Tennis Elbow Causes and Symptoms

Hopefully, since you landed on this page, you've read my previous article about the anatomy of tennis elbow. If you haven't I encourage you to, no pressure though. In this post I'll discuss the epidemiology of tennis elbow, it's causes, and it's symptoms. So, without further ado, here you go.
Tennis elbow 
Firstly, I want to clear something up. I mentioned in my previous that lateral epicondylitis is a misnomer and I'll explain why now. the suffix ,"-itis," typically means that there is inflammation present. However, with lateral epicondylitis, research shows that there is little if any inflammation, especially in the chronic stages3. One can also argue that referring to the pain as tennis elbow is also incorrect, given that roughly 5-10% of those presenting with symptoms are tennis players2. Now, moving on.


Unlike an injury like say, an ACL injury or a simple sprain, there is typically no clear cut mechanism of injury for tennis elbow. It is generally classified as an overuse injury or degenerative condition resulting in micro-tears of the common extensor tendon, particularly the fibres of the extensor carpi radialis brevis, which is "characterized by the increased presence of fibroblasts, vascular hyperplasia and disorganized collagen2." So, while there is not really a singular event that causes tennis elbow, there are persons who are more likely to experience tennis elbow. Below I will discuss what I will call pseudo-causes, or risk factors if you will.


Tennis elbow can occur to people of any age, but there seems to be an increased incidence when approaching and into middle-aged territory. Most literature states that the age group most at risk are those between 30-60 years old1-8.


While gender is not a predisposing factor to  having tennis elbow, it has been suggested that woman suffer the effects for a longer duration with greater severity than men6. This has been attributed to occupational factors. Waugh et al (2004) found that women are more likely to report onset of injury attributed to repetitive tasks at work as well presenting with more cervical joint signs. I'll talk a little more about cervical joint signs later in the article.

Occupation and Sport

As mentioned above, occupations that are repetitive in nature or involve forceful arm actions are a risk factor for developing tennis elbow. Chesterton, Mallen, and Hay (2011) cite that "plumbers, painters, decorators, bricklayers, gardens" and full-time keyboard users are at particular risk. This list can be extended to other occupations with similar tasks. Computer use is of particular interest - risk increase when use is above 20hrs per week and with years of use7. With regards to sports, activities with forceful wrist extension (such as a backhand in tennis) or any sport with "excessive quick, monotonous, repetitive eccentric contractions and gripping activities of the wrist6." I'll let you draw your own conclusions as to what sports that may be.

Cervical Signs

I debated included cervical signs as a cause. In a differential diagnosis, some may deem cervical signs as a different condition that mimics tennis and true tennis elbow being a lesion of the common extensor tendon. However, given that more than half of those who experience tennis elbow have cervical joint signs - 57% in the study by Waugh et al - I feel that it is an overwhelmingly clear a cause of tennis elbow pain. Most commonly, pain is referred from the C5-6 nerve root, which forms part of the posterior interosseous nerve. degenerative changes, poor posture, or acute injury can compress on the nerve root, which will cause a radiculopathy3.

Radian Nerve Entrapment (Posterior Interosseous Nerve Syndrome)

Again, I debate include this as a cause for the same reasons as above. But I still think it's an important aspect. One of the main differences to note between PIN syndrome and tennis elbow is that there will be point tenderness about 4cm distal to the common extensor origin rather than on the origin itself. poor neurodynamics of the radian nerve through the radial tunnel can cause compression of  the PIN, which will affect it's innervations, causing weakness and pain to the wrist extensors (for more on this read up on the arcade of Forhse).


The symptoms of tennis elbow are pretty clear cut, making diagnosis fairly simple. The main complain is a decrease in function that affects daily activities5. There will also be pain over the lateral elbow, particularly with gripping tasks and wrist extension. Supination of the forearm (turning the palm up) can also cause pain because of the relation of the supinator muscle to the posterior interosseous nerve at the radial tunnel (I should update my anaomty section to encompass this. oops).

Diagnosis is made reproducing the pain with resisted wrist extension, middle finger extension, and passive wrist flexion (putting tension on the common extensor tendon). There is also reports of pain that is worse in the or when the elbow is held in a flexed position for a prolonged period of time1. There will be no swelling or redness over lateral epicondyle, which means no inflammation.

So that's about. You may find some websites out there that talk about other causes, and that's ok. There very well may be more to it than what I've written, but this is what I've found in the literature. I feel like I should talk more about the lesions and fibroblasts, etc... of the ECRB, but I think that would push  this post to uncomfortably long length. Maybe I'll dedicate a post to it someday. If you would like to know more about the condition then feel free to contact me at I'm happy to answer any and all questions, or at the very least point you in the right direction.

next up: Tennis Elbow Treatment

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1. Chesterton, L. S., Mallen, C. D., and Hay, E. M. (2011). Management of Tennis Elbow. Open Access Journal of Sports Medicine, 2, 53-59.

2. Goyal, M., Kumar, A., Monga, M., and Moitra, M. (2013). Effect of Wrist Manipulation & Cyriax Physiotherapy Training on Pain & Grip Strength in Lateral Epicondylitis. Journal of Exercise Science and Physiotherapy, 9, (1), 17-22.

3. Levein, P. et al. (2005) Lateral Epicondylitis of the Elbow: US Findings. Radiology, 237(1), 230-234.

4. Peters, T., Champ, L., and Baker, JR. (2001). Lateral Epicondylitis. Clinics in Sports Medicine, 20(3), 549-563.

5. Stasinopoulos, D., and Panteis, M. (2013), Comparing Two Exercise Programmes for the Management of Lateral Elbow Tendinopathy (Tennis Elbow/Lateral Epicondylitis). A Controlled Clinical Trial, The Open Access Journal of Science and Technology, 1, 1-8.

6. Stasinopoulos, D., Stasinopoulou, K., and Johnson, M. I. (2005). An Exercise Programme For The Management of Lateral Elobw Tendinopathy. Br J Sports Med, 39, 944-947.

7. Village J, Frazer M, Cohen M, Leyland A, Park I, Yassi A. Electromyography as a Measure of Peak and Cumulative Workload in Intermediate Care and Its Relationship to Musculoskeletal Injury: an Exploratory Ergonomic Study. Appl Ergon. 2005;36(5):609–618.

8. Waugh, E. J., Jaglal, S. B., Davis, A. M., Tomlinson, G., Verrier, M. C., (2004). Factors Associated With Prognosis of Lateral Epicondylitis After 8 Weeks of Physical Therapy. Arch Phys Med Rehabil, 85, 308-318.

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