Elbow Pain — Why the Problem Is Rarely at the Elbow
By Dr Don Kim · Chiropractor & Acupuncturist · TOP Chiropractic Acupuncture, West Ryde
Elbow pain is one of the most frustrating conditions I treat — not because it is clinically complex, but because by the time most patients reach my clinic, they have already tried rest, braces, anti-inflammatories and cortisone injections without lasting improvement. The pain keeps returning because the elbow itself was never the real problem.
The elbow is a relay station. It sits in the middle of the upper limb kinetic chain — between the shoulder and cervical spine above it and the wrist and hand below it. It absorbs forces from both directions. When the shoulder is restricted, the elbow compensates. When the wrist is overloaded, the elbow absorbs the excess. When the cervical spine is referring pain through a compressed nerve root, the elbow is often where that pain lands.
Treating the elbow tendon in isolation — without assessing and addressing what is driving the overload from above and below — is the primary reason elbow pain recurs.
At TOP Chiropractic Acupuncture in West Ryde, every elbow presentation is assessed as part of the full upper limb and cervical chain — and treatment is structured to address the entire picture.
Common Elbow Conditions We Treat
Elbow pain presents in several distinct ways depending on the structure involved, the mechanism of overload, and the patient’s occupation and activity profile.
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CONDITION |
WHO IT AFFECTS |
WHAT’S HAPPENING |
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Lateral epicondylalgia (Tennis elbow) |
Office workers, tradespeople, chefs, gym users, parents |
Degenerative changes in the common extensor tendon at the outside of the elbow. Caused by sustained or repetitive grip and wrist extension. The tendon structure breaks down over time — this is tendinopathy, not inflammation, which is why anti-inflammatory medication provides only temporary relief. |
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Medial epicondylalgia (Golfer’s elbow) |
Golfers, climbers, gym users (chin-ups, deadlifts), manual trades |
Degenerative changes in the common flexor tendon at the inside of the elbow. Caused by forceful gripping with wrist flexion. Same underlying pathology as tennis elbow but on the opposite side. |
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Posterior elbow pain |
Gym users (dips, push-ups, overhead press) |
Triceps tendinopathy or olecranon bursitis at the back of the elbow. Caused by repetitive elbow extension under load or direct pressure on the olecranon. |
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Nerve entrapment (cubital / radial tunnel) |
Office workers, cyclists, athletes with neck issues |
Ulnar nerve compression at the cubital tunnel (inside) or radial nerve at the radial tunnel (outside). Produces numbness, tingling or burning into the forearm and hand. Can coexist with tendinopathy or originate from cervical spine pathology. |
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Referred elbow pain |
Patients who haven’t responded to local elbow treatment |
Pain at the elbow originating from cervical spine dysfunction (C5/6, C6/7 radiculopathy) or trigger points in scalenes, infraspinatus or triceps. The elbow tendons may be tender on examination, but the source is not at the elbow. |
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Not all elbow pain is tennis elbow. Nerve entrapment, cervical referral, and joint pathology can produce similar symptoms with very different treatment requirements. A thorough assessment that includes the neck, shoulder and neural system is essential before any treatment is applied.Why the Elbow Fails — The Chain Above and Below
The elbow does not function in isolation. It is part of a kinetic chain that includes the cervical spine and shoulder above it and the wrist and hand below it. When any of these structures are restricted or dysfunctional, the elbow compensates — and that compensation is what eventually produces pain.
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When the cervical spine refers The nerves that supply the elbow originate from C5–T1. Compression or irritation at the cervical level produces pain, weakness and altered muscle activation at the elbow without any local pathology. This is the most commonly missed driver of chronic elbow pain. |
When the shoulder transfers force Restricted shoulder internal rotation or scapular dyskinesis means rotational forces during throwing, serving and gripping are not absorbed by the shoulder complex. They transmit down to the elbow. The epicondylar tendons fail because they are absorbing forces they were never designed to handle. |
When the wrist and hand overload The muscles that attach to the epicondyles act on the wrist and fingers, not the elbow. Sustained grip — holding pans, tools, a mouse, a child — loads the epicondylar tendons without ever moving the elbow. The loading comes from below, and the elbow absorbs the consequence. |
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What makes our approach different is that we assess the entire biomechanical chain — not just the painful tendon. A patient with tennis elbow may have a thoracic spine restriction driving scapular dysfunction, a shoulder rotation deficit transferring force to the elbow, or a cervical disc irritation referring pain to the forearm. Identifying and addressing these contributing factors is what prevents the problem from coming back after treatment ends. |
Common Patterns We Identify in Clinic
In practice, the most common chains we identify driving elbow pain include:
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The desk worker pattern |
Years of sustained thoracic kyphosis and forward head posture creates cervicothoracic restriction, scapular protraction, and anterior shoulder tightness. The forearm extensors work harder to stabilise the wrist during mouse and keyboard use because the proximal chain is not providing adequate stability. The lateral epicondylar tendons fail from accumulated low-grade overload over months and years — not from a single incident. |
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The tradesperson / chef pattern |
Repetitive forceful grip — holding tools, pans, steering wheels, power equipment — loads the epicondylar tendons for hours each day. A single heavy lift or awkward movement is usually the final trigger, but the underlying degeneration has been building for months or years of sustained contraction the tendons were never designed to sustain. |
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The racquet sport and gym pattern |
Restricted shoulder internal rotation or posterior capsule tightness changes the mechanics of the swing, throw or pull. Forces that should be absorbed by the rotator cuff and scapular stabilisers transmit to the elbow. Treating the elbow without restoring shoulder rotation and scapular control produces temporary relief that fails on return to play. |
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The cervical referral pattern |
The patient has had extensive local elbow treatment with no improvement — because the pain is not originating at the elbow. A C5/6 or C6/7 disc bulge is referring pain through the nerve root. The key differentiator: cervical movement reproduces the elbow symptoms, and local elbow provocation tests are inconsistent or disproportionate. |
The Slow Loading Problem — Why Light Weight Hurts More Than Heavy Activity
One of the most important diagnostic clues in chronic elbow tendinopathy is what patients describe as a paradox: light activities hurt more than heavy ones.
A patient with tennis elbow may report that carrying a full kettle is agonising, but swinging a tennis racquet at full speed is fine. A gym user may find that a 5kg bicep curl triggers 3 days of elbow pain, but a fast set of chin-ups is tolerable.
The answer is the speed of loading. During fast, dynamic movements the tendon uses elastic recoil — it stores and releases energy like a rubber band, absorbing very little of the total force. During slow, sustained movements the tendon absorbs 100 percent of the load with no elastic assistance. For a chronically sensitised tendon, that slow grinding load exceeds its tolerance even at negligible weight.
If this pattern sounds familiar — if your elbow handles sport or fast movements but fails with everyday tasks like lifting a cup, turning a doorknob or shaking hands — it is almost certainly tendinopathy. And the treatment approach is fundamentally different from what most patients have been offered: progressive loading to rebuild the tendon’s capacity, not rest, braces and cortisone.
How We Treat Elbow Pain at TOP Chiropractic Acupuncture
Every elbow presentation begins with a thorough assessment — evaluating the cervical spine, thoracic spine, shoulder mechanics, scapular control, forearm muscle tone and the specific structure involved. Treatment is structured around what the assessment finds.
In most elbow presentations we use a combination of four approaches — each targeting a different layer of the problem, in a sequence that makes each one more effective.
Stage 1 — Settle the Pain and Restore the Chain
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Acupuncture and dry needling Targets the tendon directly for pain modulation. Promotes local blood flow to the degenerated tissue. Reduces the neural sensitisation that amplifies pain at the epicondyle. Particularly effective for the nerve-rich environment of the elbow. |
Chiropractic mobilisation Restores cervical and thoracic joint mobility that directly influences shoulder, scapular and upper limb mechanics. Addresses the proximal drivers that are transferring excessive force to the elbow. The elbow settles faster when the chain above it moves properly. |
Stage 2 — Shockwave Therapy for Chronic Tendinopathy
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For lateral epicondylalgia Focused acoustic pressure waves restart the biological healing response in the degenerated common extensor tendon. Stimulates collagen remodelling, new blood vessel formation, and reduction of sensitised nerve endings. Introduced after Stage 1 has addressed the surrounding restrictions. |
For medial epicondylalgia Same mechanism applied to the common flexor tendon origin. Shockwave is never used in isolation — it is always combined with manual therapy to address the chain and a progressive loading programme to rebuild tendon capacity. The shockwave restarts healing. The loading programme rebuilds strength. |
Stage 3 — Rehabilitation and Progressive Loading
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Isometric loading The first stage of tendon rehabilitation. Holding a position against resistance without moving the joint. Reduces pain at the tendon and begins stimulating structural adaptation. We find the load your tendon can tolerate and start just below it. |
Eccentric loading Slow, controlled lengthening of the muscle-tendon unit under resistance. This is the primary driver of tendon structural remodelling. The evidence consistently shows that eccentric loading produces superior long-term outcomes for elbow tendinopathy compared to rest, bracing or injection. |
Functional return Exercises that replicate the demands your tendon needs to tolerate — grip endurance for a tradesperson, racquet mechanics for a tennis player, sustained mouse work for an office worker. The exercises are selected based on YOUR contributing factors, not applied as a generic programme. |
Why Rest Does Not Fix Tendinopathy
Rest is the most commonly recommended treatment for tennis elbow and golfer’s elbow — and it is the most common reason these conditions persist for months and years.
Rest reduces pain temporarily because it removes the provocative load. But it does not improve the tendon’s structural capacity. The degenerated collagen, the ingrown nerve endings, and the disrupted tendon architecture remain unchanged during rest. When the patient returns to activity, the same load that exceeded the tendon’s capacity before exceeds it again — because the capacity has not improved.
This is the cycle that traps so many patients with chronic elbow pain: pain → rest → temporary relief → return to activity → pain returns → more rest. The tendon never gets stronger because it never receives the controlled, progressive loading stimulus that drives structural adaptation.
At TOP Chiropractic Acupuncture, we break this cycle by starting the loading programme early — at a level the tendon can tolerate without flaring. We find the load threshold, start just below it, and build systematically. Patients are often surprised that an exercise that feels easy is precisely the level their tendon needs.
A Note on Cortisone Injections
Cortisone is a powerful anti-inflammatory that reduces pain rapidly — often within days. However, the evidence consistently shows that while cortisone provides superior short-term outcomes, it produces inferior long-term outcomes. Patients who receive cortisone for lateral epicondylalgia have higher recurrence rates and worse outcomes at 6 and 12 months compared to patients who undergo a structured loading programme.
Cortisone has a role in specific situations — particularly when pain is so severe that the patient cannot participate in a loading programme. In these cases, an injection can create a treatment window where rehabilitation becomes possible. But cortisone as a standalone treatment, without addressing the structural and biomechanical drivers, is not a long-term solution.
When Further Investigation Is Needed
Most elbow conditions respond well to conservative treatment. Where an elbow is not improving within the expected timeframe, we recommend further investigation. Diagnostic ultrasound is the first-line imaging for tendinopathy. MRI is recommended where nerve entrapment is suspected or the clinical picture does not match the expected pattern.
At TOP Chiropractic Acupuncture, we set clear criteria at the start of your treatment plan for when imaging or referral would be recommended — so the decision is based on your clinical progress, not delayed until frustration sets in. In many cases, conservative treatment and specialist co-management work effectively together.
Re-Examination — Measuring Your Progress Objectively
At the end of your treatment plan, we perform a full re-examination — retesting everything from your first visit and comparing the results side by side. This gives you a clear, objective picture of how much you have improved.
There is no guesswork and no vague ‘how do you feel’ — we measure your grip strength, your tendon provocation tests, your cervical and thoracic mobility, your pain levels and your functional capacity against your original baseline. Those results determine whether you are ready for maintenance, need continued treatment, or should be referred for further investigation. The numbers make the decision.
The Combined Approach — What Each Tool Addresses
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Chiropractic Cervical and thoracic joint mobility. Scapular mechanics. Neural tension. Addresses the chain that is transferring force to the elbow. |
Acupuncture Pain modulation at the tendon. Muscle tension release. Neural desensitisation. Promotes blood flow to degenerated tissue. |
Shockwave Restarts the stalled healing response in chronic tendinopathy. Collagen remodelling. Neovascularisation. Nerve ending reduction. |
Rehabilitation Progressive loading to rebuild tendon capacity. Sport and occupation-specific exercises. The phase that makes recovery permanent. |
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When Should You Come In?
Book an assessment at TOP Chiropractic Acupuncture if you are experiencing:
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About Dr Don Kim
Dr Don Kim is a dual-qualified chiropractor and acupuncturist at TOP Chiropractic Acupuncture in West Ryde. He holds a Masters of Chiropractic, Bachelor of Chinese Medicine and Bachelor of Acupuncture, and has been treating upper limb conditions — from tennis elbow and golfer’s elbow to nerve entrapment and chronic tendinopathy — since establishing the clinic in 2016. As an active endurance athlete and Ironman competitor, Dr Don treats many active patients from the West Ryde and Ryde area who need their upper limbs functioning at full capacity for sport, training and daily life.