Epicondyalgia in 2025

Elbow pain often presents as a diagnostic and treatment dilemma. While tendinopathy is the most common pathology seen in the adult elbow, the contribution of local tissue pathology and sensorimotor impairments varies between individuals. In addition, psychosocial and environmental factors may contribute to symptom severity and chronicity. This introductory Masterclass will review the underlying mechanisms and pathophysiology related to lateral elbow tendinopathy, and the role that sensorimotor function and psychosocial factors play in the presentation of symptoms.

A Common Condition—But Not Always Benign

Lateral elbow tendinopathy affects 1–3% of the general population, but prevalence increases significantly in certain groups:

• up to 30% in manual workers (e.g., meat, fish, or craft workers),
• up to 40% in recreational tennis players.

Despite the widespread belief that it resolves spontaneously within 6 to 24 months, studies show that 20-50% of patients continue to experience persistent symptoms at 12 months regardless of the treatment received, especially following corticosteroid injections.

Diagnosis—Clinically Driven, Not Image-Based

Classic Clinical Signs:

• Localized pain over the lateral epicondyle
• Pain on palpation and with resisted wrist or middle finger extension
• Decreased pain-free grip strength

Imaging is not a reliable diagnostic tool:

• Low specificity (~47%) despite good sensitivity
• Many imaging abnormalities are found in asymptomatic individuals
• Should only be used to rule out other pathologies, not to confirm tendinopathy

👉 Bottom line: Trust your clinical examination, not the scans.

Risk Factors and Poor Prognostic

Identified Risk Factors:

• Repetitive manual work
• Advanced age
• Smoking
• Co-existing shoulder pathologies

Predictors of Poor Prognostic:

• Significant initial pain and disability
• Neck and shoulder pain
• Cold hyperalgesia
• Non-modifiable physical workload demands

Beyond the Elbow—Look Higher, Look Wider

General Upper Limb Weakness

Even in unilateral or asymptomatic patients, studies show:

• bilateral weakness in shoulder muscles (abduction, external rotation);
• deficits in wrist extensors, lower trapezius, and serratus anterior.

👉 Don’t limit your rehab to the elbow: incorporate proximal work, especially of the shoulder and scapula.

Central Sensitization

Many patients also exhibit:

• mechanical and cold hyperalgesia;
• bilateral sensorimotor deficits (speed, reaction time, wrist posture);
• increased temporal summation of pain, indicating central facilitation.

👉 The pain is not just peripheral: the central nervous system is involved.

Psychosocial Factors: The Ground on Which Symptoms Grow

Although research is still evolving:

• higher levels of pain and disability are associated with greater catastrophizing, kinesiophobia, and lower quality of life ;
• negative talk (from self or others) can worsen perceived pain and increase chronicity risk.

👉 Always assess psychosocial factors, especially in chronic or non-responsive cases.

Conclusion: A Multidimensional Physical Therapy Approach

Lateral epicondylalgia is not just a tendon issue it reflects a broader systemic imbalance:

• biomechanical (distal and proximal weaknesses, motor deficits);
• neurological (central sensitization);
• psychological (beliefs, emotions, coping strategies).

Your role as a physical therapist goes far beyond the elbow; it is about understanding the whole person behind the symptoms.

Clinical Takeaways for the Therapist:

• Assess local pain... but think globally.
• Strengthen proximal muscles, not just the wrist.
• Screen for cervical, scapular, and cold-related symptoms.
• Recognize signs of central sensitization and tailor your approach.
• Integrate education, psychosocial factors, and clinical reasoning at every stage.
• Imaging is secondary; your clinical skills come first.

Think Like a Conductor

The tendon is only one instrument. For pain-free, harmonious movement, the entire system must be tuned proximal strength, nervous system regulation, patient mindset. Your mission is to orchestrate this complex, yet powerful, symphony of recovery.