What causes Tennis Elbow?

Why Does Tennis Elbow Happen? 

That nagging, persistent aches on the outside of your elbow. It started subtly, but now it’s a constant companion, making simple tasks like lifting a coffee mug, turning a doorknob, or shaking someone’s hand a painful ordeal. If this sounds familiar, you may be one of the millions of people dealing with tennis elbows. Despite its athletic-sounding name, this condition affects far more than just tennis players. It’s a frustrating injury that can disrupt work, hobbies, and daily life. But what is it, really? And more importantly, how do you fix it for good? 

What is Tennis Elbow? 

Clinically known as lateral epicondylitis, tennis elbow is a repetitive strain injury affecting the tendons on the outside of your elbow. The primary culprit is the Extensor Carpi Radialis Brevis (ECRB) tendon, which connects your forearm muscles to the bony prominence on your outer elbow (the lateral epicondyle). 

Contrary to what the name “epicondylitis” suggests—implying inflammation (“-itis”)—modern research understands tennis elbow primarily as a degenerative process called tendinosis. This means the problem isn’t just inflammation; it’s a breakdown of the tendon’s collagen structure due to chronic overuse, leading to micro-tears and a disorganized, weakened state.  

Tennis elbow is an overuse and muscle strain injury, where repeated contractions of the forearm muscles stress the tendons to the point of damage and pain. While a powerful backhand in tennis can certainly cause it, the condition is far more commonly linked to occupational activities. Plumbers, painters, carpenters, cooks, and even desk workers who spend hours typing are at high risk due to the repetitive wrist and forearm movements their jobs demand. 

It’s crucial to differentiate this from a simple forearm muscle strain, which involves damage to the muscle belly itself, or Golfer’s Elbow (medial epicondylitis), which causes pain on the inner side of the elbow. Tennis elbow pain is specifically located on the outside of the elbow and can radiate down the forearm.  

What are the stages of Tennis Elbow? 

Understanding that the tennis elbow is a progressive condition is the first step toward effective treatment. Not all elbow pain is the same, and identifying your stage can help you and your healthcare provider choose the most appropriate interventions. We can view the progression through two lenses: the clinical pathology and the practical pain phases you experience. 

A 2020 literature review published in Pain Research & Management outlines the four clinical stages of tendinosis, as originally described by Kraushaar and Nirschl: 

• Stage I: Characterized by temporary irritation or inflammation, often without permanent tissue damage. This is the early, reversible stage. 
• Stage II: Involves pathological alterations, specifically the collagen breakdown and degeneration known as tendinosis. 
• Stage III: The tendinosis progresses to include structural failure, meaning a partial or complete tear of the tendon. 
• Stage IV: The final stage involves fibrosis (scarring) and soft matrix calcification, where calcium deposits form within the damaged tendon. 

From a patient’s perspective, these clinical stages manifest as escalating pain. The Nirschl Pain Phase Scale is a practical tool for gauging your condition’s severity: 

• Phase 1: Mild soreness after the specific activity, which disappears within 24 hours. 
• Phase 2: Soreness after activity that takes more than 48 hours to resolve. 
• Phase 3: Mild to moderate pain during the activity, but it doesn’t alter your performance. 
• Phase 4: More significant pain during activity that forces you to modify your performance. 
• Phase 5: Pain caused by everyday heavy activities. 
• Phase 6: Constant pain, even at rest, that disrupts your sleep. 
• Phase 7: Pain that is present with even light activities and at rest. 

Recognizing where you fall on this spectrum is critical. Treatment for Phase 2 soreness will be very different from managing the constant pain of Phase 6. 

How Do You Fix Tennis Elbow? 

The most common question patients ask is, “How do I fix this?” The good news is that an overwhelming majority—between 80% and 95% of patients—achieve successful outcomes with Chiropractic treatment. The key is a structured, multi-modal approach. 

Rest 

This is the first and most critical rung of the ladder, but “rest” doesn’t mean complete inactivity. It means “active rest”—a strategic reduction of stress on the injured tendon. This includes: 

• Activity Modification: Identify and stop the specific activity causing the pain. For a tennis player, this might mean temporarily stopping playing or switching to a two-handed backhand. For an office worker, it could involve adjusting keyboard and mouse height to keep the wrist in a neutral position. 

• RICE Protocol: For acute flare-ups, the RICE method (Rest, Ice, Compression, Elevation) can help manage pain and swelling. Applying ice for 15-20 minutes several times a day can reduce local discomfort. 

• Bracing: A counterforce brace or strap worn around the forearm just below the elbow can be very effective. It works by changing the angle of pull on the tendon and reducing the force transmitted to the injured ECRB origin, allowing it to rest even while you use your hand. 

Chiropractic Care 

The chiropractic approach to the tennis elbow is unique because it looks beyond the site of pain. We view the body as an interconnected kinetic chain. Dysfunction in your neck, shoulder, or wrist can alter biomechanics and place excessive strain on your elbow. Our goal is to identify and correct these root causes. 

Treatment often involves a combination of techniques: 

• Extremity Adjustments: Gentle, specific adjustments to the wrist and elbow can restore proper joint motion and reduce mechanical stress. 

• Soft Tissue Therapy: Techniques like Active Release Technique (ART) or the Graston Technique focus on breaking down scar tissue and adhesions in the forearm muscles and tendons, promoting more organized healing. 

• Spinal Manipulation: If nerve irritation originating from the cervical spine (neck) is contributing to forearm muscle weakness or dysfunction, chiropractic adjustments to the neck can be a critical component of care.  

• Kinesiology Tape: A chiropractor may use kinesiology tape for tennis elbow to reduce strain on the affected tendon, improve circulation, and support proper muscle activation during movement. The tape gently lifts the skin, helping decrease inflammation and provide pain relief without restricting motion. While it’s possible to apply at home, proper placement and tension are key—so it’s best to have it first applied or demonstrated by a trained provider. Check out this video to learn more!  

Acupuncture 

Acupuncture can be a valuable complementary therapy on the Treatment Ladder, particularly for pain management. From a traditional perspective, it works by restoring the flow of energy (Qi). From a modern medical viewpoint, its proposed mechanisms include increasing local blood flow to the poorly vascularized tendon, stimulating the release of natural pain-relieving chemicals like endorphins, and modulating the inflammatory response. It is best used to manage symptoms while you engage in the more active, rehabilitative parts of your recovery. Always seek a licensed acupuncturist (L.Ac.) for treatment. 

Massage Therapy 

Therapeutic massage is another powerful tool for addressing the soft tissue component of the tennis elbow. This is different from a general relaxation massage. A therapist experienced in treating repetitive strain injuries may use techniques like deep tissue massage to release chronic tension in the forearm extensor and flexor muscles. They may also employ cross-friction massage directly over the tendon to help break down disorganized scar tissue and stimulate a healthier healing response by improving circulation to the area. 

Physical Therapy 

Physical Therapy is the most active and arguably most important phase of recovery. Once the initial pain is under control, you must begin a progressive exercise program to remodel the damaged tendon and build resilience against future injury. This process moves from gentle stretching to crucial strengthening exercises. The focus of tennis elbow recovery shifts toward rebuilding strength, mobility, and long-term resilience. This phase involves a progressive exercise plan that moves from gentle stretching to targeted strengthening, particularly eccentric exercises for the wrist extensors to realign tendon fibers and improve load tolerance.  

Key exercises include: 

• Wrist Extensor Stretch: Gently bend your wrist downward, using your other hand to apply light pressure. 
• Wrist Flexion Stretch: Gently extend your wrist backward, using your other hand to apply light pressure. 
• Eccentric Wrist Extension: This is the cornerstone of tendinosis rehab. While seated, rest your forearm on your thigh with your hand hanging off the knee, palm down, holding a light weight (1-2 lbs). Use your good hand to lift the weight up into a wrist-extended position. Then, very slowly and controlled, lower the weight back down using only the injured arm. The “Tyler Twist” exercise, using a rubber FlexBar, is another highly effective eccentric exercise. 

Advanced Medical Interventions 

If you’ve diligently followed a conservative care plan for several months without significant improvement, it may be time to climb to the next rung of the Treatment Ladder. These interventions are typically considered for more persistent cases: 

• Injections: Corticosteroid injections can provide powerful short-term pain relief but should be used with caution, as some evidence suggests they may not improve long-term outcomes and could potentially weaken the tendon. Platelet-Rich Plasma (PRP) injections, which use your own blood healing factors, are an alternative aimed at stimulating tissue repair rather than just masking pain. 

An Integrative Approach 

At Vida Integrated Health, providers like chiropractors, acupuncture, physical therapists, massage therapists, and functional medicine physicians work collaboratively to restore proper movement patterns, address compensations, and reduce strain on the affected area. Techniques such as myofascial release, active release therapy, and joint mobilization are often incorporated to improve circulation, flexibility, and range of motion. 

A holistic recovery plan goes beyond symptom relief—it supports the body’s ability to heal and prevent reinjury. Integrative modalities such as acupuncture can enhance blood flow and reduce inflammation, while functional medicine may identify deeper contributors like chronic inflammation, nutritional deficiencies, or hormonal imbalances that slow tissue repair. By combining movement therapy, manual treatment, and whole-body assessment, this comprehensive approach helps patients not only recover fully but build lasting strength and awareness to keep them active and pain-free. 

Does Tennis Elbow Ever Go Away? 

This is the question on every patient’s mind, and the answer is overwhelmingly positive: yes, the tennis elbow almost always gets better. The prognosis is excellent, with research showing that approximately 90% of patients recover or are significantly improved within one year, often with Chiropractic care [2]. 

However, it’s important to manage expectations. “Going away” involves two parts: pain resolution and full tendon healing. You may feel pain-free within weeks or a few months, but the underlying tendinosis—the biological process of remodeling and strengthening the collagen fibers—can take much longer, from six months to over a year. 

The biggest challenge is not just getting rid of the pain but keeping it away. Preventing recurrence is critical and involves: 

• Proper Ergonomics: Ensure your workspace and tools are set up to minimize wrist strain. 

• Technique Correction: If your injury is sports- or hobby-related, work with a coach or professional to correct any faulty mechanics. 

• Warm-Ups: Always warm up your forearm muscles with gentle stretches before engaging in strenuous activity. 

• Maintenance Strengthening: Continue your eccentric strengthening exercises 1-2 times per week even after you are pain-free to maintain the tendon’s resilience. 

Final Thoughts 

Tennis elbow, or lateral epicondylitis, is more than just a simple case of inflammation. It is a degenerative condition of the tendon (tendinosis) that progresses through predictable stages. But it is not a life sentence. 

By understanding the true nature of the injury and identifying your stage, you can take an active role in your recovery. The “Treatment Ladder” provides a logical, patient-centered framework for navigating your options, starting with active rest and progressing through a multi-modal plan that can include chiropractic care, therapeutic massage, and a dedicated rehabilitation program. From a holistic, chiropractic perspective, success lies in addressing not just the elbow pain, but the full kinetic chain and the root biomechanical causes. 

Lasting relief is achievable. Empowerment comes from understanding your condition and having a clear, actionable plan to get you back to living a strong, pain-free life. 

If you’re struggling with persistent elbow pain and are tired of temporary fixes, don’t wait for it to get worse. Schedule a comprehensive evaluation with our team at Vida Integrated Health today. We’ll help you identify your specific stage and create a personalized, integrative recovery plan to get you back to living pain-free. 

References 

1. Ma, K. L., & Wang, H. Q. (2020). Management of Lateral Epicondylitis: A Narrative Literature Review. Pain research & management, 2020, 6965381. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC7222600/ 
2. Vaquero-Picado, A., Barco, R., & Antuña, S. A. (2016). Lateral epicondylitis of the elbow. EFORT open reviews, 1(11), 391–397. https://eor.bioscientifica.com/view/journals/eor/1/11/2058-5241.1.000049.xml?rskey=8LsYjL&result=453  
3. Howell, E. R. (2015). Chiropractic management of lateral epicondylitis: a case report. Journal of chiropractic medicine, 14(1), 47–52. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322013/ 
4. American Academy of Orthopaedic Surgeons (AAOS). (N.D.). Therapeutic Exercise Program for Epicondylitis (Tennis Elbow / Golfer’s Elbow). OrthoInfo. Retrieved from https://orthoinfo.aaos.org/globalassets/pdfs/a00790_therapeutic-exercise-program-for-epicondylitis_final.pdf