Can Someone Have Tennis Elbow Without Pain on Resistive Dorsiflexion?
Yes, someone can have tennis elbow (lateral epicondylitis) with tenderness at the lateral epicondyle but without pain during resistive wrist dorsiflexion, though this presentation is atypical and should prompt consideration of the diagnosis along with clinical context.
Understanding the Clinical Presentation
The classic diagnostic criteria for tennis elbow typically includes both components, but the absence of one does not definitively rule out the condition:
Standard Diagnostic Features
- Tenderness at the lateral epicondyle is a hallmark finding and represents pathology at the common extensor origin, particularly the extensor carpi radialis brevis tendon 1, 2, 3
- Pain with resisted wrist extension is the typical provocative maneuver that stresses the affected tendon and reproduces symptoms 1, 2
Why Pain May Be Absent on Resistive Testing
The absence of pain during resistive dorsiflexion (wrist extension) does not exclude tennis elbow for several important reasons:
- Stage of pathology matters: Tennis elbow represents a degenerative tendinosis rather than acute inflammation 3. In early or mild cases, the tendon may be tender to palpation but not yet symptomatic enough to produce pain with loading
- Pain mediation is complex: Neurochemicals including glutamate, substance P, and calcitonin gene-related peptide mediate pain in chronic tennis elbow, and their presence varies between patients 3. This explains why pain presentation can be inconsistent
- Testing technique sensitivity: The force applied during resistive testing, the position of the forearm (pronation vs. supination), and whether the elbow is extended or flexed can all affect whether pain is elicited 1
Clinical Approach to This Presentation
Key Diagnostic Considerations
When tenderness is present but resistive testing is negative, consider:
- Timing of examination: Pain may be activity-dependent and not reproducible at rest or with standard office testing 4
- Alternative provocative maneuvers: Try testing with forceful gripping combined with wrist extension, as this creates more stress on the lateral epicondyle than isolated wrist extension 5
- Functional activities: Ask about pain during specific activities like shaking hands, opening doors, or lifting objects with the wrist extended 6, as these may be more sensitive than formal resistance testing
Differential Diagnosis to Consider
Point tenderness at the lateral epicondyle without positive resistive testing should also prompt consideration of:
- Radial tunnel syndrome (nerve entrapment) 1
- Inflammatory or arthritic conditions affecting the elbow joint 1
- Early-stage tendinopathy that has not yet progressed to cause pain with loading 3
Practical Clinical Recommendation
If a patient has lateral epicondyle tenderness with appropriate risk factors (age 40+, repetitive wrist extension activities, dominant arm involvement), treat as presumptive tennis elbow even without positive resistive testing 7, 6, 4:
- The condition affects adults over 40 years old and involves the dominant arm 75% of the time 7, 6
- Repetitive wrist extension is the primary causative movement pattern 6
- Conservative treatment is safe and appropriate even for presumptive cases 5
Initial Management Strategy
Start with conservative measures that carry minimal risk:
- Activity modification to reduce repetitive wrist extension 8
- Cryotherapy for acute symptoms 8
- NSAIDs for short-term pain relief 8
- Eccentric strengthening exercises once acute symptoms settle 8
Important Caveats
Do not dismiss the diagnosis solely based on negative resistive testing, as tennis elbow is primarily a clinical diagnosis based on history and physical examination findings 8, 1. The combination of appropriate age, occupational or athletic risk factors, and point tenderness at the lateral epicondyle may be sufficient for diagnosis, particularly in early or mild cases where loading has not yet become painful.
If symptoms persist or worsen despite conservative treatment, or if the diagnosis remains uncertain, consider imaging (plain radiographs initially) to rule out other pathology 8.