Lateral Epicondylitis: Causes, Symptoms and Treatment

Tennis elbow epicondylitis: Lateral epicondylitis, known as tennis elbow, is a tendinopathy of the wrist extensor muscles that insert on the lateral epicondyle of the humerus. Despite the name, in clinical practice the most frequent cause is not tennis but computer work: prolonged mouse use now represents the triggering factor in 40-50% of cases. Prevalence: 1-3% of the population, peak between 35 and 55 years. For more details, consult the guide on elbow anatomy.

Causes

From Mouse and Computer

• Repetitive wrist extension movements
• Static mouse grip with fingers in extension
• Repetitive clicking, wrist resting in extension
• Mouse far from body, desk too high/low
• Proper workstation ergonomics is the most important preventive factor

Sports

• Tennis (backhand), padel, golf, weight lifting

Occupational

• Repetitive manual work, musicians, gardening

Biomechanical

• Shoulder weakness, cervical or thoracic stiffness, coexistence with carpal tunnel or De Quervain

Symptoms

• Pain on lateral epicondyle (outer side of elbow), with radiation along the forearm
• Grip weakness: difficulty grasping objects, shaking hands
• Positive Cozen test: pain with resisted wrist extension
• Chair test: pain when lifting a chair with straight arm and palm down

Treatment

Acute Phase (2-4 weeks)

• Relative rest, ice, topical NSAIDs
• Epicondylitis brace: strap 2-3 cm below the epicondyle
• Immediate ergonomic modification (vertical ergonomic mouse)

Physiotherapy

• Mulligan MWM techniques: lateral mobilization of elbow with movement — often immediate relief
• Myofascial release of extensors
• Eccentric exercises (best scientific evidence)
• Shock waves in chronic forms

Injections

• Cortisone: rapid relief but worse outcome at 6-12 months vs physiotherapy. Reserve as “bridge”
• PRP: promising results in chronic forms

Exercises

Phase 1 — Initial (Weeks 1-3)

Exercise 1: Wrist Extensor Stretching

Difficulty: Easy | Equipment: None | Duration: 3 minutes

For a complete overview, see the comprehensive guide to elbow pain.

For a complete overview, see the comprehensive guide to elbow pain.

Starting position:
Standing or sitting, extend the affected arm in front of the body with elbow completely straight and palm facing down.

Step-by-step execution:

1. Step 1: With the opposite hand, grasp the back of the hand of the affected arm
2. Step 2: Gently flex the wrist downward, bringing fingers toward the floor
3. Step 3: Hold position for 30 seconds, feeling tension (not pain) along the forearm
4. Step 4: Release slowly and repeat

Sets and repetitions: 5 repetitions of 30 seconds — 3-4 times per day (can be done at desk)

Common errors to avoid:

• Bending elbow during stretch, reducing effectiveness of elongation
• Forcing wrist excessively until causing pain on epicondyle
• Holding breath instead of breathing normally

How to know you’re doing it correctly:
You feel a moderate stretching sensation along the upper forearm, from epicondyle to wrist. You should not feel acute pain.

Exercise 2: Self-Massage of Extensors

Difficulty: Easy | Equipment: None | Duration: 2-3 minutes

Starting position:
Sitting with affected forearm resting on table or thigh, palm facing down, muscles relaxed.

Step-by-step execution:

1. Step 1: Place thumb of opposite hand on lateral epicondyle (bony prominence on outer elbow)
2. Step 2: Apply moderate pressure and slowly slide from elbow toward wrist, following extensor muscles
3. Step 3: Focus with small circular movements on most painful or tight points
4. Step 4: Repeat the path for 2-3 minutes

Sets and repetitions: 2-3 continuous minutes — 2-3 times per day

Common errors to avoid:

• Pressing too hard causing excessive pain
• Massaging in reverse direction (from wrist toward elbow) which doesn’t promote drainage
• Contracting forearm muscles during massage

How to know you’re doing it correctly:
After massage you feel a sense of relaxation in forearm muscles. Points of greatest tension feel less rigid. Slight skin redness may appear, which is completely normal.

Phase 2 — Eccentric Protocol (Weeks 3-12)

Exercise 3: Eccentric Extensors (Fundamental Exercise)

Difficulty: Intermediate | Equipment: Table, light dumbbell (0.5-2 kg) | Duration: 5 minutes

Starting position:
Sitting at table, rest affected forearm on edge with hand extending beyond table, palm facing down. Hold light dumbbell (start with 0.5 kg).

Step-by-step execution:

1. Step 1: With healthy hand, help bring wrist into extension (hand raised upward)
2. Step 2: Release healthy hand and lower weight SLOWLY, controlling descent for 5-6 seconds
3. Step 3: Return to starting position always with help of healthy hand (never with affected arm)
4. Step 4: Repeat slow, controlled movement for prescribed repetitions

Sets and repetitions: 3 sets x 10-15 repetitions — 60-second pause — Once daily

Common errors to avoid:

• Lowering weight too quickly, losing eccentric component (slow phase is therapeutic)
• Using affected arm to lift weight (concentric phase done with healthy hand)
• Starting with too heavy weight

How to know you’re doing it correctly:
Descent movement lasts at least 5 seconds. You feel moderate tension in extensor muscles without acute pain on epicondyle. Increase weight when exercise becomes painless for 3 consecutive sessions.

Exercise 4: Tyler Twist with FlexBar

Difficulty: Intermediate | Equipment: Flexible bar (FlexBar) | Duration: 5 minutes

Starting position:
Standing, grip lower end of FlexBar with affected hand, wrist in extension. Grasp upper end with healthy hand.

Step-by-step execution:

1. Step 1: With healthy hand, twist flexible bar forward keeping affected hand still
2. Step 2: Extend both arms in front of body maintaining twist
3. Step 3: Slowly release twist controlling movement with affected hand (5-6 seconds)
4. Step 4: Return to initial position and repeat

Sets and repetitions: 3 sets x 10-15 repetitions — 60-second pause — Once daily

Common errors to avoid:

• Releasing twist too quickly
• Using FlexBar with resistance too high for your condition
• Compensating with shoulder movements instead of isolating wrist

How to know you’re doing it correctly:
Controlled release lasts at least 5 seconds. Pain reduction is progressive and, according to studies, 60-80% reduction is achieved in 6-8 weeks of consistent practice.

Exercise 5: Progressive Grip

Difficulty: Easy | Equipment: Stress ball or hand grip | Duration: 3 minutes

Starting position:
Sitting or standing with arm alongside body, elbow slightly flexed. Hold stress ball or hand grip in affected hand.

Step-by-step execution:

1. Step 1: Squeeze ball (or hand grip) with complete grip, involving all fingers
2. Step 2: Hold grip for 3-5 seconds
3. Step 3: Release slowly and rest 2-3 seconds before next repetition

Sets and repetitions: 3 sets x 15-20 repetitions — 30-second pause

Common errors to avoid:

• Squeezing too hard causing pain on epicondyle
• Compensating with wrist in extension: keep wrist in neutral position
• Performing exercise with jerky movements instead of controlled ones

How to know you’re doing it correctly:
You feel muscular work in forearm without causing pain on epicondyle. Grip becomes progressively stronger over weeks.

Phase 3 — Global Strengthening (Weeks 12+)

Exercise 6: Complete Wrist Strengthening

Difficulty: Intermediate | Equipment: Light dumbbell (1-3 kg) | Duration: 5 minutes

Starting position:
Sitting at table with forearm resting and hand extending beyond edge. Hold light dumbbell.

Step-by-step execution:

1. Step 1: Palm down: lift and lower wrist slowly (10 repetitions)
2. Step 2: Palm up: flex and extend wrist slowly (10 repetitions)
3. Step 3: Thumb up: radial and ulnar deviation of wrist slowly (10 repetitions)

Sets and repetitions: 3 complete sets (all 3 movements) — 60-second pause

Common errors to avoid:

• Using excessive weight forcing compensation with arm movements
• Performing movements too quickly, losing control

How to know you’re doing it correctly:
Movement is fluid and controlled in both directions. You feel diffuse muscular work in forearm without pain on epicondyle.

Exercise 7: Shoulder and Scapula Strengthening

Difficulty: Intermediate | Equipment: Resistance band | Duration: 5 minutes

Starting position:
Standing with erect posture. Resistance band fixed to stable point at waist height.

Step-by-step execution:

1. Step 1: External rotation: elbow at 90 degrees close to side, rotate forearm outward against band resistance
2. Step 2: Scapular retraction: arms extended forward, pull band toward body squeezing shoulder blades together
3. Step 3: Controlled scapular elevation: lift shoulders toward ears and lower slowly

Sets and repetitions: 3 sets x 12 repetitions for each movement — 45-second pause

Common errors to avoid:

• Compensating with trunk during external rotation
• Lifting shoulders during scapular retraction
• Using band with resistance too high

How to know you’re doing it correctly:
You feel work in shoulder area and between shoulder blades. Affected arm feels more stable and upper limb kinetic chain is involved completely.

Exercise 8: Desk Exercises for Maintenance

Difficulty: Easy | Equipment: None (desk) | Duration: 10 minutes

Starting position:
Sitting at your workstation, back against chair back, feet on ground.

Step-by-step execution:

1. Step 1: Wrist extensor stretching (like Exercise 1) for 30 seconds per side
2. Step 2: Shoulder rotations forward and backward, 10 repetitions per direction
3. Step 3: Chest opening: interlace hands behind neck, bring elbows back and hold 10 seconds (5 repetitions)
4. Step 4: Stress ball grip (like Exercise 5) for 1 minute

Sets and repetitions: Perform complete circuit every 45-60 minutes during work day

Common errors to avoid:

• Skipping breaks because too focused on work
• Performing movements too quickly without getting real benefit
• Forgetting to alternate hands during stretching

How to know you’re doing it correctly:
After each micro-session you feel reduced tension in forearm and shoulder area. Computer work stiffness decreases progressively.

Computer Ergonomic Prevention

• Vertical ergonomic mouse: reduces pronation — most useful investment
• Mouse close to body, correct height (elbow at 90 degrees)
• Flat keyboard (no raised feet), wrists in neutral position
• 20-20-20 rule: every 20 minutes, 20-second pause
• Micro-pauses: every 30-45 minutes, 2 minutes of forearm stretching
• Also prevent carpal tunnel from mouse, cervicalgia from computer, office back pain

Healing Times

Frequently Asked Questions (FAQ)

Frequently Asked Questions

What is lateral epicondylitis?

Lateral epicondylitis, commonly known as tennis elbow, is a tendinopathy affecting the wrist extensor muscles where they attach to the lateral epicondyle of the humerus. This condition is prevalent in 1-3% of the population, with a peak incidence between 35 and 55 years of age.

What are the primary causes of lateral epicondylitis?

While traditionally associated with tennis, prolonged computer mouse use is now the most frequent triggering factor, accounting for 40-50% of cases. Other contributing factors include repetitive wrist extension movements, static mouse grip, and improper workstation ergonomics.

What is the recommended treatment approach for lateral epicondylitis?

Consulting a physical therapist for accurate assessment is crucial when experiencing pain or grip weakness. Physiotherapy, incorporating specific exercises and manual techniques, is considered the most effective treatment with strong scientific evidence.

How can lateral epicondylitis be prevented, especially in computer users?

Proper workstation ergonomics is the most important preventive factor, particularly concerning mouse use. This includes avoiding repetitive wrist extension, static mouse grip, and ensuring the mouse is positioned correctly relative to the body and desk height.

Resources

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Scientific References

1. Coombes BK, et al. Management of lateral elbow tendinopathy. J Orthop Sports Phys Ther. 2015;45(11):938-949.
2. Bisset L, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see. BMJ. 2006;333(7575):939.
3. Tyler TF, et al. Addition of isolated wrist extensor eccentric exercise. J Shoulder Elbow Surg. 2010;19(6):917-922.
4. Coombes BK, et al. Effect of corticosteroid injection, physiotherapy, or both. JAMA. 2013;309(5):461-469.
5. Stasinopoulos D, et al. An exercise programme for lateral elbow tendinopathy. Br J Sports Med. 2005;39(12):944-947.
6. Herd CR, Meserve BB. Manipulative therapy in lateral epicondylalgia. J Man Manip Ther. 2008;16(4):225-237.
7. Shiri R, et al. Prevalence of lateral and medial epicondylitis. Am J Epidemiol. 2006;164(11):1065-1074.
8. Descatha A, et al. Physical exposure and medial/lateral epicondylitis. Occup Environ Med. 2013;70(9):670-673.
9. Vaquero-Picado A, et al. Lateral epicondylitis of the elbow. EFORT Open Rev. 2016;1(11):391-397.
10. Pienimaki TT, et al. Strengthening and stretching for chronic lateral epicondylitis. Physiotherapy. 1996;82(9):522-530.

Dr. Cosimo Pilotto — physical therapist | MyPhysioHelp.it

Related articles:

• Carpal Tunnel from Mouse
• Carpal Tunnel
• De Quervain
• Cervicalgia from Computer
• Computer Pathologies
• Workstation Ergonomics
• Desk Exercises

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Recommended Products for Rehabilitation Support

• Epicondylitis strap (counterforce brace) (paid link)
• Elbow brace with splints (paid link)
• Flexion/extension bar (FlexBar) (paid link)
• Elbow gel pack (paid link)

Product links are affiliate: purchasing doesn’t incur additional costs for users. These products don’t replace advice from your doctor or physical therapist.

Sources and Scientific References

1. Landesa-Piñeiro L et al. (2022). Physiotherapy treatment of lateral epicondylitis: A systematic review. J Back Musculoskelet Rehabil. 35:463-477. DOI | PubMed
2. Lenoir H et al. (2019). Management of lateral epicondylitis. Orthop Traumatol Surg Res. 105:S241-S246. DOI | PubMed
3. Stasinopoulos D et al. (2004). Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med. 38:675-7. DOI | PubMed
4. Viswas R et al. (2012). Comparison of effectiveness of supervised exercise program and Cyriax physiotherapy in patients with tennis elbow (lateral epicondylitis): a randomized clinical trial. ScientificWorldJournal. 2012:939645. DOI | PubMed
5. Ma X et al. (2024). Therapeutic Effects of Dry Needling on Lateral Epicondylitis: An Updated Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 105:2184-2197. DOI | PubMed