When pain strikes the outer elbow, the immediate assumption is often “tennis elbow” (lateral epicondylitis). This condition involves inflammation or degeneration of the tendons connecting the forearm extensor muscles to the bony prominence on the outside of the elbow. It is characterized by localized pain and tenderness that typically worsens with activities requiring gripping or wrist extension. Lateral epicondylitis is frequently misdiagnosed because numerous other conditions can produce nearly identical symptoms. A proper diagnosis is paramount, as the effective treatment for a tendon issue differs significantly from that required for nerve compression or a joint problem.
Pain Originating from Nerves and the Spine
Conditions mimicking tennis elbow often involve referred pain from nerve compression, either locally in the elbow or originating from the spine. Approximately 70% of patients presenting with lateral elbow pain show related symptoms originating in the neck or upper back region. This distinction is important because treating the elbow alone will not resolve the issue if the pain source is the nervous system.
Radial Tunnel Syndrome
Radial Tunnel Syndrome (RTS) occurs when the radial nerve becomes compressed near the elbow as it passes through the radial tunnel. The pain often overlaps with tennis elbow, but a key differentiator is the location of maximum tenderness. While tennis elbow pain is concentrated directly on the lateral epicondyle, RTS tenderness is usually located about two inches further down the forearm, over the supinator muscle belly. RTS pain is often described as a deep, aching sensation that may worsen with resisted forearm rotation or middle finger extension.
Cervical Radiculopathy
Pain felt at the elbow can also be referred from a pinched nerve in the neck, a condition known as Cervical Radiculopathy. When a nerve root is compressed in the cervical spine—most commonly at the C5-C6 or C6-C7 levels—the pain travels down the arm and is perceived in the elbow region. Unlike localized tennis elbow, radiculopathy often includes neurological symptoms such as tingling, numbness, or a burning sensation traveling into the hand or fingers. Neck stiffness or pain that changes with specific head movements also helps distinguish this spinal issue from a localized elbow tendon problem.
Nearby Tendon and Muscle Conditions
Other conditions causing elbow pain involve soft tissues, such as adjacent tendons and muscles, but are structurally distinct from lateral epicondylitis. These injuries require different recovery approaches because they affect different muscle groups. Proper diagnosis relies on identifying the exact location of tenderness and the specific movements that provoke the pain.
Medial Epicondylitis (Golfer’s Elbow)
Medial Epicondylitis, or Golfer’s Elbow, affects the tendons on the inner side of the elbow. This condition involves the flexor-pronator muscle group, responsible for bending the wrist and turning the palm down. The pain is localized to the medial epicondyle, the bony bump on the inside of the elbow, and is exacerbated by wrist flexion and gripping. The primary difference is the anatomical location: inner (medial) versus outer (lateral).
Distal Biceps Tendinopathy
Distal Biceps Tendinopathy involves the biceps tendon where it attaches to the radius bone, causing pain in the front of the elbow. The pain is felt in the anterior elbow crease, not the outer side. Pain is typically aggravated by movements requiring elbow flexion or supination (turning the palm upward against resistance). This contrasts with lateral epicondylitis, where pain is triggered by resisted wrist extension.
Forearm Muscle Strain
A strain or tear in the forearm extensor muscles can mimic the diffuse discomfort of tennis elbow. This injury is not localized to the bony attachment point (the epicondyle) but rather to the muscle belly itself, a few inches down the forearm. Palpation reveals the tenderness is not at the tendon’s origin. The acute onset of pain, often following a sudden, forceful activity, helps differentiate a muscle strain from the typically gradual onset of chronic tendinopathy.
Issues Within the Elbow Joint
Conditions affecting the joint structures—including bone, cartilage, and stabilizing ligaments—can produce pain easily confused with a tendon issue. These joint-related problems often present with symptoms beyond simple pain, such as mechanical sensations not characteristic of pure tendinopathy. Stiffness or a mechanical catching sensation points toward a joint surface issue.
Elbow Osteoarthritis
Elbow Osteoarthritis (OA) involves the breakdown of cartilage within the joint, leading to friction and inflammation. Unlike the localized tenderness of tennis elbow, OA pain is typically deep within the joint and accompanied by significant stiffness. Patients often report a reduced range of motion, difficulty achieving full extension or flexion, and may feel a grinding or grating sensation (crepitus) during movement.
Ligament Instability
Injury to the collateral ligaments, such as the Lateral Collateral Ligament (LCL), can cause pain and instability on the outer side of the elbow, mimicking tennis elbow. An LCL sprain usually results from trauma or repetitive stress placing an outward (varus) force on the elbow. Distinguishing features include a feeling of the joint “giving way” or instability, and pain specifically provoked by stress tests designed to challenge the ligament’s stability.
Olecranon Bursitis
Olecranon Bursitis is the inflammation of the bursa, a fluid-filled sac located at the tip of the elbow bone (olecranon). While often visually distinct due to the large, soft swelling that can resemble a golf ball, early stages can present as simple pain at the back of the elbow. Pain is usually aggravated by direct pressure, such as leaning on the elbow. The presence of warmth, redness, or significant swelling is a clear indicator of bursitis, especially if an infection is present.