Cause of disease

A tennis elbow usually is the result of excessive and repetive strains. The tendon connects a muscle (wrist extensor) to the bone so that movement in the wrist is possible. When these muscles are tightened, the tendons must be able to absorb these muscle forces. In tennis elbow, the tendons of the wrist extensors are overloaded. The tendon of the extensor carpi radialis brevis (ECRB) muscle is often the most affected.

The reasons why the tendons are overloaded must be examined. Here, the load-load balance of the tendons must be taken into account: how much the tendons are loaded (load) and what the tendons are used to doing (load). This balance is often disturbed if you have temporarily exercised more than before or if you have worked a lot of overtime for a long time at work (higher than normal load). It can also be the case that one has done less for a long time (sport stop, temporary work or holiday), and one is no longer used to the regular load on the tendons (reduced load capacity)

In addition to the primary cause, the general ability to work, your physiotherapist will also look for other factors that may contribute to the cause. The complaints can occur at any age, but are most frequently seen in a population between 30-50 years of age.

Once symptoms develop, the tendons go through a whole series of biochemical reactions, resulting in pain and increased sensitivity. The pain you feel will cause the muscles connected to the painful tendons to tighten. However, this is counterproductive, which means that the tendons will be put under even more strain.

As a result, during this period you will often use your muscles less - to protect the tendons - which greatly reduces the load-bearing capacity. After all, we know that tendons do not like big changes; after all, it is the primary cause and therefore the reason why patients develop symptoms again when they resume their activities afterwards. The load-bearing capacity is lowered even more, and one is now burdening a tendon that can no longer handle any load.

Evolution of the clinical picture

Rehabilitation can take 6-9 months before one is completely free of pain. The recovery depends on several factors, such as how faithfully the strengthening exercises (see below) are done and whether a corticosteroid injection has already been used (this makes for a longer rehabilitation). Initially, the load on the tendons must be reduced. This means that activities are adapted to the load capacity. It is therefore strongly encouraged to continue playing sports, working, etc., as long as this does not aggravate the symptoms. Your physiotherapist will examine individually how activities need to be temporarily adapted in function of the recovery process.


Patients often describe a nagging, pressing pain on the outside of the upper arm (this is where the tendons of the wrist extensors attach to the epicondyle lateralis of the bone). However, it is not abnormal that the complaints sometimes vary and one feels them more in the forearm or even up to the wrist. The symptoms are usually triggered when grasping objects or when stretching the muscles. Specific movements that involve a lot of twisting with the forearm (e.g. screwdriver, painting, cleaning, etc.) are more likely to cause problems than others.


A tennis elbow is not an articular problem. However, it is important to make the correct diagnosis because articular symptoms can appear in the same region as a tennis elbow.


A tennis elbow is not a neurological problem. Again, it is important to make the correct diagnosis because these complaints can present themselves in the same region as a tennis elbow.


  • Sensitivity to pressure of the tendons on the outside of the elbow
  • Sensitivity to stretching when the muscle is stretched
  • If the muscle is stretched more forcefully, a deep pain can also be experienced
  • One can also experience a deep, nagging pain at rest due to excessive muscle tension
  • In the morning (especially after using the muscle a lot) you may feel stiffness in the forearm


Not applicable in tennis elbow

Role of physiotherapy and your physiotherapist

It is important not to jump to the conclusion of tennis elbow. There are many complaints that can occur at the same place. That is why it is important to consult your physiotherapist. He/she will examine you thoroughly.

Physiotherapeutic examination

By means of an interview and specific tests, your physiotherapist will determine the cause and/or local factors of the muscles and tendons: (muscle length, muscle strength, reduced load capacity of the tendons, increased load on the tendons,...). Secondary factors that may indirectly contribute to the complaints are also evaluated.

Treatment from your physiotherapist

The treatment of tennis elbow requires a good mix of exercise therapy, muscle relaxation and continuous assessment of load and load capacity.

Pain control

By reducing the muscle tension in the wrist extensors and the surrounding muscles, the pain will be reduced. Massage, trigger point treatment and possibly dry needling can be used. You can use heat packs and self-massage. Hard pushing, however, is not recommended as this can irritate the tendons even more. For self-treatment, however, there is little evidence of pain relief.

Manual physiotherapy

Manual therapy is initially not indicated. However, certain techniques may be applicable here. If, for example, a restriction is found in the joint, manual therapy can relieve the region.

Exercise therapy

This is the most important component of the therapy. The aim of exercise therapy is to optimise the tendon's load capacity so that it exceeds the daily, normal load. In order to increase the tendon's load capacity, it is necessary to exercise several times a week. It is normal for this rehabilitation to go through ups and downs. There may be slight pain during exercise, but it should not increase after exercise or the next morning. Your physiotherapist will adapt your individual programme to your specific rehabilitation path.

Revalidation trajectory

Within each rehabilitation, we always distinguish between short-term and long-term goals. Depending on the type of pathology, this will differ.

Short term

During the first phase of treatment, the most important thing is to get the pain under control. The load is temporarily reduced and then gradually built up again.

Long term

In the long term, the aim is that, with a lot of exercise therapy, the load capacity of the tendons is high enough so that the daily load no longer causes symptoms. It is important to remember that, after therapy, symptoms can develop again if the load capacity drops again and the load is suddenly increased again. Your physiotherapist will therefore also inform you to avoid relapse.

Multidisciplinary approach

Medication for tennis elbow consists of anti-inflammatory and pain relieving medication. Anti-inflammatory drugs (ibuprofen) only work for a limited 2-3 weeks in the event of an acute flare-up of symptoms, as the inflammation phase disappears after 2-3 weeks. This can help to alleviate the symptoms but will not solve them.

A corticosteroid injection can be opted for. This often initially provides pain relief in the first few weeks. After a few months, however, it is observed that patients with a corticosteroid injection do less well than patients who follow good exercise therapy under the supervision of a physiotherapist2. After a corticosteroid injection, patients are 11 times more likely to have the symptoms return, to be more painful and to require longer treatment than without the injection. Corticosteroids affect the tendons.3

Surgical interventions are rarely performed for this pathology4.

Unless you were involved in an accident or have recently fallen on the elbow, imaging is not applicable here.



  1. Sanders Jr TL, Maradit Kremers H, Bryan AJ, Ransom JE, Smith J, Morrey BF. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med. 2015;43(5):1066-1071. doi:10.1177/0363546514568087
  2. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial - PubMed. Accessed December 2, 2020.
  3. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial - PubMed. Accessed December 2, 2020.
  4. Nirschl RP. The epidemiology and health care burden of tennis elbow: a population-based study. Ann Transl Med. 2015;3(10):133. doi:10.3978/j.issn.2305-5839.2015.05.05

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