Lateral Epicondylitis (Tennis Elbow)


Lateral epicondylitis, commonly called tennis elbow, is a painful inflammatory condition felt at the outside of the elbow. While the condition is often associated with tennis, it can also occur from occupational overuse from repetitive twisting motions.

Tennis Elbow Symptoms

Tennis elbow is marked by pain, burning and tenderness at the outside of the elbow, usually on the dominant arm. Inflamed tissue may feel warm to the touch. Pain may escalate when carrying objects with an extended elbow, or during rotating motions like opening a jar or turning a doorknob.

Causes of Tennis Elbow

  • Tennis elbow is most commonly caused by repetitive wrist and arm movements, particularly in young and middle aged adults.
  • In older adults, tennis elbow may be associated with joint degeneration, cervical nerve compression, and a heightened sensitivity to pain stimuli.

There are four subcategories of lateral epicondylitis:

  • Osteogenic, originating from the bony prominence of the lateral epicondyle
  • Myofascial, stemming from too tight or too lax muscle tension at the elbow
  • Tendinosis, caused by degeneration of the common extensor tendon that extends the wrist
  • Arthrogenic, hyperactivity of the elbow musculature secondary to cervical spine degeneration

Diagnosis of Lateral Epicondylitis

Clinical diagnosis begins with a health history and physical exam. Diagnostic ultrasound may be used to confirm diagnosis and rule out other causes of elbow pain.

Some conditions that mimic tennis elbow include:

  • Impingement of the radial nerve
  • Arthritis of the elbow
  • Cervical nerve compression
  • Lateral epicondyle fracture
  • Posterior interosseous nerve impingement

Case Study

A 48 year old female writer presented at our clinic with pain in her lateral elbow. She had been diagnosed with lateral epicondylitis, and treated with steroid injections. When her symptoms were not resolved, she went to another practitioner who treated her elbow with extracorporeal shock wave therapy (ESWT) and five months of physical therapy. Nine months later, she was still in pain.

We used diagnostic ultrasonography to examine her elbow, and found no evidence of tendinosis at the lateral epicondyle, but we did discover a compression of the posterior interosseous nerve (PIN), which is a common mimicker of tennis elbow, and which is easily missed on MRI. Diagnostic ultrasound provides a clear image of the structures of the elbow in motion, in real time, offering precise insight into the nature and cause of the patient’s elbow pain. Early diagnosis with ultrasound can spare the patient ineffective conservative treatment approaches, and unnecessary surgery.

Risk Factors

There are several risk factors that predispose a patient to tennis elbow:

  • Postural support: The distribution of forces along the elbow and forearm are directly affected by postural support of the spine, shoulder and neck. Inadequate support of the neck and shoulder blades contributes to muscle imbalances at the shoulder, elbow and wrists. Clinical evidence shows that recovery time for tennis elbow is shortened when shoulder blade stability is also addressed.
  • Wrist mobility: Wrist and finger mobility are key factors that contribute to lateral elbow strain.
  • Tissue texture quality: The quality of soft tissues can affect upper extremity musculoskeletal health. The presence of knots, adhesions and scar tissue can inhibit fluid joint movement. Weakened or tight tissues can cause muscle imbalances that increase injury risk.
  • Female gender: Women are at higher risk of painful wrist and elbow conditions due to a hormonal profile that affects the tensile quality of soft tissues.

Treatment for Tennis Elbow Pain

Poor grip strength associated with disrupted coordination of the shoulder-elbow-wrist connection is a primary dysfunction of people with tennis elbow, which in turn leads to pain in the lateral epicondyle. Therapeutic exercise has long been the mainstay of treatment for severe elbow pain. Isometric exercise is sometimes effective in reducing pain when held in a non-compressed position. Extracorporeal shockwave therapy has been shown to have a high rate of success in treating lateral epicondylitis.

Tennis Elbow Treatment at NYDNRehab

At NYDNR, we use a holistic and comprehensive approach to treat our patients with tennis elbow pain. After diagnosis using real-time ultrasound, we follow up with innovative therapeutic treatments, including:

  • DNS (Dynamic Neuromuscular Stabilization) to restore alignment, stability and mobility to upper body structures
  • Myofascial manipulation to improve motor control and lengthen myofascial tissue
  • Acupuncture to eliminate active trigger points in the forearm
  • ESWT (Extracorporeal Shock Wave Therapy) to enhance circulation and promote cellular regeneration

For the best elbow pain treatment to help you heal quickly and improve your performance, contact NYDNR today. We are the very best clinic to treat tennis elbow in NYC.



In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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