Lateral (outside) elbow pain is a common issue that can affect people from all walks of life, not just athletes. While tennis elbow is one well-known cause, there are other conditions that can also lead to pain in the lateral elbow. This blog article will delve into the various causes of lateral elbow pain, their symptoms, and how physiotherapy can play a crucial role in alleviating this discomfort. If you stand with your palms facing upwards, ‘lateral’ refers to the outside of your elbow (the same side as your thumb).

Structure of the elbow

The elbow is quite a stable and congruent joint (one of the most congruent joints in the body, where all the parts fit well together).

The elbow is a hinged joint made up of three bones (see diagram). The ends of these bones are covered with cartilage, which has a rubbery consistency to allow the joints to slide easily against each other and absorb shock.

  1. the humerus (upper arm bone);
  2. the radius (forearm bone on the thumb side); and
  3. the ulna (forearm bone on the pinky side).
Diagram of the bones in the elbow to help target lateral elbow pain

These bones form three joints within a capsule (a closed cylindrical area), namely the humeroulnar, humeral-radial, and the superior radio-ulnar. The three joints of the elbow include:

  1. the ulnohumeral joint is where movement between the ulna and humerus occurs;
  2. the radio humeral joint that allows movement between the radius and humerus; and
  3. the proximal radioulnar joint where movement takes place between the radius and ulna.

The elbow is stabilised by several structures  – ligaments, muscles, the joint capsule and bony anatomy. All these elements work together synergistically (for an enhanced effect) to maintain the structural integrity and stability of the elbow joint, allowing for efficient movement while minimising the risk of injury.

Tennis Elbow (Lateral Epicondylitis)

Tennis elbow, or lateral epicondylitis, presents as pain locally in the region of the outside part of the elbow. Pain can radiate upwards along the upper arm and downwards along the outside of the forearm (rare cases even to the third and fourth fingers). Interestingly only 5% of people suffering from tennis elbow relate the injury to tennis. This injury is often work-related and any activity involving wrist extension and wrist rotations during manual labour, housework and hobbies can be a risk factor. Tennis elbow is equally common in both genders. 20% of cases persist for more than a year, between 1-3% of the population is affected and patients are usually between 35-50 years old.

Contributing factors

When can this condition start?

  • After a period of decreased load (resting, have not trained in a while) or overload (increasing the amount of exercise you do, or doing an activity you are not use to). For example spontaneously deciding to put up all the shelves in your house with a screw driver (repetitive twisting) can cause tennis elbow.
  • Where BMI (Body Mass Index) is greater than 28, there is a definite association between tendinopathy and body fat.
  • Aging > 35, especially if associated with increased waist girth (belly).
  • Genetic: Blood type, collagen diseases, Systemic diseases: diabetes, arthritis, hypertension.
  • Women less than men until the post-menopause stage as oestrogen seems to protect the tendons.
  • Use of Quinolone antibiotics (read more about this in our other article).

What to do?

Step 1: Relative rest, which is rest from the activity that caused your injury to happen in the first place.
Step 2: Going to see your physiotherapist is a good call. They will do a few tests to confirm or negate whether your condition is indeed tennis elbow. They will then have a look at what factors are adding to the development of your pain to determine what can be done to help alleviate your symptoms now and prevent the likelihood of recurrence.

Non-operative management is always the first line of treatment for tennis elbow. This includes Physiotherapy, NSAID’s (anti-inflammatories), green tea (good for tendon healing), and a Counter-force brace.

Cortisone Injections may be considered, but there is evidence to support that although cortisone may help initially, in the long run you may be better off trying a more conservative approach (Smidt et al; 2002).

Radial Tunnel Syndrome

Radial tunnel syndrome is a condition that can cause significant discomfort and impact daily activities. Unlike tennis elbow, which affects the tendons, radial tunnel syndrome involves compression or irritation of the radial nerve. In this short blog, we’ll explore what radial tunnel syndrome is and how physiotherapy can help.

Radial tunnel syndrome occurs when the radial nerve is compressed as it passes through the radial tunnel, a narrow space in the forearm near the elbow. This compression can lead to pain and other symptoms that mimic those of tennis elbow, making it essential to correctly diagnose and treat the condition.

This type of lateral elbow pain presents with localised tenderness over the radial nerve (about 5 cm under the outside bone of your elbow) and can also have diffuse aching, sometimes radiating into the back of the hand, or sharp shooting pain along the back of the forearm. The pain is often worse at night. Radial nerve compression occurs in throwing and overhead activities. Repetitive rotation of the wrist and elbow can also cause similar symptoms.

However, often there is not one specific cause/event leading to the development of symptoms, which can include:

i. Pain: Aching pain on the outer part of the elbow and forearm, which may worsen with arm movement.

ii. Weakness: Difficulty in extending the wrist or fingers.

iii. Tenderness: Pain when pressing on the forearm muscles.

iv. Nerve-related Symptoms: Tingling or numbness in the forearm or hand, though this is less common.

Lateral ligament injuries

The lateral elbow is stabilised by ligaments, including the lateral collateral ligament (LCL) complex, which helps maintain joint stability during movement. Injuries to these ligaments can occur due to acute trauma, such as a fall, or from repetitive stress and overuse.


Common Causes:
      • Acute Trauma: A sudden injury, such as a direct blow to the elbow or a fall on an outstretched hand.
      • Overuse: Repetitive activities that strain the elbow ligaments, common in sports like tennis, baseball, and weightlifting.
      • Degeneration: Wear and tear over time, which can weaken the ligaments and make them more prone to injury.
    • Pain: Sharp or aching pain on the outer part of the elbow.
    • Swelling: Swelling around the elbow joint.
    • Instability: A feeling of instability or weakness in the elbow.
    • Reduced Range of Motion: Difficulty in fully extending or flexing the elbow.

Physiotherapy can help Lateral Elbow Pain

Physiotherapy is a non-invasive and effective treatment option. It focuses on reducing pain, improving nerve function, and preventing recurrence.

Comprehensive Assessment

A physiotherapist will conduct a thorough assessment to confirm the diagnosis of radial tunnel syndrome and rule out other potential causes of elbow pain, such as lateral epicondylitis. This assessment helps in creating a tailored treatment plan.

1) Pain Management

a. Manual Therapy: Techniques such as soft tissue massage and nerve mobilization can help reduce nerve compression and alleviate pain.

b. Modalities: Therapists may use techniques like ultrasound, ice, or heat therapy to reduce inflammation and provide pain relief.

2) Strengthening and Flexibility Exercises

a. Nerve Gliding Exercises: These exercises help the radial nerve move smoothly through the radial tunnel, reducing compression and irritation.

b. Strengthening Exercises: Gradual strengthening exercises for the forearm and wrist muscles improve overall arm stability and function.

c. Stretching: Gentle stretching of the forearm muscles helps reduce muscle tension and prevent further nerve compression.

3) Functional Training

a. Activity Modification: Physiotherapists advise on modifying daily activities to reduce strain on the radial nerve. This might include ergonomic adjustments at work or altering techniques in sports and manual tasks.

b. Sport-specific Rehabilitation: For athletes, physiotherapists design sport-specific rehabilitation programs to safely return to their activities with reduced risk of re- injury.

4) Education and Prevention

a. Educating patients about the importance of proper body mechanics and techniques in their daily activities is crucial. Physiotherapists teach strategies to avoid excessive strain on the elbow, emphasizing the significance of taking breaks and using ergonomic tools.

b. Cognitive behavioural therapy

5) Other modalities

Shockwave, dry needling, strapping, bracing and taping.