You feel pain on the outside of your elbow. It hurts when you grip, lift a kettle, shake someone’s hand, or even open a jar.
You’re told it’s “tennis elbow.”
You rest it.
You ice it.
You try braces, injections, or exercises.
But months later… the pain is still there.
Here’s the reality: not all lateral elbow pain is tennis elbow. In fact, research shows a surprising number of people are misdiagnosed, meaning the real problem is never addressed.
For people living active lives on Sydney’s Northern Beaches, whether that’s surfing, lifting at the gym, working on a laptop, or playing weekend sport, getting the diagnosis right matters.
Let’s explore why tennis elbow is sometimes the wrong diagnosis, what the science says, and how identifying the true cause of elbow pain can dramatically change treatment and recovery.
The Problem With the “Tennis Elbow” Label
“Tennis elbow” (medically called lateral epicondylitis) is one of the most commonly diagnosed elbow conditions.
It affects roughly 1–3% of adults every year and typically occurs when the tendons that attach to the lateral epicondyle become overloaded from repetitive wrist and forearm activity.
But a fascinating 2025 study by Blonna and colleagues looked deeper into patients who weren’t improving with standard treatment.
The researchers studied 189 patients who had:
- Been diagnosed with tennis elbow
- Experienced symptoms for more than 6 months
- Failed standard non-surgical treatments
What they discovered was surprising.
11% of these patients had been misdiagnosed entirely.
In other words, their elbow pain wasn’t tennis elbow at all.
The Conditions That Mimic Tennis Elbow
Among the misdiagnosed patients, researchers discovered several different conditions causing the elbow pain.
Posterolateral Elbow Instability (29%)
This was the most common hidden diagnosis.
Posterolateral instability occurs when the lateral collateral ligament complex becomes weakened, allowing subtle instability in the elbow joint.
Symptoms often include:
- Clicking or clunking in the elbow
- A feeling of instability when pushing up from a chair
- Pain during weight-bearing through the arm
Interestingly, some patients had received multiple corticosteroid injections, which may have weakened the ligament over time.
Posterior Interosseous Nerve Compression (14%)
Sometimes elbow pain is neurological rather than tendon-related.
Compression of the posterior interosseous nerve (PIN) can mimic tennis elbow but often presents with pain located a few centimetres further down the forearm.
Key symptoms may include:
- Deep aching in the forearm
- Weakness with finger extension
- Pain 3–4 cm below the elbow
Inflammatory Arthritis (14%)
Conditions such as:
- Rheumatoid arthritis
- Psoriatic arthritis
can cause elbow pain that mimics tendon injury.
However, inflammatory arthritis often includes:
- Joint swelling
- Morning stiffness
- Pain in multiple joints
Osteochondritis Dissecans (10%)
This condition occurs when a small piece of cartilage and bone loosens within the joint.
It is more common in younger athletes, particularly those who perform repetitive throwing motions.
Symptoms can include:
- Joint locking
- Catching sensations
- Reduced elbow mobility
Posterolateral Plica (10%)
A plica is a fold of synovial tissue within the elbow joint that can become inflamed and painful.
Patients may experience:
- Snapping sensations
- Pain with elbow extension
- Mechanical irritation within the joint
Primary Osteoarthritis (10%)
Degeneration within the elbow joint itself can cause pain that is easily mistaken for tendon injury.
Typical signs include:
- Reduced elbow motion
- Grinding sensations
- Deep joint pain rather than tendon tenderness
Red Flags That Suggest It’s Not Tennis Elbow
One of the most valuable findings of the study was identifying specific warning signs that point away from tennis elbow.
1. Young Age
This was the strongest indicator of misdiagnosis.
The study found:
- All patients under 20 had a different diagnosis
- Most patients aged 21–30 also had non–tennis elbow conditions
This suggests that lateral elbow pain in young patients should not automatically be labelled tennis elbow.
2. History of Trauma
Previous elbow injury significantly increases the chance that the pain is related to:
- Joint instability
- Post-traumatic arthritis
- Ligament damage
3. Swelling or Mechanical Symptoms
Classic tennis elbow usually does not restrict elbow movement.
Red flags include:
- Elbow swelling
- Clicking or snapping
- Locking of the joint
- Reduced range of motion
These symptoms suggest joint pathology rather than tendon irritation.
4. Multiple Cortisone Injections
Repeated corticosteroid injections may actually worsen certain conditions, particularly ligament instability.
In the study, patients with instability had received a median of five injections, which may have contributed to ligament weakening.
The Importance of Clinical Assessment
Diagnosing elbow pain correctly requires careful assessment, not simply assigning a label based on location.
Several clinical clues can reveal when tennis elbow isn’t the real issue.
Pain Location Matters
Pain located directly over the lateral epicondyle is typical of tennis elbow.
However:
- Pain further down the forearm may indicate nerve compression
- Pain inside the joint may indicate arthritis or cartilage damage
In the study, atypical pain location had a sensitivity of over 90% for identifying misdiagnosis.
The Cozen Test
A common clinical test for tennis elbow involves resisted wrist extension.
If this test does not reproduce pain, the diagnosis of tennis elbow becomes less likely.
Anconeus Muscle Fasciculations
A fascinating observation from the study was involuntary twitching of the anconeus muscle during instability testing.
This occurred frequently in patients with posterolateral elbow instability, suggesting a potential new diagnostic indicator.
Further research is needed, but it highlights how subtle neurological signs may reveal deeper joint problems.
Why Correct Diagnosis Matters
Misdiagnosing elbow pain doesn’t just delay recovery — it can make the condition worse.
For example:
- Treating instability as tendon pain may weaken ligaments further
- Surgical tendon release could worsen joint instability
- Ignoring nerve compression can lead to persistent dysfunction
Accurate diagnosis ensures treatment targets the true source of the problem.
A Whole-Body Perspective on Elbow Pain
At Neurohealth Wellness on Sydney’s Northern Beaches, elbow pain is rarely viewed in isolation.
Your elbow is part of a larger system involving:
- The shoulder and scapula
- The neck and nervous system
- The wrist and hand mechanics
Restrictions or dysfunction in these areas can overload the elbow and contribute to chronic symptoms.
This is why our chiropractors assess the entire kinetic chain, not just the painful joint.
You may also find these articles helpful:
- The Jaw–Pelvis Connection and Back Pain
- From Pain to Power: Overcoming Plantar Fasciitis
Both highlight how pain often originates from deeper movement imbalances rather than a single irritated tissue.
Take the First Step Toward the Right Diagnosis
If you’ve been dealing with elbow pain for months and treatments haven’t worked, the diagnosis may need a second look.
At Neurohealth Wellness, our practitioners focus on identifying the root cause of pain, not just treating symptoms.
Through detailed assessment of the nervous system, joints, and movement patterns, we aim to restore balance and help your body heal.
https://www.neurohealthwellness.com.au/booking
📞 (02) 9905 9099
Lateral elbow pain is commonly labelled tennis elbow, but research shows that up to 1 in 10 patients may be misdiagnosed, particularly when symptoms persist despite treatment.
Conditions such as elbow instability, nerve compression, inflammatory arthritis, and joint pathology can all mimic tennis elbow but require completely different management.
Key red flags include young age, history of trauma, swelling, mechanical symptoms, atypical pain location, and failed treatments.
A comprehensive assessment that considers the whole body and nervous system is essential for identifying the true cause and restoring long-term function.
References
- Blonna, D., et al. (2025). When Lateral Epicondylitis Is Not Lateral Epicondylitis.
- Ahmad, Z., Siddiqui, N., Malik, S. S., Abdus-Samee, M., Tytherleigh-Strong, G., & Rushton, N. (2013). Lateral epicondylitis: A review of pathology and management. Bone & Joint Journal.
- Sanders, T. L., et al. (2015). The epidemiology and health care burden of tennis elbow. American Journal of Sports Medicine.
- Morrey, B. F. (2010). The Elbow and Its Disorders.
- Safran, M. R. (2004). Nerve injury about the elbow. Journal of the American Academy of Orthopaedic Surgeons.
- Bhabra, G., et al. (2016). Lateral elbow tendinopathy: Development of a pathophysiology-based treatment algorithm. British Journal of Sports Medicine.
