This narrative review proposes a conceptual model of lateral epicondylalgia (tennis elbow). It integrates three interrelated components: local tendon pathology, pain system changes, and motor system impairment. The goal is to explain why presentations differ between patients and to guide individualized, multimodal treatment.
When you see a patient with tennis elbow, stop thinking of it as inflammation. The histology is angiofibroblastic hyperplasia, a failed degenerative healing response, which is why anti-inflammatory strategies underperform.
The practical decision rule this model teaches: profile each patient by which component dominates. A recalcitrant case with structural tendon change is managed differently than an acute case dominated by pain-system sensitisation or one with widespread motor deficits.
The corticosteroid data is the highest-yield takeaway. Injection looks good early but produces 72% recurrence at one year versus 9% with wait-and-see, and is inferior to exercise-based physiotherapy at 26 weeks. Use pain-free grip strength, not maximum grip, to track progress. It is more sensitive and reflects the pain system rather than provoking it.
When prescribing loading, start wrist extensor exercise with the elbow flexed, since elbow extension increases compressive load at the ECRB insertion and provokes symptoms.
This narrative review proposes a conceptual model of lateral epicondylalgia (tennis elbow). It integrates three interrelated components: local tendon pathology, pain system changes, and motor system impairment. The goal is to explain why presentations differ between patients and to guide individualized, multimodal treatment.
When you see a patient with tennis elbow, stop thinking of it as inflammation. The histology is angiofibroblastic hyperplasia, a failed degenerative healing response, which is why anti-inflammatory strategies underperform.
The practical decision rule this model teaches: profile each patient by which component dominates. A recalcitrant case with structural tendon change is managed differently than an acute case dominated by pain-system sensitisation or one with widespread motor deficits.
The corticosteroid data is the highest-yield takeaway. Injection looks good early but produces 72% recurrence at one year versus 9% with wait-and-see, and is inferior to exercise-based physiotherapy at 26 weeks. Use pain-free grip strength, not maximum grip, to track progress. It is more sensitive and reflects the pain system rather than provoking it.
When prescribing loading, start wrist extensor exercise with the elbow flexed, since elbow extension increases compressive load at the ECRB insertion and provokes symptoms.