Article Review: Tennis Elbow

Managing lateral elbow pain for long-term resilience

By Spencer Wilbert, DPT, Founder of Keep PT
Published: January 2026 | Read time: ~5 minutes

Background / Why This Matters

A randomized controlled trial by Mostafaee et al., Shoulder and Scapula Muscle Training Plus Conventional Physiotherapy Versus Conventional Physiotherapy Only: A Randomized Controlled Trial of Patients with Lateral Elbow Tendinopathy, compared two rehabilitation approaches for individuals with lateral elbow tendinopathy (Mostafaee et al., 2022).

Lateral elbow tendinopathy (LET), commonly referred to as tennis elbow, is a frequent source of pain and functional limitation for active adults and workers alike. Tasks that require gripping, lifting, or repetitive hand use can become painful, interfering with exercise, work, and daily activities. Many clients, particularly weightlifters, start noticing it while progressing in the gym. 

Conventional physical therapy for LET often focuses on the elbow itself, using a combination of contraction types during forearm exercises. This approach is supported by research and generally outperforms corticosteroid injections or simply waiting. However, the bigger issue is many patients experience persistent symptoms or recurrence after initial improvement with this approach.

One potential reason for these inconsistent outcomes is that LET is often treated as a localized elbow problem, despite evidence that shoulder and scapular muscle weakness is common in this population (Mostafaee et al., 2022). Deficits in the rotator cuff and scapular stabilizers may disrupt normal force transfer through the upper-extremity kinetic chain, increasing load on the wrist extensors and lateral elbow during functional tasks.

This raises an important clinical question:
If the elbow is overloaded because of proximal weakness, can long-term outcomes improve by addressing the shoulder and scapula in addition to the forearm?

The study reviewed here directly examines that question, comparing traditional elbow-focused rehabilitation with a more comprehensive approach that includes targeted shoulder and scapular strengthening in combination with elbow treatment.

What the Evidence Shows

This randomized controlled trial compared these two approaches for elbows with LET (tennis elbow). Conventional elbow focused therapy alone, and a group with the same elbow program combined with shoulder and scapular strengthening. Both groups had 3x a week sessions for 4 weeks. Their measurements were taken at 4 weeks, then 4 months after being told to continue on their own until the 4 month mark.

At the four-week mark, both groups demonstrated significant improvements in pain and function, with no meaningful between-group differences. This suggests that conventional elbow-focused rehabilitation remains effective in the short term.

However, the most clinically relevant findings emerged at the four-month follow-up. Participants in the combined elbow and shoulder group continued to improve in pain and function, while the elbow-only group showed signs of regression and symptom recurrence. These findings suggest that long-term outcomes may depend less on eliminating elbow pain early and more on improving proximal capacity to support sustained load tolerance (Mostafaee et al., 2022).

This research would suggest that the long term solution to LET or tennis elbow may not be in just trying to reduce elbow pain with elbow treatments. Addressing shoulder and scapular capacity might be critical for maintaining improvements and preventing recurrence in the long term.

Clinical or Practical Implications

The findings of this study suggest that successful management of lateral elbow tendinopathy should include both elbow-specific loading and shoulder and scapular strengthening. While progressive wrist extensor exercises remain a cornerstone of rehabilitation, incorporating proximal strength and endurance may improve the durability of short-term gains.

In practice, this supports a more global assessment of upper-extremity function to identify contributing factors beyond the elbow itself. Addressing rotator cuff and scapular stabilizer capacity may not only help reduce pain, but also improve performance and tolerance during work, training, and sport.

Common Mistakes or Overcorrections

A common mistake in managing lateral elbow tendinopathy is treating it as an isolated elbow problem. Focusing solely on local pain relief, grip strength, or short-term symptom reduction may lead to early improvement, but it can overlook deficits in shoulder and scapular capacity that contribute to ongoing overload and recurrence. This study highlights that grip strength gains alone do not ensure efficient load sharing across the upper extremity, and discontinuing proximal strengthening too early may limit long-term benefit. Progressing elbow loading without adequate proximal control can unintentionally reinforce compensatory patterns, emphasizing the need for a balanced approach that continues to address shoulder and scapular strength alongside forearm loading.

The Keep Perspective

Importantly, the benefits of including shoulder and scapular programming in elbow rehabilitation reflect Keep’s focus on long-term prevention and performance enhancement. While traditional physical therapy often ends once pain resolves, Keep’s approach continues beyond symptom relief, emphasizing improved load tolerance, movement efficiency, and resilience so individuals return stronger and more durable than before injury.

References

Mostafaee, N., Divandari, A., Negahban, H., et al. (2022). Shoulder and scapula muscle training plus conventional physiotherapy versus conventional physiotherapy only: A randomized controlled trial of patients with lateral elbow tendinopathy. Physiotherapy Theory and Practice, 38(9), 1153–1164.