which sensitise the pain response, and to direct irritation from chemicals such as lactate, which have been found to be increased in tendinopathy.31
Both of these mechanisms can lead to a cascade of changes in neurons in the peripheral nervous system that ultimately leads to sensitisation of the central nervous sys- tem. This may be the explanation for why patients with lat- eral epicondylitis can present with pain in neurological regions distant to the site of injury. It has been reported that 56% of patients with lateral epicondylitis have associated pain in the neck.27 However, neck and shoulder pain could be due to the overuse of or change in biomechanics as a result of the elbow pain.32