out all sources of lateral elbow pain.[33]
  • If clicking or locking are present, MRI, CT or magnetic resonance arthrography can be used to detect other pathologies such as loose bodies articular cartilage damage, ligament injury, or elbow synovial fold (plica) syndrome
  • Tendon neovascularisation in LE has been detected with Doppler ultrasound and correlated with degenerative tissue on biopsy. The absence of both tendon neovascularity and grey-scale changes was shown to rule out Lateral Tennis Elbow as a diagnosis and should prompt further investigation. [34]Neovascualrity wasn't associated with pain severity or function.

Resources

Clinical Resources:

References

  1. ↑ 1.0 1.1 Keijsers R, de Vos RJ, Kuijer PPF, van den Bekerom MP, van der Woude HJ, Eygendaal D. Tennis elbow. Shoulder Elbow. 2019;11(5):384-92.
  2. ↑ Cutts S, Gangoo S, Modi N, Pasapula C. Tennis elbow: A clinical review article. Journal of orthopaedics. 2020 Jan 1;17:203-7.
  3. ↑ Yanai K, Tajika T, Arisawa S, Hatori Y, Honda A, Hasegawa S, Nakajima I, Goto W, Chikuda H. Prevalence and factors associated with lateral epicondylitis among hospital healthcare workers. JSES Int. 2024 Feb 8;8(3):582-587.
  4. ↑ 4.0 4.1 Lucado AM, Day JM, Vincent JI, MacDermid JC, Fedorczyk J, Grewal R, Martin RL, Dewitt J, Paulseth S, Dauber JA, Szekeres M. Lateral elbow pain and muscle function impairments: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of hand and upper extremity physical therapy and the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of orthopaedic & sports physical therapy. 2022 Dec;52(12):CPG1-11.
  5. ↑ KNEW WW. Physical Therapy for People with Lateral Elbow Tendinopathy. J Orthop Sports Phys Ther. 2023 Jan;53(1):5-6.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: one size does not fit all. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):938-49.
  7. ↑ Chesterton LS, Mallen CD, Hay EM. Management of tennis elbow. Open access journal of sports medicine. 2011;2:53.
  8. ↑ Blanchette MA, Normand MC. Impairment assessment of lateral epicondylitis through electromyography and dynamometry. The Journal of the Canadian Chiropractic Association. 2011 Jun;55(2):96.
  9. ↑ Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bmj. 2006 Nov 2;333(7575):939.
  10. ↑ Tedeschi R, Platano D, Melotto G, Danilo D. Effectiveness of neurodynamic treatment in managing lateral epicondylitis: a systematic review. Manuelle Medizin. 2024 Nov;62(4):276-83.
  11. ↑ 11.0 11.1 Alizadehkhaiyat O, Fisher AC, Kemp GJ, Frostick SP. Pain, functional disability, and psychologic status in tennis elbow. The Clinical journal of pain. 2007 Jul 1;23(6):482-9.
  12. ↑ Garnevall B, Rabey M, Edman G. Psychosocial and personality factors and physical measures in lateral epicondylalgia reveal two groups of “tennis elbow” patients, requiring different management. Scandinavian journal of pain. 2013 Jul 1;4(3):155-62.
  13. ↑ Coombes BK, Connelly L, Bisset L, Vicenzino B. Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial. Br J Sports Med. 2016 Nov 1;50(22):1400-5.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. British journal of sports medicine. 2009 Apr 1;43(4):252-8.
  15. ↑ Bisset LM, Russell T, Bradley S, Ha B, Vicenzino BT. Bilateral sensorimotor abnormalities in unilateral lateral epicondylalgia. Archives of physical medicine and rehabilitation. 2006 Apr 1;87(4):490-5.
  16. ↑ Ljung BO, Lieber RL, Friden J. Wrist extensor muscle pathology in lateral epicondylitis. Journal of Hand Surgery. 1999 Apr;24(2):177-83.
  17. ↑ Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. British journal of sports medicine. 2009 Apr 1;43(4):252-8.
  18. ↑ Tomašević-Todorović S, Spasojević T. Central Sensitization in Patients With Chronic Musculoskeletal Pain. Acta Clin Croat. 2023 Nov;62(Suppl4):102-106.
  19. ↑ Fernández-Carnero J, Fernández-de-las-Peñas C, Sterling M, Souvlis T, Arendt-Nielsen L, Vicenzino B. Exploration of the extent of somato-sensory impairment in patients with unilateral lateral epicondylalgia. J Pain. 2009 Nov;10(11):1179-85.
  20. ↑ 20.0 20.1 20.2 20.3 Nijs J, Van Houdenhove B, Oostendorp RA. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy. 2010 Apr 1;15(2):135-41.
  21. ↑ Nijs J, Lahousse A, Kapreli E, Bilika P, Saraçoğlu İ, Malfliet A, Coppieters I, De Baets L, Leysen L, Roose E, Clark J. Nociplastic pain criteria or recognition of central sensitization? Pain phenotyping in the past, present and future. Journal of clinical medicine. 2021 Jul 21;10(15):3203.
  22. ↑ 22.0 22.1 Keating C, Puentedura E, Lucado A, Cleland J. Exploring the Relationship Between Central Sensitization, Pain Characteristics, and Function in a Cross-Sectional Study of Individuals With Lateral Elbow Tendinopathy. The Clinical Journal of Pain. 2026 Jan 1;42(1):e1335.
  23. ↑ Zwerus EL, Keijsers R, Colaris JW, The B, van den Bekerom MP, Eygendaal D. Clinical diagnosis of lateral sided elbow pain: Predictors for recognizing a diagnosis other than tennis elbow. Journal of Shoulder and Elbow Surgery. 2025 Nov 3.
  24. ↑ Fleming J, Muller C, Lambert K. Lateral epicondylitis: A common cause of elbow pain in primary care. Osteopathic Family Physician. 2021;13(1):34-8.
  25. ↑ Hung CC, Chen HS, Chang CH, Wang MW, Hung KL, Wang HK. Evaluation and Surveillance of Lateral Elbow Tendinopathy in Manual Workers: Identifying Elbows at Risk. Journal of Medical Ultrasound. 2025 Jan 1;33(1):47-53.
  26. ↑ 26.0 26.1 Sveinall H, Brox JI, Engebretsen KB, Hoksrud AF, Røe C, Johnsen MB. Measurement properties of core outcomes in patients with tennis elbow. Shoulder Elbow. 2025 May 29:17585732251344264.
  27. ↑ Albishi W, Alsanawi H, Alsharidah M, Alhuqbani M, Aldosari Z, Aldosari O, Elmaraghy A. Systematic review of measurement properties of patient-reported outcome measures in patients with elbow-related orthopedic conditions. JSES Reviews, Reports, and Techniques. 2025 May 6.
  28. ↑ Young I, Dunning J, Mourad F, Escaloni J, Bliton P, Fernández-de-Las-Peñas C. Clinimetric analysis of the numeric pain rating scale, patient-rated tennis elbow evaluation, and tennis elbow function scale in patients with lateral elbow tendinopathy. Physiotherapy Theory and Practice. 2025 Aug 3;41(8):1712-20.
  29. ↑ Measuring Grip Strength. Available from: https://www.youtube.com/watch?v=phAC-VIWr5Q
  30. ↑ Jeon JY, Lee MH, Jeon IH, Chung HW, Lee SH, Shin MJ. Lateral epicondylitis: Associations of MR imaging and clinical assessments with treatment options in patients receiving conservative and arthroscopic managements. Eur Radiol. 2018;28(3):972-81.
  31. ↑ Krogh TP, Fredberg U, Ammitzbøll C, Ellingsen T. Clinical Value of Ultrasonographic Assessment in Lateral Epicondylitis Versus Asymptomatic Healthy Controls. Am J Sports Med. 2020;48(8):1873-83.
  32. ↑ Manske RC, Wolfe C, Page P, Voight M. Diagnostic Musculoskeletal Ultrasound for the Evaluation of the Lateral Elbow: Implications for Rehabilitation Providers. International Journal of Sports Physical Therapy. 2025 Jan 1;20(1):137-43.
  33. ↑ Manske RC, Wolfe C, Page P, Voight M. Diagnostic Musculoskeletal Ultrasound for the Evaluation of the Lateral Elbow: Implications for Rehabilitation Providers. International Journal of Sports Physical Therapy. 2025 Jan 1;20(1).
  34. ↑ du Toit C, Stieler M, Saunders R, Bisset L, Vicenzino B. Diagnostic accuracy of power Doppler ultrasound in patients with chronic tennis elbow. Br J Sports Med. 2008 Nov;42(11):872-6.
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