It's possible you have been given the wrong diagnosis if you don't have a tendon problem

By Dr. Jordan Duncan
For West Sound SportsPlus

If you type “tennis elbow” into Google, look it up in most medical textbooks, or ask your doctor what it is, chances are you will get the same answer. 

You will learn that tennis elbow is caused by irritation of the common extensor tendon — made up of the tendons of several forearm muscles — where it attaches at your elbow. 

You will discover that tennis elbow causes lateral (thumb-side) elbow pain, and that predisposing movements are those which stress the involved tendon (e.g. the backhand swing in tennis, where the diagnosis gets its name, the lead arm in golf, and swinging a hammer, to name a few).

Most healthcare professionals will make a diagnosis of tennis elbow if a patient has pain on the lateral side of their elbow, whether they play tennis or not, and as a result prescribe treatment directed at the involved tendon. 

This sounds great on the surface, however it may not when you consider that this explanation of tennis elbow is just one of several reasons why people experience lateral-elbow pain. 

Here are four of the most common reasons for lateral elbow pain that receive the label of ‘tennis elbow’ from both medical professionals and Dr. Google. 

True Tennis Elbow 

This is the tennis elbow that Google defines, that most medical textbooks outline, that your doctor likely thinks that you have, and that I describe earlier. If you have this condition, they all hit the nail on the head.

True tennis elbow is an actual tendon problem, therefore it should follow the six rules for tendon pain that I describe in a previous article (see the link at the end of this article).

  • Pain provocation is very consistent (only motions that stress the common extensor tendon cause pain). 
  • The pain is very localized (about the size of a quarter at the lateral elbow).
  • The pain gets worse when more load is applied to the tendon. 
  • There is no passive motion loss at the affected joint (elbow). 
  • There is no pain at rest (unless you overdid an activity and created inflammation). 
  • The pain doesn’t tend to get better with more activity. 

If your pain doesn’t behave in this way, it makes a diagnosis of tendon pain (e.g. true tennis elbow) far less likely, rendering treatment for true tennis elbow ineffective. 

A Problem Inside the Elbow Joint Complex 

This is termed an Elbow Derangement in the McKenzie Method system (the system I use). Pain due to derangements is the result of the displacement or deformation of soft tissues inside a joint (e.g. cartilage), creating a disturbance in the normal resting position of the affected joint surfaces. 

Elbow Derangements account for the majority of the cases of elbow pain that are diagnosed as tennis elbow. 

Common features are obstruction to movement (e.g. you can’t fully extend your elbow), variability in symptom presentation (sometimes movements hurt and other times they don’t), perhaps a more broad area of pain, and even constant pain.

A Spinal Component

This is termed Extremity Pain of Spinal Source. I touched on a similar-type condition in a previous article where I explained that foot pain (which was actually due to my lumbar spine) kept me from running for many months (see link at the end of the article).

The spine, particularly the neck and mid back, can refer to the elbow and is an often overlooked cause of pain diagnosed as tennis elbow. 

Common features include pins and needles in the affected extremity, pain that is worse with sitting (due to prolonged static loading of the spine), other locations of pain in the upper extremity (e.g. shoulder pain, scapular pain, etc), neck pain, and/or neck stiffness. 

In addition, if you have bilateral tennis elbow (pain in both elbows), it is far more likely to be due to a spinal source as opposed to a problem with both elbows simultaneously. 

Neurogenic Tennis Elbow

There is some overlap between this condition and the previous one. The cause here is irritation of nerve tissue, either in the elbow, the neck, or both. 

As it pertains to pain in the lateral elbow, the affected nerve is the radial nerve. The radial nerve can become irritated or entrapped as it courses through soft tissues around the elbow. 

There is usually a reproduction of lateral-elbow pain when stretching the radial nerve, which is described as follows:

  • Stand with your involved arm at your side.
  • Bend your wrist so your palm faces up.
  • Rotate your arm inward so your elbow and hand point out.
  • Move your arm away from your body.
  • Depress your shoulder.
Dr. Jordan Duncan demonstrates a stretch that can help differentiate between the different types of tennis elbow.

This test may also increase pain in cases of true tennis elbow, however the way to differentiate it from neurogenic tennis elbow is to tilt your head away from the side that is stretched. If it increases your elbow pain, involvement of the radial nerve is likely. 

In addition, there may be a feeling of pins and needles in the radial nerve distribution, either during the radial nerve stretch or at other times. This includes most of the back of the hand, except for the back of the pinky finger and adjacent half of the back of the ring finger. 

Why is this Important?

When you take into account these other reasons for lateral elbow pain, it leaves a much smaller percentage of people who have true tennis elbow compared to what Google, most medical textbooks, or your doctor may tell you. 

For example, if you have lateral elbow pain, yet you can’t straighten your elbow all the way, or you have tingling into your fingers, or you have simultaneous scapular pain and neck stiffness, I would strongly doubt that you have true tennis elbow. 

So why is this differentiation important? 

Because each one of these lateral elbow pain subgroups requires different treatment.

To use an analogy, it is no different than different infections receiving different antibiotics. 

In each of these other causes of lateral elbow pain, if you receive treatment designed for true tennis elbow, it is unlikely it will be effective, regardless of the intervention applied. 

Unfortunately, many people receive treatment for true tennis elbow when their pain is due to another cause. When it doesn’t work, they often resort to wearing an elbow brace, the same one you see worn around the gym, hardware store, or tennis court. 

I would bet, based on the odds, that most people you see wearing a brace like this don’t have True Tennis Elbow. 

They have been given the wrong ‘antibiotic’. 

If you have been diagnosed with a tennis elbow, and you aren’t getting better despite treatment, a second opinion is warranted. This requires differentiation between the different types of lateral-elbow pain. There are several conditions which mimic true tennis elbow, which is why proper diagnosis is absolutely crucial for effective treatment.

If you have any questions or would like more information, I would love to hear from you. You can contact Dr. Duncan at jordanduncandc@gmail.com

Links to Articles

Diagnosed with tendonitis? Unlikely if pain doesn’t have these six features

My Journey to Becoming a Runner


Dr. Duncan is one of a small handful of chiropractors in the state of Washington to be certified in the McKenzie Method® of Mechanical Diagnosis and Therapy, a reliable evidenced based method of assessment and treatment for musculoskeletal conditions of the spine and extremity joints. 

In addition to treating a diverse patient population, Dr. Duncan enjoys treating athletes and has worked with numerous high school, collegiate, and professional athletes. He has served as an expert opinion for a wide variety of healthcare and fitness articles. 

As a competitive athlete growing up in Kitsap County and a current runner, Dr. Duncan understands the importance of quickly returning to your sport, whether you are a long distance bike rider, high school soccer player, recreational golfer, avid CrossFitter, or enjoy another activity. 

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