Tennis Elbow Treatment in North Vancouver

Common symptoms:

• Pain on the outside of the elbow, worst when gripping or lifting with the palm down
• Weak grip — dropping things, trouble opening jars
• Pain with repeated wrist movement — typing, tools, cooking
• Tenderness over the bony point on the outside of the elbow
• Aching or tightness through the forearm toward the wrist
• Sometimes tingling, numbness, or a heavy feeling in the forearm or hand

When to seek treatment: if elbow pain has lasted more than three or four weeks despite rest, if a brace hasn't helped, or if grip weakness is affecting your work or daily activities.

Why the pain is at the elbow

Karel Lewit, one of the founders of the Prague School of Rehabilitation Medicine, treated lateral elbow pain as the end result of dysfunction elsewhere rather than as a local injury. In his approach, the regions to examine are:

• the cervical spine, particularly the C5–C7 segments
• the shoulder and how the shoulder blade moves and holds position
• the thoracic spine and ribs
• the wrist and forearm, and how their muscles coordinate

The elbow is examined too — but as one link, and often not the decisive one.

What examination finds. In a case-control study of 165 people with tennis elbow, more than a third had measurable dysfunction in the cervical spine and 41% had a positive nerve-tension test for the radial nerve — in a group selected to exclude anyone reporting neck or arm symptoms (Coombes et al., JMPT, 2014). These findings are usually silent. They show up on examination, not in the patient's account of their problem.

The nerve. The radial nerve runs from the neck, spirals behind the upper arm, and passes the outside of the elbow on its way to the hand. Ultrasound imaging shows it is measurably thicker and more sensitive to pressure along its course in people with tennis elbow than in people without (Cancela-Cilleruelo et al., Diagnostics, 2023). Where the nerve is involved, it produces pain that behaves like tendon pain.

Treatment above the elbow changes the elbow. In a placebo-controlled, double-blind trial, a single treatment applied to the neck immediately increased pain-free grip strength in the affected hand (Vicenzino et al., Pain, 1996). In a sham-controlled trial, a single two-minute mobilisation of the mid-back increased pain-free grip strength by an average of 4.4 kg (Zunke et al., BMC Musculoskeletal Disorders, 2020).

This is Lewit's central point in practice: the site of the pain and the site of the disturbance are frequently not the same place. So the examination starts away from the elbow and works toward it.

Dysfunction in the movement system

The disturbance Lewit describes is not a single faulty structure. It is a pattern across the movement system — joints that have lost their joint play, muscles holding tone they don't need, and a grip that recruits far more than it should. The painful tendon sits at the end of that pattern.

Muscle tone and trigger points.

Trigger points in the forearm muscles — extensor carpi radialis brevis and longus, extensor digitorum, brachioradialis — reproduce the elbow pain patients describe when pressed (Fernández-Carnero et al., Clin J Pain, 2007). Lewit treated these as a principal contributor, alongside supinator, triceps, and sometimes the shoulder muscles.

The shoulder blade.

People with tennis elbow have reduced strength and endurance in the muscles that stabilise the shoulder blade — the middle and lower trapezius and serratus anterior — compared with matched, pain-free people (Day et al., JOSPT, 2015). When the shoulder blade doesn't hold a stable base, the forearm works harder for the same task.

How you grip.

Much of what keeps a tennis elbow going is coordination rather than strength: gripping harder than the task requires, holding the wrist in a position that keeps the extensors loaded, stabilising with the forearm because the shoulder isn't doing it. This is what Dynamic Neuromuscular Stabilisation addresses — restoring the position and control of a joint so it works from a settled base rather than a braced one (Kobesová & Kolář, J Bodyw Mov Ther, 2014).

What about the tendon?

Degenerative change in the tendon can be present — wear and failed healing rather than active inflammation. It is worth knowing about, and it is seldom what treatment is usefully directed at.

Imaging findings of tendon damage do not reliably match how much pain or difficulty a person has (Chourasia et al., JOSPT, 2013). The same tendon changes appear on scans in people with no symptoms at all — around 10% of people aged 35 to 44, rising to about 60% by ages 55 to 65 (Paluch et al., Shoulder & Elbow, 2022).

A tendon finding, on its own, explains very little and offers treatment very little to work with. What responds is the dysfunction around it.

Why elbow-only treatment stalls

Can you see the imbalance that affects the elbow?

A 2024 multicentre randomised trial of 143 people compared standard multimodal physiotherapy with the same programme plus treatment directed at the neck and upper limb. At three months, 78% of the group receiving the wider treatment rated themselves much improved, against 36% of those treated locally (Dunning et al., Clinical Rehabilitation, 2024).

A corticosteroid injection follows a different pattern: best results at six weeks, worst results long-term, with a high rate of recurrence. In the same trial, physiotherapy outperformed a wait-and-see approach in the short term, and by twelve months most people in both groups had improved (Bisset et al., BMJ, 2006).

Treatment

• Look beyond the elbow. Evaluate trunk stability, shoulder girdle function, cervical spine, and wrist mechanics to identify the “key link” contributing the overload
• Restore Joint function – cervical and upper thoracic spine.
• Reduce muscle hypertonicity – muscle tightness
• Re-establish proper movement patterns with stability exercises

What to expect

Tennis elbow improves for most people over time — around 80% of cases resolve within a year (Sayegh & Strauch, Clin Orthop Relat Res, 2015). Treatment is about getting there sooner, staying able to work and train while you do, reducing the chance of it returning, and identifying the cases that aren't resolving and finding out why.

Assessment and treatment begin in the same session. Eva will explain what she found, which findings relate to your symptoms, and what the plan is.

Progress is usually gradual rather than sudden, and the exercises you do between appointments carry a good share of the work.

The Scandinavian Clinic

• Assessment that begins away from the elbow. Neck, upper back, shoulder-girdle, and forearm coordination are examined as standard.
• Swedish-trained orthopaedic manual therapy. Five years of university-level training in Sweden, with a strong emphasis on clinical reasoning and biomechanical assessment.
• Czech-trained in Dynamic Neuromuscular Stabilisation, in the Prague School tradition of Lewit, Janda and Kolář — where the approach on this page comes from. Learn more
• Covered by most extended health plans. As a Registered Massage Therapist, Eva's treatments are eligible for extended health benefits.

See all conditions Eva treats

Frequently asked questions