Tennis Elbow: Why It Happens, Why It Hurts, and How We Fix It (Properly)
Tennis elbow (lateral elbow tendinopathy) is one of the most common upper-limb injuries I treat as a sports physiotherapist in London. And despite its name, the condition affects far more than just tennis players — I see it regularly in boxers, recreational athletes, weightlifters, desk-based workers, and anyone experiencing a sudden or sustained overload to the elbow and forearm.
This week alone, I’ve had two new tennis elbow patients, and both developed symptoms after boxing. It’s a perfect example of how this condition is not simply an elbow problem, but often a whole-upper-limb load management problem.
Understanding why the tendon becomes irritated is the first step toward effective, long-term recovery.
Why Tennis Elbow Develops (The Load–Capacity Explanation)
1: Sudden or rapid increase in load
High-quality research on tendon pathology — particularly the Tendon Continuum Model by Cook & Purdam (2009) — shows that tendinopathy often develops when load exceeds tissue capacity.
This can occur when someone:
Starts boxing or hitting the bag more frequently
Returns to gym training after time off
Performs repetitive gripping or lifting tasks
Increases training intensity too quickly
When the forearm extensors are exposed to a spike in demand, the tendon becomes reactive and symptomatic.
2: Gradual overload without adequate recovery
Some people develop tennis elbow gradually.
Micro-loading accumulates over time, and because recovery doesn’t match training stress, the tendon slowly becomes overloaded.
This explains why some patients say:
“It just crept up on me — I can’t think of a single moment where it started.”
When Tennis Elbow Isn’t Just a Tendon Problem: The Neural Component
Several studies, including a systematic review by Clewley et al. (2014), highlight that neural sensitivity — particularly involving the radial nerve — can contribute to lateral elbow pain.
This is why SOME patients experience:
Sharp, shooting discomfort
Pain radiating down the forearm
Tightness that doesn’t respond to stretching alone
Ignoring the neural component can delay recovery. Addressing it accelerates progress. Having an assessment by a professional who is capable to identify if you have any neural component of your injury will be crucial to help manage the condition effectively.
Why the Elbow Takes the Hit: Poor Load Transfer in the Upper Limb
A common question patients ask is:
“Why is it my elbow that hurts, not my wrist or shoulder?”
The answer lies in biomechanics and load transfer.
If the shoulder lacks stability, or the rotator cuff and scapula aren’t controlling movement well, the elbow becomes the compensator.
Similarly, poor wrist stability during gripping or punching increases strain on the common extensor tendon.
Research by Lucado et al. (2019) supports this, showing that proximal (shoulder and scapular) strengthening plays a significant role in reducing elbow overload.
This is especially relevant in sports like boxing, where force transmission through the upper limb must be highly coordinated.
Evidence-Based Treatment Approach for Tennis Elbow
As a sports physiotherapist, my treatment framework combines hands-on therapy with targeted loading, neural intervention when required, and structured strengthening that addresses both local symptoms and global biomechanics.
1. Mobilisations With Movement (MWM)
A common treatment technique used widely by Australian and New Zealand Physiotherapists, Mobilisations with Movement (MWM) techniques aim to work immediately, and is a form of ‘Active therapy’.
I really like using MWM’s as the client feels like they’re part of the recovery, not just coming in to get a massage and needles poking into their arm.
Vicenzino et al. (2001) demonstrated that MWM techniques can:
Reduce pain immediately
Improve pain-free grip strength
Enhance function
In clinic, a lateral glide applied while the patient performs the painful movement often reduces symptoms by 30% or more — a reliable indicator that the technique is effective.
2. Taping to Reinforce the Lateral Glide
I often apply specific taping that mimics the MWM glide.
This supports the joint, reduces strain on the tendon, and provides short-term relief during daily activities or sport.
When applied properly, the tape usually allows our clients to continue using their arm with significantly less pain, which ends up ‘tricking’ the brain to think that it’s not painful to do the previously painful thing (eg carrying your bag, opening a bottle, lifting weights etc).
It allows your muscles to function, allowing you to take active steps toward your own recovery.
3. Dry Needling for Pain Modulation
Dry needling can effectively reduce muscular tone, decrease pain sensitivity, and improve movement tolerance — making it a helpful adjunct before beginning heavier exercise loading.
4. A Structured, Progressive Rehabilitation Plan (The Foundation of Recovery)
Research consistently shows that progressive tendon loading is the most effective long-term treatment for lateral elbow tendinopathy.
Landmark Study:
Stasinopoulos & Stasinopoulos (2006) demonstrated that isometric, eccentric, and eccentric–concentric exercises all significantly improve pain and function.
This is why exercise rehabilitation is the backbone of my approach.
Direct Tendon-Targeted Exercises
Isometric Wrist Extensions
Isometrics reduce pain and restore muscle activation.
The analgesic effect is well supported by Rio et al. (2015).
Heavy Grip Holds (e.g., kettlebell carries)
These load the entire extensor mechanism and help rebuild strength for functional gripping tasks.
Isotonic Strengthening Progressions
Including:
Wrist extension
Supination
Pronation
These gradually increase tendon capacity and resilience.
Wrist extension isotonic exercise for tennis elbow.
Indirect Exercises: Fixing the Root Cause
To prevent recurrence, rehab must address the proximal factors that overloaded the elbow in the first place.
My go-to exercises include:
Dumbbell external rotations (rotator cuff)
Powell raises (scapular stability)
These exercises improve shoulder mechanics, enhance force transfer, and reduce stress on the elbow — supported by Lucado et al., 2019.
The Key Principle: Treat the Upper Limb as a Biomechanical System
Long-term success comes from addressing:
The tendon
The neural component
The shoulder and scapular stability
The movement patterns that caused overload
The sport-specific demands (e.g., boxing, tennis, weight training)
When these components are integrated, people don’t just get pain-free — they return to sport stronger than before.
If You’re Experiencing Tennis Elbow in London
I specialise in treating tennis elbow, boxing-related elbow pain, and sports injuries across:
Tower Bridge
Canary Wharf
New Malden (Bounce Gym)
My approach combines manual therapy, evidence-based rehabilitation, and high-level strength programming to help people return to their sport with confidence.
About the Author
Ryan Tan is a London-based Sports Physiotherapist and the founder of Physiologic, a specialist clinic dedicated to treating sports injuries and spinal conditions. With extensive experience working in Australia, Hong Kong, and now London, Ryan is known for his evidence-based approach, advanced manual therapy skills, and expertise in tendon rehabilitation, dry needling, and gym-based strength programming.
He currently consults at Ultra Sports Clinic (Tower Bridge and Canary Wharf) and Bounce Gym in New Malden, where he helps athletes, runners, boxers, and active individuals recover from injuries and return to high performance with confidence.
Ryan is recognised for his ability to diagnose complex issues, provide clear explanations, and deliver structured, progressive rehabilitation plans that create long-lasting results.
