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Clinical Topic: Lateral Epicondylalgia, aka, Tennis Elbow
Learning Objectives: By the end of this newsletter, you will be able to:
Differentiate lateral epicondylalgia from radial tunnel syndrome, cervical radiculopathy, and posterior interosseous nerve entrapment using specific examination findings and provocation tests
Apply proper treatments to extensor carpi radialis brevis, extensor digitorum, and supinator muscles including anatomical landmarks, needle depth, and rehab expectations
THE CLINICAL PRESENTATION
Your patients picks up his coffee cup and winces.
"I've had this pain on the outside of my elbow for six months," he says. "It started as a dull ache. Now it's sharp when I grip anything."
He's 45. Works in IT. Lots of mouse work, typing, repetitive gripping. He tried resting it for a month. Wore a tennis elbow brace religiously. The pain improved some but never went away.
Now he's back to work and the pain is back… this time worse than ever.
His grip strength is shot. Opening doors hurts. Shaking hands is embarrassing. He's worried he won't be able to keep working.
This is one of the most frustrating conditions for both patients and practitioners. Why? Because the standard approach of rest, brace, and NSAIDs rarely works long-term.
What Usually Happens Before They Get to You:
Primary care doctor diagnosed "tennis elbow" based on lateral elbow pain and positive Cozen's test. Prescribed rest, ice, and NSAIDs for 2-3 weeks.
Patient complied.
Pain improved by maybe 20%. As soon as he returned to normal activities, pain came back with a vengeance
Doctor recommended a tennis elbow brace (the kind with the strap just below the elbow). Patient wore it for 6-8 weeks. It helped while wearing it, but didn't actually fix anything.
Next step: corticosteroid injection into the lateral epicondyle. This helped for 4-6 weeks. Then the pain returned… sometimes worse than before with certain activities.
Physical therapy was the last resort before considering him for surgery. But after 4 weeks of wrist extensor stretching and eccentric exercises, he quit because it made his pain worse.
Now he's in your office, discouraged and wondering if he'll ever be pain-free again.
What do you do?
THE COMMON MISDIAGNOSIS
Most practitioners diagnose this as "tennis elbow" or "lateral epicondylitis" and treatment focuses on reducing inflammation at the tendon insertion site.
Here's the problem: By the time patients see you (usually 3-6 months after symptom onset), this isn't an inflammatory condition anymore. The suffix "-itis" implies inflammation.
Chronic lateral elbow pain is tendinosis, if you took my course at Logan you know, degenerative changes in the tendon combined with trigger points in the forearm extensor muscles.
Why the Standard Approach Fails:
The typical treatment pathway looks like this:
Rest and avoid aggravating activities → minimal improvement
Tennis elbow brace → temporary relief only while worn, no lasting change
Corticosteroid injection → 4-6 weeks of relief, then symptoms return
Physical therapy with stretching/strengthening → often makes pain worse
Patient ends up in our office months later, frustrated and in more pain
The reason this fails: We've been treating the symptom (pain at the lateral epicondyle) instead of the cause (muscle dysfunction in the forearm extensors creating abnormal tension on the tendons).
The Actual Pathophysiology:
Lateral epicondylalgia involves:
Degenerative changes (tendinosis, not tendinitis) in the common extensor tendon, particularly extensor carpi radialis brevis (ECRB)
Trigger points and hypertonicity in the forearm extensor muscles
Failed healing response due to continued abnormal loading
Possible neural involvement (radial nerve or posterior interosseous nerve irritation)
The extensor muscles can develop trigger points that maintain constant tension on the already-degenerative tendons. The tendons can't heal because the muscles keep pulling on them abnormally.
Rest doesn't fix this. Corticosteroid injections can actually weaken tendons over time with repeated use. Generic stretching and strengthening often loads dysfunctional muscles, making pain worse.
Red Flags Indicating Different Diagnosis:
Numbness or tingling in the hand → consider cervical radiculopathy (C6-C7) or radial nerve entrapment
Pain with supination (palm up) more than extension → consider radial tunnel syndrome or posterior interosseous nerve syndrome
Weakness out of proportion to pain → consider nerve entrapment
Night pain or pain at rest unrelated to activity → consider referred pain from cervical spine or serious pathology
History of trauma with immediate onset → consider fracture or ligament injury
THE CORRECT DIFFERENTIAL DIAGNOSIS
I examine every lateral elbow pain case systematically. The examination tells me whether I'm dealing with true lateral epicondylalgia or something pretending to be it.
Subjective Findings Consistent with Lateral Epicondylalgia:
Gradual onset of lateral elbow pain (weeks to months)
Pain with gripping, lifting, twisting motions (opening jars, turning doorknobs, shaking hands)
Pain with wrist extension against resistance
Minimal to no pain at rest
History of repetitive gripping, typing, or manual work
Failed previous conservative treatment (rest, bracing, injections)
Objective Examination Protocol:
Observation:
Assess posture: forward head position, rounded shoulders, hyperkyphosis (can contribute to neural tension)
Note any visible atrophy in forearm extensors (chronic cases) and hand
Observe how patient uses the affected arm (guarding, avoidance patterns)
Active Range of Motion:
Wrist extension: Should be full (70°) but may be painful at end-range
Wrist flexion: Usually full and pain-free
Forearm pronation/supination: Assess for pain or restriction (radial tunnel syndrome causes pain with pronation)
Elbow flexion/extension: Should be full and pain-free
Passive Range of Motion:
Generally full in all planes
Passive wrist flexion with elbow extended may reproduce symptoms (stretches the extensor muscles and tendons)
Strength Testing (Resisted Isometric Tests):
Cozen's Test (Resisted Wrist Extension):
Positive: Reproduces lateral elbow pain
Sensitivity: 88%, Specificity: 50% for lateral epicondylalgia
This is your primary diagnostic test
Mill's Test (Passive Wrist Flexion with Elbow Extension):
Positive: Reproduces lateral elbow pain
Sensitivity: 78%, Specificity: 55%
Stretches the extensor tendons maximally
Maudsley's Test (Resisted Middle Finger Extension):
Patient extends middle finger against resistance
Positive: Reproduces lateral elbow pain
Suggests ECRB involvement specifically
Sensitivity: 85%, Specificity: 57%
Coffee Cup Test (Functional Assessment):
Patient attempts to lift a full coffee cup (fill it with water, not hot coffee) with affected arm
Positive: Unable to lift without pain or hand trembling
This is a functional assessment I use to track progress. If they can't lift a coffee cup, they can't function normally.
Grip Strength Testing:
Use dynamometer if available
Affected side typically 30-50% weaker than unaffected side
Pain usually prevents full effort
Track this at every visit! Improvement in pain-free grip strength indicates good recovery and you can progress treatment.
Palpation Findings:
Lateral Epicondyle:
Point tenderness directly over the lateral epicondyle
This is where ECRB attaches
Palpation reproduces patient's familiar pain
May feel thickening or nodularity in chronic cases
ECRB Muscle Belly:
Located in proximal forearm, 3-5cm distal to lateral epicondyle
Palpate along posterior-lateral forearm
Taut bands and trigger points common
Trigger points refer pain proximally to the lateral epicondyle (exactly where patient feels their pain)
Extensor Digitorum:
Located just lateral/posterior to ECRB
Palpable trigger points in mid-forearm
Refers pain to lateral elbow and dorsal hand
Supinator:
Deeper muscle, harder to palpate
Located just distal to radial head
Tender on deep palpation
Often involved, especially if patient has pain with supination
Differential Diagnosis Tests:
Radial Tunnel Syndrome:
Pain located more distal (4-5cm below lateral epicondyle)
Pain with resisted supination
Pain with resisted middle finger extension
Tenderness over radial tunnel (just distal to radial head)
Cervical Radiculopathy (C6-C7):
Neck pain or stiffness
Dermatomal sensory changes (thumb/index/middle finger for C6, middle/ring finger for C7)
Reflex changes (biceps reflex for C6, triceps reflex for C7)
Positive Spurling's test
Pain radiates from neck to elbow, not just localized at elbow
Posterior Interosseous Nerve Syndrome:
Weakness of finger extension without sensory loss
Pain with resisted supination
Tenderness distal to radial head
No pain directly at lateral epicondyle
Differential Diagnosis Table:
Clinical Finding | Lateral Epicondylalgia | Radial Tunnel Syndrome | Cervical Radiculopathy | PIN Syndrome |
|---|---|---|---|---|
Location | Lateral epicondyle | 4-5cm distal to epicondyle | Neck to arm | Proximal forearm |
Cozen's Test | Positive | Variable | Negative | Negative |
Resisted Supination | Mild pain | Significant pain | Negative | Significant pain |
Palpation | Tender at epicondyle | Tender distal to radial head | Cervical spine tender | Tender over radial tunnel |
Sensory Changes | None | None | Dermatomal pattern | None |
Grip Strength | Weak, painful | Weak, painful | May be weak | Finger extension weak |
SOAP Note - Assessment Section:
"Lateral epicondylalgia, right elbow, affecting extensor carpi radialis brevis and extensor digitorum muscles. Clinical presentation consistent with chronic tendinosis with myofascial trigger point involvement.
Positive Cozen's test, positive Mill's test, positive Maudsley's test, all reproducing familiar lateral elbow pain.
Grip strength reduced by 40% compared to contralateral side (30 lbs vs 50 lbs).
Palpation reveals significant trigger points in ECRB and extensor digitorum muscle bellies with referral to lateral epicondyle.
Differential diagnoses of radial tunnel syndrome ruled out by pain location at epicondyle rather than distal forearm. Cervical radiculopathy ruled out by negative Spurling's test, no dermatomal sensory changes, normal reflexes. No neurological deficits noted."
CDNP - DRY NEEDLING APPROACH
Here's what I tell patients when they come in to the office with chronic tennis elbow:
"Your muscles are holding your tendons hostage. The tendons at your elbow are trying to heal, but the muscles in your forearm have trigger points that keep the muscle tension active on those tendons. This is common, but not normal. We need to work on those trigger points so your tendons can actually recover and heal. That's what dry needling does. Then we need to rebuild the strength in those muscles gradually. That's what your program will do."
Most patients get it. Some look skeptical since they've tried so many things that didn't work. But when I show them the tight, ropy bands in their forearm and press on them, reproducing their exact elbow pain, it clicks.
The Mechanism:
Dry needling alters the painful stimuli at the forearm extensors by releasing a cascade chemicals locally, and systemically throughout the body. This aids in disrupting tension in the forearm extensors, reduces painful stimuli, stimulates local blood flow and healing factors to the degenerative tendon, and creates a therapeutic window for loading the tissue to promote remodeling.
Treatment Protocol:
The key structures to target are the ECRB muscle belly, the common extensor tendon insertion, extensor digitorum, and supinator. Don't just needle the epicondyle and hope for the best, now we need to address the entire kinetic chain.
EXTENSOR CARPI RADIALIS BREVIS (ECRB) - Primary Target
Clinical Rationale:
ECRB is the primary culprit in 90% of lateral epicondylalgia cases. This muscle originates at the lateral epicondyle and inserts at the base of the third metacarpal. It extends and radially deviates the wrist. In activities involving gripping (where the wrist stabilizes in extension), ECRB is under constant load. Trigger points develop in the muscle belly, creating tension on the already-degenerative tendon insertion.
Anatomical Landmarks:
Identify the lateral epicondyle via palpation
Move distally 3-5cm along the posterior-lateral forearm
Palpate for the ECRB muscle belly—it's the first muscle belly you encounter moving distally from the epicondyle
The muscle sits between the brachioradialis (anteriorly) and extensor digitorum (posteriorly)
Needle Specifications:
30-40mm x 0.25mm needle (most patients)
Insertion Technique:
Palpate and isolate taut bands in the ECRB muscle belly
Insert needle perpendicular to the skin
Typical depth: 15-25mm (muscle is more superficial than you might expect)
Use twirling or e-stim to elicit local twitch response
Multiple trigger points are common—needle 2-3 sites in the muscle belly
Expected Response:
Local twitch response (may see visible forearm muscle contraction)
Patient reports referral of pain proximally to the lateral epicondyle
"That's it, that's exactly where my elbow hurts"
Deep aching in the muscle
Safety Considerations:
Minimal safety concerns for muscle belly needling. The radial nerve passes anterior to the ECRB, so staying perpendicular to the skin keeps you safe. Avoid angling anteriorly.
COMMON EXTENSOR TENDON INSERTION - The Epicondyle
Clinical Rationale:
The common extensor tendon at the lateral epicondyle often has degenerative changes, disorganized collagen, and possible neovascularization (abnormal blood vessel formation). Dry needling directly into the tendon insertion creating controlled microtrauma that stimulates healing response and disrupts the pathological neovascularization.
This is uncomfortable for patients. Makes sure to let your patient know what to expect.
Anatomical Landmarks:
Palpate the lateral epicondyle—the bony prominence on the lateral elbow
The most tender spot is usually just distal and anterior to the bony prominence
This is where ECRB primarily attaches
Needle Specifications:
30mm x 0.25mm needle
Insertion Technique:
Palpate the point of maximum tenderness at the lateral epicondyle
Insert needle perpendicular to the skin, directly into the tender area
Depth: 5-10mm (very superficial—you're needling the tendon insertion, not going deep)
You may piston the needle in this session: Insert to depth, then make 5-8 small back-and-forth movements without fully withdrawing the needle through the skin
You're creating multiple small perforations through the degenerated tendon tissue
This should take 30-60 seconds per site
Expected Response:
This is painful. Warn patients ahead of time: "This is going to be uncomfortable. You'll feel a deep ache right at your elbow. It'll last 30-60 seconds while I'm needling, then it'll ease up."
No dramatic twitch response expected (you're in tendon, not muscle)
Patients report reproduction of their familiar pain
Safety Considerations:
Stay superficial (5-10mm depth maximum). You're needling tendon tissue, not going deep. The radial nerve passes anterior to this area, so perpendicular insertion is safe.
Clinical Pearl:
Not every patient needs tendon insertion needling. If trigger points in the muscle belly are severe, start there. If the patient improves 70-80% with muscle needling alone, you may not need to needle the insertion. Save this technique for patients who plateau at 60-70% improvement despite muscle treatment.
EXTENSOR DIGITORUM
Clinical Rationale:
The extensor digitorum extends the fingers and assists with wrist extension. It's located just posterior/lateral to ECRB. Trigger points here contribute to lateral elbow pain and also cause dorsal hand and finger pain. Many patients don't realize their finger pain is connected to their elbow problem until you treat this muscle.
Anatomical Landmarks:
Locate the ECRB muscle belly (as described above)
Move slightly posterior/lateral
The extensor digitorum is the next muscle belly you encounter
It's located in the mid-posterior forearm, 5-8cm distal to the lateral epicondyle
Needle Specifications:
30-40mm x 0.25mm needle
Insertion Technique:
Palpate for taut bands and trigger points in the extensor digitorum
Insert perpendicular to skin
Depth: 15-25mm
Twirl the needle to elicit LTR
Expected Response:
Local twitch response
Referral to lateral elbow and/or dorsal hand
Some patients report finger pain they didn't even know they had
Safety Considerations:
Minimal concerns. Stay perpendicular to skin surface.
SUPINATOR
Clinical Rationale:
The supinator is a deeper muscle that supinates the forearm (rotates palm up). It wraps around the proximal radius, and the radial nerve (specifically the posterior interosseous nerve) passes through it. Trigger points or hypertonicity in the supinator can compress the nerve, causing pain that mimics or coexists with lateral epicondylalgia. If your patient has pain with supination in addition to extension, the supinator is involved.
Anatomical Landmarks:
Locate the radial head (rotate the forearm—you'll feel the radial head move just distal to the lateral epicondyle)
The supinator sits just distal to the radial head, wrapping posteriorly around the radius
It's deeper than ECRB and extensor digitorum
Needle Specifications:
40mm x 0.25mm needle (you need length to reach this deeper muscle)
Insertion Technique:
Palpate just distal and posterior to the radial head
Insert perpendicular to skin
Depth: 30-40mm (this is a deep muscle)
You'll pass through more superficial muscles (ECRB, extensor digitorum) before reaching supinator
When you reach the supinator, you'll feel resistance and patients report deep aching pain
Expected Response:
Deep aching sensation
Pain referral to lateral elbow
Possible referral into dorsal forearm
Less dramatic twitch response than superficial muscles
Safety Considerations:
This is the highest-risk technique due to proximity to the radial nerve. The posterior interosseous nerve passes through the supinator muscle. If the patient reports electric shock sensation radiating down the forearm or into the hand, you've contacted the nerve. Withdraw immediately and redirect slightly.
If you're not confident with this technique, review your videos. If you are not a CDNP, find an upcoming course. Focus on ECRB and extensor digitorum. Those alone will get you 80-90% results in most patients.
Post-Needling Protocol:
Immediate Response (0-2 hours):
Patients typically notice immediate improvement in grip strength and reduction in pain with gripping. The coffee cup test often improves dramatically.
This is your therapeutic window.
Immediate interventions:
Gentle active wrist extension and flexion (15-20 reps each)
Gentle gripping exercises (squeeze soft ball, 15-20 reps)
Expected Post-Needling Soreness (24-48 hours):
Forearm soreness is expected. Warn patients: "Your forearm will feel like you did a hard workout. It'll be sore for 1-2 days. This is good, it means we reached the right structures. The elbow pain should actually be better even while the forearm is sore."
If they're prepared for this, they won't panic.
SOAP Note - Objective Section (Post-Needling):
"Grip strength improved from 30 lbs to 42 lbs on dynamometer immediately post-needling (40% improvement) Only if you are testing it… don’t make numbers up. Cozen's test remains positive but less painful (4/10 vs 7/10 pre-needling). Patient able to lift coffee cup without tremor or severe pain (previously unable). Patient reports subjective feeling of 'looseness' in forearm."
SOAP Note - Plan Section:
"Dry needling performed to right ECRB muscle belly (3 sites, 40mm needle, depth 20mm), extensor digitorum (2 sites, 40mm needle, depth 20mm), and common extensor tendon insertion at lateral epicondyle (peppering technique, 30mm needle, depth 8mm). Local twitch responses elicited at muscle sites. Patient tolerated tendon needling with expected discomfort. Post-needling soreness expected in forearm for 24-48 hours. Patient educated on home exercise program (written instructions provided). Follow-up in 1 week for reassessment and exercise progression."
EXERCISE AND REHAB PROGRAMMING
Here's what I tell every tennis elbow patient after needling:
"The needling gives us a pain-free window to recondition muscles and tendons. Now we get to load them to begin reconditioning how the muscles behave. Tendons love load, so exercising them adequately and progressively is a non-negotiable."
I'm direct about this because compliance is everything with lateral epicondylalgia. Patients who do the home program get better. Patients who don't, don't.
Why Dry Needling Alone Isn't Enough:
Lateral epicondylalgia is in most chronic cases tendon changes. Tendons don't heal from rest. They heal from progressive loading. The tendon needs mechanical stimulus to remodel and rebuild.
But you can't load a tendon effectively when the muscles attached to it have uneccessary tension. That's why previous physical therapy failed, they tried to load dysfunctional muscles.
Now that we've created a window of opportunity and the muscles can contract “normally.” Now we can load the tendons to stimulate healing.
The rehab has three phases:
Isometric loading (no movement, just muscle contraction)
Eccentric loading (the gold standard for tendon healing)
Progressive strengthening (rebuilding capacity)
Skip any phase and you leave results on the table.
PHASE 1: IMMEDIATE POST-NEEDLING (Same Day)
Goal: Begin loading the tissue while it's in a receptive state
Exercise Protocol:
1. Gentle Active Wrist ROM
Wrist extension and flexion
15-20 reps each direction
Pain-free range only
No resistance
2. Isometric Wrist Extension
Seated at table, forearm supported, palm down
Place opposite hand on top of affected hand
Attempt to extend wrist while providing resistance with opposite hand (no movement occurs)
Hold 5 seconds, 10 reps. (You may think this is not enough, but for a patient suffering, its more than enough to begin with)
Should feel muscle contraction in forearm without pain >3/10
3. Gentle Gripping
Squeeze soft ball or therapy putty
20 reps, hold every 10 squeeze for 3 seconds
Light resistance only
PHASE 2: WEEKS 1-2
Goal: Isometric strengthening, pain reduction, begin eccentric loading
Frequency: Daily
Exercise Protocol:
1. Isometric Wrist Extension (Progressive)
Same as Phase 1, but increase hold time to 30 seconds
5 reps, twice daily
Can gradually increase resistance by pressing harder with opposite hand
Pain should not exceed 3/10
2. Eccentric Wrist Extension - The Tyler Twist (Week 2)
This is the gold standard exercise for tennis elbow
Hold a FlexBar or rolled towel in both hands
Affected hand on bottom, unaffected hand on top
Extend both wrists (twisting the bar/towel)
Relax the unaffected hand while maintaining wrist extension with the affected hand
Slowly allow the affected wrist to flex (eccentric phase)
3 sets of 15 reps, three times daily
This should be uncomfortable (up to 5/10 pain during the exercise)—that's expected and therapeutic
3. Grip Strengthening
Squeeze tennis ball or therapy putty
Progress resistance weekly (soft → medium → firm)
3 sets of 15-25 reps, once daily
4. Forearm Stretching
Wrist flexor stretch: arm straight, palm up, pull fingers down gently with opposite hand
Hold 30 seconds, 3 reps, twice daily
Wrist extensor stretch: arm straight, palm down, pull fingers down
Hold 30 seconds, 3 reps, twice daily
Patient Education:
"The Tyler Twist exercise will be uncomfortable. That's okay. We're loading the tendon to make it heal and remodel. Pain up to 5/10 during the exercise is acceptable. If it's worse the next day and doesn't return to baseline within 24 hours, back off slightly."
If advanced lifters - you may use light dumbbells to recreate the Tyler Twist exercise.
PHASE 3: WEEKS 3-4
Goal: Progressive eccentric loading, functional strengthening
Frequency: 4-5 days per week
Exercise Protocol:
1. Continue Tyler Twist
Progress to stiffer FlexBar or double-rolled towel
4 sets of 15 reps, twice daily
2. Eccentric Wrist Extension with Dumbbell
Seated, forearm supported on table, palm down, wrist hanging off edge
Hold light dumbbell (2-5 lbs to start)
Use opposite hand to lift wrist into extension
Remove opposite hand, slowly lower weight (eccentric phase) with affected hand
3 sets of 15 reps, once daily
Progress weight by 2.5 lbs every week as tolerated
3. Wrist Extension Against Resistance Band
Forearm supported, palm down
Resistance band looped around hand
Extend wrist against band resistance
Emphasize 3-second eccentric (lowering phase)
3 sets of 15 reps, once daily
4. Functional Gripping Activities
Begin return to light functional activities
Carry light groceries, open jars (with technique modification if needed)
Track pain response: should not exceed 4/10 during activity and should return to baseline within 24 hours
PHASE 4: WEEKS 5-8
Goal: Heavy loading, return to full function, prevent recurrence
Frequency: 3-4 days per week with rest days
Exercise Protocol:
1. Heavy Eccentric Wrist Extension
Progress dumbbell weight to 10-15 lbs
Same technique as Phase 3
3 sets of 12 reps, once daily
2. Farmer's Carries
Hold dumbbell or kettlebell in affected hand, walk 30-60 seconds
Start light (10-15 lbs), progress to heavier weights
This builds grip endurance and wrist stabilization
3 sets, 3x per week
3. Dead Hangs (if appropriate for patient)
Hang from pull-up bar for time
Start with 10-20 seconds, progress to 60 seconds
Builds massive grip strength and forearm endurance
3 sets, 2x per week
4. Return to Sport/Work Activities
Gradually reintroduce aggravating activities
If patient plays tennis: start with 50% normal play duration, progress 10% weekly
If office worker with mouse-intensive work: ensure ergonomic setup, take frequent breaks
Monitor for symptom increase—if pain worsens significantly, reduce intensity
Modifications Based on Patient Presentation:
If Patient Has Significant Neural Symptoms (Radial Tunnel Syndrome Component):
Add neural gliding exercises for radial nerve
Reduce aggressive loading in Phase 3-4
Consider additional needling to supinator
If Patient is Overhead Athlete (Tennis Player, Pitcher):
Include sport-specific exercises starting Phase 3
Coordinate with coach for gradual return to play
Address any technique flaws contributing to overload
If Patient Has Bilateral Symptoms:
Treat both sides but stagger heavy loading days
Progression may be slower
Consider workstation ergonomics or tool modifications
Expected Timeline:
Week 1: 20-30% improvement in pain, significant improvement in grip strength
Week 3: 40-50% improvement, able to perform most daily activities with minimal pain
Week 6: 50-70% improvement, return to most functional activities
Week 8-10: 80-90% improvement, return to full activity including sports
Red Flags:
If patient isn't improving by week 3-4:
Reassess for compliance with home program (Compliance is the biggest issue)
Consider additional needling session
Rule out cervical spine contribution
Assess ergonomics and aggravating factors
SOAP Note - Plan Section (Exercise Prescription):
"Home exercise program prescribed for lateral epicondylalgia rehabilitation.
Phase 1 (Immediate): Isometric wrist extension, gentle gripping.
Phase 2 (Weeks 1-2): Progressive isometric strengthening, Tyler Twist eccentric exercise (twice daily).
Phase 3 (Weeks 3-4): Eccentric wrist extension with dumbbell, resistance band exercises.
Phase 4 (Weeks 5-8): Heavy eccentric loading, functional strengthening, gradual return to full activity.
Written instructions with videos provided via app. Patient verbalized understanding of program, especially importance of eccentric loading despite discomfort. Follow-up in X weeks to assess progress and advance program."
CLINICAL PEARLS
A few things I've learned after treating lots of tennis elbow cases:
1. Don't skip the muscle belly needling to jump straight to the epicondyle.
The tendon insertion is where patients feel the pain, so it's tempting to just needle there and call it done.
But the muscle belly is where most of the dysfunction lives. Trigger points in ECRB maintain abnormal tension on the tendon. Release those first. Then, if needed, needle the insertion.
I've had patients improve 70-80% with muscle needling alone, never needing tendon insertion needling.
2. The Tyler Twist is your best friend.
This exercise has the strongest evidence for tennis elbow. Teach it properly, demonstrate it, make sure they understand the eccentric component.
Here's the key: patients need to do it despite discomfort.
Most patients have been told "avoid pain." Now you're telling them to exercise into pain (up to 5/10). This requires education and reassurance.
I tell them: "Pain during the exercise doesn't mean you're damaging anything. The tendon needs this load to heal. If you avoid all pain, you avoid the stimulus the tendon needs."
3. Corticosteroid injections have a place, but not as first-line treatment.
If a patient has had 2+ corticosteroid injections before seeing you, their tendon is likely weaker and more fragile. Set realistic expectations, in most cases they will need 12-16 (up to 20) weeks instead of 8-10 weeks.
Repeated injections can delay healing and increase risk of tendon rupture. I don't refer for injections until we've tried dry needling + eccentric loading for at least 8-10 weeks.
4. Ergonomics matter more than patients think.
Office workers with tennis elbow almost always have poor ergonomic setup:
Mouse too far away (requires reaching)
Mouse too small (requires death grip)
Wrist unsupported during typing
Have them take a photo of their workstation. Review it. Make specific recommendations. This is how you can prevents recurrence at work.
5. Tennis elbow in actual tennis players is usually technique-related.
Late backhand preparation, "arm" backhand instead of rotating from the trunk, poor grip size on racket.
If you have a tennis player with lateral elbow pain, refer them to a teaching pro for technique analysis. Otherwise it keeps coming back. If they are working with a coach, connect with them and let them know your thoughts.
Teamwork in these cases will help the patient (athlete) improve better as there’s a consistent message being told.
6. Grip strength is your best outcome measure.
Track grip strength with a dynamometer at every visit. It's objective, reliable, and correlates directly with function.
When grip strength returns to within 10% of the unaffected side, the patient is ready for discharge.
When to Modify or Refer:
Patient not improving 30-40% by week 3 despite needling and exercise → Consider imaging (ultrasound or MRI) to assess tendon integrity
Severe weakness or inability to extend wrist → Consider posterior interosseous nerve syndrome, get EMG/NCS
Numbness or tingling in hand → Consider cervical radiculopathy or nerve entrapment, examine cervical involvement.
Patient has had 3+ corticosteroid injections → Set conservative timeline.
CASE EXAMPLE
Let me tell you about Mark.
He was a 45-year-old software engineer. Six months of right lateral elbow pain, rated 7/10 at worst. Couldn't open doors without pain. Couldn't shake hands without grimacing. Typing all day was agony.
He worked from home, spent 8-10 hours per day on the computer. Mouse work, typing, repetitive clicking.
He'd tried everything: rested for a month (didn't help), wore a tennis elbow brace for 8 weeks (helped while wearing it, didn't fix anything), got a corticosteroid injection (4 weeks of relief, then pain came back worse).
When he walked into my office, he was frustrated. "I can't do my job like this. I'm worried I'll have to get surgery and then I’ll be off work for too long and could lose my job.”
Examination Findings:
Cozen's test: Positive, reproduces pain 7/10
Mill's test: Positive, reproduces pain 6/10
Maudsley's test: Positive, reproduces pain 7/10
Grip strength: 30 lbs right (affected), 52 lbs left (unaffected) - 42% deficit
Coffee cup test: Unable to lift full coffee cup without hand slightly shaking and pain
Palpation: Severe tenderness at lateral epicondyle, multiple taut bands and trigger points in ECRB muscle belly (3-4cm distal to epicondyle), trigger points in extensor digitorum, moderate tenderness over supinator region
Working Diagnosis:
Lateral epicondylalgia, right elbow, affecting ECRB and extensor digitorum muscles, with chronic tendinosis at common extensor tendon insertion.
Treatment Approach:
Session 1 (Week 0):
Dry needling to ECRB muscle belly (3 sites, strong local twitch responses, patient reported "that's exactly where my elbow hurts")
Dry needling to extensor digitorum (2 sites)
Immediate improvement: grip strength increased to 42 lbs (40% improvement)
Could lift coffee cup without trembling (pain still present)
Prescribed Phase 1 exercises: isometric wrist extension, gentle gripping
Discussed ergonomic modifications for workstation
Session 2 (Week 1):
Patient reported 25% overall improvement
Sleeping better (wasn't waking from pain when rolling onto right arm)
Post-needling soreness resolved after 36 hours
Compliance with exercises: good
Made ergonomic changes: external monitor, ergonomic mouse, wrist rest
Repeat needling: ECRB (2 sites), extensor digitorum (1 site)
Advanced to Phase 2 program: Tyler Twist exercise added
Session 3 (Week 3):
Patient at 55% improvement
Grip strength improved to 46 lbs (88% of unaffected side)
Could shake hands without pain
Tyler Twist exercise going well, tolerating discomfort
Trigger points still palpable but less intense
Repeat needling: ECRB (2 sites), added common extensor tendon insertion needling
Progressed to Phase 3: eccentric wrist extension with dumbbell
Session 4 (Week 5):
Patient at 70% improvement
Working full days without significant pain increase
Grip strength: 50 lbs (96% of unaffected side)
Able to open doors, shake hands, use mouse without pain
Trigger points nearly resolved
Advanced to Phase 4 program: heavy eccentric loading, farmer's carries
8-Week Follow-Up:
Mark reported 85% improvement. Pain was now 2/10 on worst days, 0/10 most days. He was working full-time without issues. Grip strength was 52 lbs (equal to unaffected side).
I discharged him to our maintenance performance program.
What Made the Difference:
Three things:
Correct diagnosis and treatment of muscle dysfunction: The trigger points in his ECRB were maintaining tension on the tendon. Previous treatments (brace, injection) never addressed this.
Progressive eccentric loading: The Tyler Twist exercise specifically loads the ECRB tendon eccentrically, which is exactly what it needs to remodel and heal.
Ergonomic modifications: His workstation setup was perpetuating the problem. Fixing it prevented recurrence.
Six months later, he was still pain-free and back to all activities including recreational rock climbing (which he'd stopped due to elbow pain).
KEY TAKEAWAYS FOR YOUR PRACTICE
Lateral epicondylalgia is tendinosis, not tendinitis. Stop treating it like an inflammatory condition. Rest and corticosteroid injections are temporary band-aids at best.
Trigger points in the ECRB muscle belly are the primary problem. Don't skip muscle needling to jump straight to the epicondyle. The muscle is where the dysfunction lives.
The Tyler Twist eccentric exercise has the strongest evidence. Teach it properly and emphasize that discomfort during the exercise (up to 5/10) is expected and therapeutic.
Grip strength is your best objective outcome measure. Track it at every visit with a dynamometer. Recovery means returning to within 10% of the unaffected side.
Ergonomics are critical for prevention and recurrence. Office workers need proper setup. Manual workers may need tool modifications. Athletes may need technique analysis.
Set realistic timelines: 30-40% improvement by week 2-3, 70-80% by week 6-8. Chronic cases (6+ months duration, multiple previous injections) may need 10-12 weeks.
SOAP NOTE TEMPLATE FOR LATERAL EPICONDYLALGIA
S: [Age]-year-old [M/F] presents with [duration] history of [R/L] lateral elbow pain, rated [#/10]. Pain worsens with gripping, lifting, twisting motions. Reports difficulty [specific functional limitations]. Previous treatments: [list with outcomes].
O:
Cozen's test: [+/-, pain level]
Mill's test: [+/-, pain level]
Maudsley's test: [+/-, pain level]
Grip strength: [#] lbs affected side, [#] lbs unaffected side ([%] deficit)
Coffee cup test: [able/unable to lift without pain or tremor]
Palpation: [Tender at lateral epicondyle Y/N], trigger points in [specific muscles with locations], reproducing [referral pattern]
A: Lateral epicondylalgia, [R/L] elbow, affecting [specific muscles]. Clinical presentation consistent with chronic tendinosis with myofascial trigger point involvement. [Differential diagnoses ruled out with rationale].
P:
Trigger point dry needling performed: [muscle list with needle specs, depth, number of sites, LTR Y/N]
[If performed: Tendon insertion needling via peppering technique]
Patient tolerated well, post-needling forearm soreness expected 24-48h
Home exercise program: [Phase and specific exercises], frequency [specify]
Ergonomic recommendations: [specific modifications discussed]
Written instructions provided
Re-evaluation in [timeframe]
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NEXT EDITION: February 6, 2026
Topic: Tension-Type Headaches
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In health and strength,
Dr. Thomas Kauffman, DC, CDNP, CSCS, USAW
The Clinical Coach™
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