The Elbow Isn’t Special
And treating it like it is might be why your patients aren’t getting better
“It hurts right here.”
Cool. That tells me almost nothing.
The elbow is one of the most overdiagnosed, overtreated, and misunderstood joints in rehab. Not because it’s complex—but because clinicians keep asking the wrong question:
“What structure is causing pain?”
Instead of:
“Why is this system failing to tolerate load?”
If you treat every elbow like a local tissue problem, you’re going to:
Miss nerve involvement
Ignore cervical drivers
And build a beautifully progressive loading program… for the wrong problem
Let’s clean this up.
1. The “It’s Definitely Tennis Elbow” Crowd
(Spoiler: it’s not always tennis elbow)
Yes—local elbow pain exists. Shocking.
Actual local presentations:
Lateral epicondylalgia
Medial epicondylalgia
Triceps / distal biceps tendon irritation
Joint irritation / OA
What real local pain looks like:
You can pinpoint it with one finger
It’s predictable
It hurts when you load it directly
It doesn’t wander around like it’s got commitment issues
Here’s where people screw up:
They find tenderness at the lateral elbow (you always will), call it tennis elbow, and start:
Eccentrics
Soft tissue work
Graston, scraping, BFR, floss bands and voodoo rituals
Meanwhile the patient says:
“Yeah… it still kind of feels weird and goes down my arm sometimes.”
And you ignore that.
2. The Nerve You Keep Pretending Isn’t Involved
(Because it ruins your clean little diagnosis)
Let’s say this clearly:
If the symptoms are weird, it’s probably a nerve.
Common culprits:
Ulnar nerve → medial elbow, ring/pinky
Radial nerve → deep lateral forearm ache (the fake tennis elbow)
Median nerve → vague, annoying, hard-to-pin-down garbage
What nerve pain actually does:
Moves
Changes
Feels “off” instead of sharp
Gets worse with positions, not just load
Clinical reality:
That “stubborn lateral elbow pain” you’ve been hammering for 8 weeks?
It might be radial nerve irritation getting absolutely bullied by your loading program.
Nice work.
3. The Neck (Yes, Again)
(The thing everyone screens… and then ignores)
You did a quick cervical screen.
It “wasn’t that bad.”
So you moved on.
That’s how you miss it.
Cervical-driven elbow pain:
Poorly localized
Changes with neck position
Often paired with subtle weakness or fatigue
Check grip strength!!!
Comes with that classic patient description:
“It’s just… weird.”
Here’s the uncomfortable truth:
If moving the neck changes the elbow pain and you ignore it…
You’re not treating the problem.
You’re negotiating with it.
4. The Stuff You Actually Shouldn’t Miss
(But sometimes do because you’re busy dry needling everything)
Not everything is a load management issue.
Don’t be that clinician:
Big swollen elbow? → maybe not “just irritation”
Hot, red joint? → probably not a mobility restriction
Night pain + systemic symptoms? → not your goblet squat fix
Sometimes the right move is:
“This isn’t my lane.”
The 60-Second Screen (That’ll Save You Weeks of Guessing)
1. “Point to it.”
One finger, dead-on → local
Vague, shifting → not local
2. Resist it
Wrist extension, flexion, supination
Clean reproduction? → tissue likely involved
No reproduction?
Stop pretending it is.
3. Ask better questions
Burning? Tingling? Weird?
→ Congratulations, you have a nerve involved
4. Move the neck
Rotation, extension
If it changes symptoms and you ignore it, that’s on you.
5. Look at behavior, not just pain
Load = pain → tissue
Position = pain → nerve
Random = pain → zoom out, you’re missing something
The Takeaway (That Might Annoy You)
Most elbow pain isn’t complicated.
But clinicians make it complicated by:
Over-fixating on the elbow
Ignoring the nervous system
Treating symptoms instead of systems
Final Rant
If your patient has had “tennis elbow” for 3 months and:
It moves
It feels weird
It hasn’t responded to load
Then it’s time to ask a better question:
“Why am I so confident this is actually the elbow?”
-the pissed-off PT- like, subscribe, comment-