ELBOW PAIN

Lateral Elbow Pain (Tennis Elbow): Is It Really Just Tendinopathy?

Lateral Elbow Pain (LEP)—commonly referred to as tennis elbow—has traditionally been attributed to degenerative changes in the Extensor Carpi Radialis Brevis (ECRB) tendon. For decades, this tendon-centric model has guided diagnosis and treatment.

However, emerging research challenges this one-dimensional explanation.

Recent evidence indicates that in a significant subset of patients, lateral elbow pain may not be caused by tendinopathy alone. Instead, symptoms may arise from Symptomatic Minor Instability of the Lateral Elbow (SMILE)—a subtle but clinically meaningful micro-instability of the lateral ligament complex.

Rethinking Tennis Elbow: The Role of Lateral Elbow Instability

Studies increasingly suggest that ligamentous involvement, rather than isolated tendon pathology, may play a critical role in persistent or severe LEP.

Key Research Findings

Arrigoni et al. (2017) identified intra-articular signs of lateral ligament laxity during elbow arthroscopy in patients with chronic lateral elbow pain.
Ando et al. reported a significantly higher incidence of radial collateral ligament (RCL) injuries in patients with severe LEP compared to asymptomatic controls.

Together, these findings shift the understanding of tennis elbow toward a ligament-involved pain mechanism, consistent with the SMILE framework.

Arthroscopic Signs of SMILE (Arrigoni et al., 2017)

In their landmark arthroscopic study, Arrigoni and colleagues described three key diagnostic features of Symptomatic Minor Instability of the Lateral Elbow:

1. Radial Head Ballottement

Anterior–posterior translation of the radial head
Indicates subtle lateral elbow instability

2. Incomplete Annular Ligament Coverage

Observed during dynamic arthroscopic assessment
Suggests attenuation or laxity of the annular ligament

3. Radial Collateral Ligament (RCL) Laxity

Present without gross dislocation
Reflects pathological looseness of the lateral ligament complex

Clinical Significance: Why This Matters for Elbow Pain Treatment

The study demonstrated a strong correlation between these arthroscopic findings and pain severity in patients with LEP:

Nearly 50% of patients with chronic lateral elbow pain showed at least one instability-related finding
Over 85% exhibited intra-articular abnormalities within the lateral elbow compartment

These results provide compelling evidence that lateral elbow pain is often not solely due to ECRB tendinopathy, but may reflect underlying lateral ligament insufficiency.

Key Takeaway for Clinicians and Rehabilitation Professionals

For patients with persistent or treatment-resistant tennis elbow, it is essential to consider:

Lateral ligament complex integrity
Subtle elbow instability
SMILE as a contributing pain mechanism

This broader diagnostic lens has important implications for physiotherapy, manual therapy, sports medicine, and upper-limb rehabilitation, particularly when conventional tendinopathy-focused approaches fail.

Reference

Arrigoni P, Cucchi D, D’Ambrosi R, Menon A, Randelli P. Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE). Knee Surgery, Sports Traumatology, Arthroscopy. 2017;25(7):2255–2263. doi:10.1007/s00167-017-4519-9

Bernholt DL, Rosenberg S, Brady A, Storaci H. Quantitative and qualitative analyses of the lateral ligamentous complex and extensor tendon origins of the elbow: an anatomic study. Orthop J Sports Med. 2020;8(10):2325967120961373. doi:10.1177/2325967120961373

Author

Dr. Vivek Babaria, DO Dr. Vivek Babaria, DO, FAAPMR is a double board-certified specialist in Interventional Spine, Sports, and Regenerative Medicine. Known for his precision diagnostics and minimally invasive approach, Dr. Babaria integrates cutting-edge technologies like musculoskeletal ultrasound, biologic therapies, and image-guided interventions to restore function and relieve pain. He trained at top institutions and brings a high-touch, patient-first philosophy to every consultation. Whether you're a high-performance athlete, weekend warrior, or navigating chronic pain, Dr. Babaria is committed to personalized, evidence-based care that helps you move, feel, and live better. His practice blends modern medicine with a holistic understanding of the body, making him a leader in the future of non-surgical musculoskeletal care.

You Might Also Enjoy...

What Are the Non-Surgical Options for My Pain?

This article is about effective non-surgical pain treatments ranging from steroid and regenerative injections to nerve blocks, radiofrequency ablation, and spinal cord stimulation.

OCCIPITAL PAIN, HEADACHES WON'T GO AWAY

Occipital neuralgia is a type of headache and nerve pain that comes from irritation or injury of the occipital nerves, which run from the upper neck, through the back of the scalp, toward the top of the head and sometimes behind the eyes.

PLANTAR FASCIA PAIN

Plantar fasciitis is a leading cause of heel pain. Steroid injections give quick relief but are short-lived and carry risk; PRP targets tissue healing and durability. The practical question: for chronic plantar fasciitis, which injection wins over time?

A Greater Platelet Dose May Yield Better Clinical Outcomes for Platelet

Deliverable platelets represent the actual volume of viable platelets in a PRP treatment. A high number of deliverable platelets significantly enhances the effectiveness of platelet-derived growth factors and cytokines in tissue healing.

Knee PRP: What It Is and How It Heals

By Dr. Vivek Babaria, DO, FAAPMR National Leader in Regenerative Orthopedics | Founder, Orange County Spine & Sports, Newport Beach, CA

PRP and Muscle Healing: What the Latest Science Says

Takeaway: Not all PRP preparations are the same, and subtle differences—like white blood cell concentration—could make a big impact on healing. For athletes or active individuals dealing with muscle injuries, this line of research is worth watching close.