Do you have elbow pain with lifting, gripping, twisting, typing, or playing sports?
In this blog, I’m going to discuss tennis elbow, dispel the most common myths associated with the diagnosis, and teach you everything you need to know about managing the condition!
Be sure to also check out our Tennis Elbow Rehab Program!
Elbow Anatomy
To best understand tennis elbow, it’s important to briefly review some basic elbow anatomy.
The two bones of the forearm are known as the radius and ulna, while the arm bone is known as the humerus. Together, these three bones form the humeroradial and humeroulnar joints, which make up the elbow.
If you feel the bony prominence on the inside of your elbow, this is a part of your humerus known as the medial epicondyle. The medial epicondyle is the location of pain for people who experience golfer’s elbow.
If you feel a similar bony prominence on the outside of your elbow, this is a part of your humerus known as the lateral epicondyle. The lateral epicondyle, as you might guess, is the area of pain relevant to tennis elbow.
Many of the muscles that control the movements of your forearm, wrist, and fingers attach to the medial and lateral epicondyles via their tendons (because tendons attach muscles to bones).
The muscles that attach to the lateral epicondyle have 3 primary actions: wrist extension, finger extension, and supination, which involves turning your palm up toward the ceiling. If you squeeze your hand into a fist or extend your wrist, you should be able to see and feel these muscles contract.
Tennis Elbow (or not?)
There are a lot of names used to describe this outer elbow pain: lateral epicondylitis, lateral epicondylalgia, tennis elbow, etc. This can be confusing.
Lateral epicondylitis refers to inflammation of the lateral epicondyle, or more specifically, inflammation of the tendons that attach to the lateral epicondyle. However, lateral epicondylitis has fallen out of favor as a diagnosis because current research suggests that local inflammation is likely not the primary driver of the condition.
This is not to say that inflammation can never be a contributing factor, but it likely doesn’t need to be the focus of management. This is important to know because most people associate inflammation with the need for complete rest, ice, and anti-inflammatory medication, which are not going to be the main recommendations in this blog.
Since lateral epicondylitis is inaccurate, the term epicondylalgia was introduced to replace epicondylitis. However, lateral epicondylalgia just means that the lateral epicondyle is painful, which is not very helpful.
We also shouldn’t call it “tennis elbow” because it doesn’t only occur in tennis players. In fact, it’s most common in manual workers who use their dominant arm for repetitive movements or forceful activities on a regular basis. Shiri 2006, Van Rijn 2009, Walker-Bone 2012, Descatha 2016, Vicenzino 2017, Aben 2018
And, as some of you reading may be aware, golfers also get tennis elbow.
So what should we call it?
Lateral Elbow Tendinopathy
According to Scott et al in 2020, lateral elbow tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading of the lateral elbow tendons. Mechanical loading refers to any movements or activities that load the lateral elbow tendons, such as working with your hands, lifting weights, and playing sports.
The diagnosis is typically given when someone’s pain is reproduced with pinpoint pressure to the tendons, stretching of the tendons, or loading of the tendons, such as with resisted wrist extension, resisted middle finger extension, or gripping. The tendon most often involved is believed to be the Extensor Carpi Radialis Brevis.
Based on this information, lateral elbow tendinopathy is generally considered a clinical diagnosis, meaning that imaging, such as x-rays and MRIs, are not indicated unless there is suspicion of something like a fracture, dislocation, or instability.
But why did you get lateral elbow tendinopathy?
Think of it like this – you load your lateral elbow tendons every day when you’re working, lifting, playing sports, etc. However, if the intensity, frequency, and volume of that loading exceeds your capacity to recover and adapt from those loads appropriately, lateral elbow tendinopathy may occur.
Oftentimes, it comes down to doing too much, too soon. Here are three examples:
- You decided you wanted to get in better shape, so you started lifting weights every day without any prior experience.
- You’re a new tennis player who wanted to get good fast, so you joined a club to play after work each day.
- You took a week off of work to take care of a few projects around the house.
In these examples, you likely loaded your lateral elbow tendons more than what they’re used to. Therefore, the goal of rehab is pretty simple: it’s to initially reduce those loads to a tolerable amount and then make sure that your capacity is greater than or equal to the various loads you’re going to be experiencing on a day-to-day and week-to-week basis.
Load Management & Activity Modifications (Recommended)
Based on this information, my first recommendation for rehab is to modify aggravating activities.
If you’re a gym-goer who can’t tolerate your current training program, you need to temporarily scale back by doing less sets per day or throughout the entire week, reducing the amount of weight you’re lifting, or making other adjustments to your routine. Here are five examples:
If upper body exercises that require significant gripping like pull-ups, pulldowns, and rows are provocative, an easy modification is to use lifting straps.
If leg exercises with weights in your hands are uncomfortable, like dumbbell lunges or split squats, use lifting straps, try a barbell, or perform a machine-based exercise instead.
If heavy deadlift variations are problematic, even with lifting straps, pick a different exercise that trains similar muscle groups without placing any demand on your grip, such as single leg hip extension on a roman chair.
If you have pain with dumbbell lateral raises, you can put a cuff around your wrist and do them using the cable column.
If a certain position of your forearm is problematic, whether it’s pronated, supinated, or neutral, try a different position.
You can also try equipment or handles that provide you with more movement variability.
There are a lot of options.
If you’re a tennis player, or any other athlete, reduce how often you play, the total time you play each session, or the intensity at which you play. This can actually be a good time to focus on your technique.
Compared to your legs, trunk, and shoulder, your elbow should only be contributing a fraction of your overall power when you’re hitting the ball in tennis. Working with a coach might help you discover errors in your technique that are contributing to excessive loading of your elbow. This is true for tennis, golf, and other sports that may be contributing to your symptoms.
If you’re an office worker who spends a lot of time at your computer, you might have to adjust your workstation and incorporate periodic walking breaks. Set a timer on your phone or place a sticky note on your monitor as a reminder.
I understand that modifying aggravating activities may be more challenging for some individuals than others. For example, if your job requires repetitive bending and twisting of your elbow and wrist, you might need to get creative if you work for yourself or request modified duty if you’re employed by someone else.
I also want to highlight that most of these changes are meant to be temporary. The idea is that you’re taking one step back, so you can eventually take two steps forward.
Wearing Elbow or Wrist Support (Optional)
Wearing elbow or wrist support is an optional method for potentially decreasing symptoms during aggravating activities, but it’s not a long-term solution or a substitution for the recommendations I just provided.
There are typically three types: a wrist brace, an elbow sleeve, and a counterforce strap. A counterforce strap, which wraps around your forearm, or elbow sleeve is usually preferred because a wrist brace is purposefully restrictive of your movement. If you decide to wear one, pick the option that provides you with the most relief and is most suitable for your situation.
Understanding and Monitoring Pain (Recommended)
Another fundamental component of rehab is understanding and monitoring pain.
Do you have to avoid pain during exercise or is it safe to push into a little pain?
Many people are concerned that exercising into pain means that they’re damaging their tendons or making their condition worse, but that’s not the case.
Remember:
- We’re not thinking about lateral elbow tendinopathy like a predominantly inflammatory condition (“epicondylitis”).
- The goal of rehab is building your capacity by improving your tolerance to various forms of loading and gradually restoring your function.
Plus, research demonstrates that the severity of tendon changes on imaging is poorly associated with symptoms, and these tendon changes are prevalent in people and elbows without any symptoms.
I’m not suggesting to take a “no pain, no gain” approach, but it’s actually acceptable to have some discomfort during exercise as it doesn’t necessarily mean that you’re hindering progress or damaging your tendons.
Most tendinopathy research involves exercising within a tolerable level of pain. “Tolerable” is unique to you. There’s not necessarily a right or wrong way to go about it, but there are some strategies that you can do to help find what works best for you.
You’re not only going to monitor symptoms during exercise, but immediately after and the following day. Ask yourself 3 questions:
1. Is my pain tolerable during exercise? If it’s helpful for you, you can rate your pain on a scale from 0-10 and determine the highest acceptable number for you. Some physical therapists might recommend staying at a 2-3/10 pain or less while others might suggest a 4-5/10 pain or less. Ultimately, you get to decide.
2. Is my pain better, worse, or the same after exercise? Lateral elbow tendinopathy may exhibit a warm-up phenomenon, so it’s possible that you feel better after short bouts of exercise.
3. Is my pain better, worse, or the same the day after exercise? This is the most important question because it gives you an understanding of how you’re responding to the current dosage of exercise. If you feel fine during and immediately after exercise, but you have a significant worsening of symptoms the next day, that’s an indication that you’re doing too much and need to back off a bit.
You can assess your next-day symptoms with your normal functional activities or use a specific assessment, such as squeezing a ball.
For example, you rate your pain on day 1 with squeezing a ball as a 2/10 pain. You then perform your exercise routine within tolerance, go about your day, and go to bed without any major issues. The next morning you squeeze the ball again, but this time you rate your pain as a 5/10. This means that even though your symptoms were tolerable during exercise, you might have done more than what you can currently recover from. You didn’t do any harm, but decreasing the volume or intensity of exercise would be recommended.
So, do you have to avoid pain during exercise? Not necessarily. Is it safe to push into a little pain? Yes. However, you’re going to have to find what works best for you.
How Long Does It Take To Get Better?
Although the recovery can vary between weeks, months, and years, a systematic review and meta-analysis by Ikonen et al in 2022 reported this as one of their key findings: “We found that approximately 90% of patients who received no active treatment for tennis elbow had either completely recovered or were much improved by 1 year, and they had little remaining pain and disability by that point.”
This means that if you stopped reading this blog right now and do nothing else, there’s a very good chance that you’ll naturally get better within the next year, if not sooner.
Exercise Overview
So why would you choose to do exercise? Well, you don’t have to, but it’s an option and probably the reason you’re reading this blog. Plus, a systematic review and meta-analysis by Karanasios et al in 2021 found that exercise does lead to better outcomes, although the effect is small.
Research also demonstrates that individuals with lateral elbow tendinopathy have weakness of their hand, forearm, elbow, and shoulder muscles. This is a chicken or egg scenario because it’s possible that the weakness is secondary to pain and deconditioning from disuse as opposed to being the reason for the development of symptoms in the first place. Regardless, this still ties into the goal of improving your tolerance to various forms of loading and gradually restoring your function.
Wrist Extension Strengthening (Recommended) & Wrist Flexion Strengthening (Optional)
The first recommended exercise is resisted wrist extension because wrist extension is one of the primary actions of the lateral elbow tendons.
If you’re also experiencing golfer’s elbow or just want to be a little more comprehensive, you can include wrist flexion strengthening as well.
You can superset 2-3 sets of 8-15 repetitions of each exercise, 3 times per week.
Ideally, you’ll be seated with your forearm supported on a table, bench, or your thigh. You can use a dumbbell, a band with or without a handle, or whatever household objects you have laying around.
If the full range of motion is uncomfortable, you can shorten the range of motion or just perform an isometric which involves a static hold for 30-60 seconds.
Supination Strengthening (Recommended) & Pronation Strengthening (Optional)
The second recommended exercise involves supination strengthening because supination is also one of the primary actions of the lateral elbow tendons. For simplicity, you’ll likely include pronation strengthening as well.
For both, your elbow should be bent with your arm tucked by your side, forearm supported or unsupported, and you can be sitting or standing. Hold onto the end of a dumbbell, dowel, hammer, or another household object. The closer you grab to the center of that object, the easier pronation and supination become. Make the movements harder by grabbing lower, using something that’s heavier, or adding resistance in the form of a cuff weight.
You can also use a band, but you’ll have to train each direction individually. Pronation would be optional in that scenario.
Once again, aim for 2-3 sets of 8-15 repetitions, 3 times per week.
Grip Strength & Endurance (Recommended)
The last recommended exercise is geared toward grip strength and endurance. There’s no shortage of options. If you want to keep it simple, you can periodically squeeze a lacrosse ball, tennis ball, towel, or one of those grippers throughout the day.
If you want to do gym-based movements, aim for 2-3 sets of farmer’s carries or suitcase carries with dumbbells or kettlebells. You can grab the wide portion of either, like the hex part of a dumbbell or the bottom of a small kettlebell, for a different challenge. You can also do plate pinches with a larger bumper plate or with 2 smaller plates held together.
Aim for 2-3 sets of 30-60 seconds of total work, 3 times per week.
Shoulder Strengthening (Optional)
The first group of optional exercises involves shoulder strengthening.
There are 2 possible reasons you might choose to perform these exercises:
- You play a sport that would benefit from improving your shoulder strength, such as golf, tennis, or baseball.
- You also experience shoulder stiffness, weakness, or discomfort. Research demonstrates an association between lateral elbow tendinopathy and shoulder–related symptoms, so these exercises may help with both issues.
There are an infinite number of options, so here are 5 to choose from:
Option 1: Side Lying External Rotation – Place your top arm at your side with your elbow bent to 90° while holding a weight in your hand. Rotate your arm outward as far as you can while keeping your arm at your side. Lower back to your stomach and repeat.
Option 2: External Rotation with Elbow on Knee – Sit with your elbow supported on your knee and a weight in your hand. Slowly lower the weight, rotating your arm inward as far as possible without letting your shoulder roll forward. Then, rotate back to the starting position.
Option 3: Banded External Rotation – With your elbows bent to 90° and pinned at your side, think about pulling the band apart. If you’re using a loop band, you can put it around your wrists so you don’t have to worry about gripping it. If you’re using a ribbon band, you can rotate your arms straight out or think about creating a “W.”
If you want to progress these exercises, you can perform them in what’s known as a “90/90 position” while standing or lying on your stomach.
Option 4: Scaption – With thumbs pointing up, raise your arms to about shoulder height or slightly higher. You are not raising your arms directly to the side or in front of you, but an angle in between. You can use a band or dumbbells.
Option 5: Prone Angel Progression – If you have access to minimal equipment, you can lie on your stomach and progress from performing Prone A’s to Prone T’s to Prone Y’s to Prone Angels.
If you decide to incorporate these optional shoulder strengthening exercises, aim for 2-3 sets of 10-15 repetitions or 30-60 seconds of total work, 3 times per week.
Thoracic Mobility (Optional)
The second group of optional exercises involves thoracic mobility.
There are 3 possible reasons you might choose to perform these exercises:
- You want to use them as a way to break up repetitive tasks. I’ll provide options that require no equipment and can be done anywhere.
- You play a sport that would benefit from improving your thoracic mobility, such as golf, tennis, or baseball.
- You also experience neck and/or upper back stiffness and discomfort. Research demonstrates an association between lateral elbow tendinopathy and neck–related symptoms, so these exercises may help with both issues.
Here are 4 options:
Option 1: Side Lying Thoracic Rotation – Lie on your side with your hips and knees bent, and head supported. Rotate your top shoulder and arm toward the floor behind you, or as far as you can comfortably go.
Option 2: Seated Thoracic Rotation – With your arms out in front of you, reach one hand toward the wall behind you, return to the starting position, and then repeat on the other side. You can also lean forward, grab the opposite knee, and reach up toward the ceiling.
Option 3: Half Kneeling Thoracic Rotation – Set up in half kneeling against a wall with your arms out in front of you. Rotate your shoulder and arm toward the wall behind you, or as far as you can comfortably go. You can make this more challenging by turning the movement into more of a windmill.
Option 4: Deep Lunge with Thoracic Rotation – Step back, place one hand on the floor, reach up toward the ceiling with the other hand, lower back down, repeat, and then switch sides.
If you decide to incorporate any of these optional thoracic mobility exercises, aim for 1-2 sets of 6-8 repetitions per side as part of your workout or periodically throughout your day.
Guidelines, Not Rules
I’ll put an example program together in the summary of this video, but please understand that these are guidelines, not hard and fast rules. I can’t provide suggestions that will account for every person’s unique goals, preferences, circumstances, etc. Find what works best for you.
Let me also quickly answer questions that I anticipate receiving about why I excluded certain exercises:
- Why didn’t I include an exercise for finger extension?
- 1. Research demonstrates that lateral elbow tendinopathy is not associated with weakness of the finger extensors.
- 2. The finger extensors are typically loaded with gripping because they contract to counteract the finger flexors. Whenever you grip an object, like the exercises I discussed, both your finger flexors and extensors are engaged.
- Why didn’t I include an exercise for radial deviation?
- 1. There is a lack of research associated with radial deviation.
- 2. The extensor carpi radialis brevis, the muscle believed to be most often involved in lateral elbow tendinopathy, isn’t the primary radial deviator of the wrist.
- 3. Radial deviation will be indirectly strengthened with other exercises that I provided.
- Why didn’t I include stretching?
- Any benefits from stretching should be achieved through the exercises I’ve given when performed slowly and through a full range of motion. You certainly can stretch if it feels good, doesn’t exacerbate symptoms, and doesn’t detract from the other exercises.
- Why didn’t I include exercises for biceps and triceps strengthening?
- I don’t think strengthening of the biceps and triceps is always an essential component of rehab for lateral elbow tendinopathy.
Once again, individualize this program in a way that works best for you. If you want to incorporate isolated finger extension strengthening, radial deviation strengthening, or biceps and triceps strengthening, you’re welcome to do 2-3 sets of 10-15 repetitions, 2-3 times per week. Just keep in mind that more isn’t necessarily better, especially when you first start.
Two other questions:
1. Why didn’t I discuss eccentric wrist extension, which involves assistance from your other hand so you’re just doing the lowering portion of the exercise?
Eccentric exercises were traditionally believed to be the best approach for lateral elbow tendinopathy, but the systematic review and meta-analysis by Karanasios et al in 2021 found “No difference between concentric–eccentric and eccentric exercise alone…” Just perform every exercise slowly and with control.
2. Is there anything else you can do?
Yes! There is a growing body of literature, including research related to lateral elbow tendinopathy, that tendinopathies are often associated with other lifestyle and metabolic factors, such as cardiovascular disease, diabetes, smoking, etc.
This is NOT to say that they are the cause of your symptoms or even a contributing factor, but if you’ve been meaning to positively influence your general health and well-being by changing your exercise, nutrition, and/or sleeping habits, this might be a good time to kickstart your journey.
One of the easiest methods for improving health is simply walking more. Something is always better than nothing, and short walks throughout the day can be a great way to help break up any repetitive tasks that you’re doing with your wrist or elbow.
Surgery, Injections, Adjunct Treatments
What about surgery, injections, and other adjunct treatments? Since the goal of rehab isn’t to reduce inflammation or change the tendon structure, many of these interventions don’t make rational sense. And they’re not well supported by research.
A systematic review by Bateman et al in 2019 stated that “The findings of this systematic review suggest that surgical interventions for tennis elbow are no more effective than nonsurgical and sham interventions.”
And this is regardless of symptom duration. The systematic review and meta-analysis by Ikonen et al in 2022 reported the following: “We found that longer durations of symptoms were not associated with poorer prognosis, which suggests that persistent symptoms are no justification to recommend surgical interventions that have questionable efficacy profiles and known risks, such as surgery for tennis elbow.”
The research related to corticosteroid injections has been clear-cut for the past 20 years, yet recommendations and implementation haven’t changed. These injections can provide short-term relief, but they lead to worse outcomes in the long-term compared to exercise or doing nothing at all. Smidt 2002, Bisset 2006, Coombes 2013, Olaussen 2015, Coombes 2015, Vicenzino 2017, Karanasios 2021, Couple 2022
As for PRP injections, a Cochrane systematic review in 2021 concluded: “Data in this review do not support the use of autologous blood or PRP injection for treatment of lateral elbow pain…With no evidence of benefit, the costs and risks are not justified.”
What about massage, icing, or whatever else you can think of? If it’s low cost and low risk, you can pretty much try out anything. However, these things aren’t the focus of rehab and shouldn’t take away from the goal of progressively improving function.
Summary
In summary, lateral elbow tendinopathy is the preferred term for persistent tendon pain and loss of function related to mechanical loading of the lateral elbow tendons. Mechanical loading refers to any movements or activities that load the lateral elbow tendons, such as working with your hands, lifting weights, and playing sports.
We shouldn’t call it “tennis elbow” because it doesn’t only occur in tennis players. In fact, it’s most common in manual workers who use their dominant arm for repetitive movements or forceful activities on a regular basis. Golfers and other athletes also experience these symptoms.
Lateral elbow tendinopathy is thought to occur when the intensity, frequency, and volume of loading exceeds your capacity to recover and adapt appropriately.
Therefore, the goal of rehab is pretty simple: it’s to initially reduce those loads to a tolerable amount and then make sure that your capacity is greater than or equal to the various loads you’re going to be experiencing on a day-to-day and week-to-week basis.
If you plan on incorporating exercise and just want to focus on the local function of the lateral elbow tendons, these are three things you want to do:
1. Wrist extension strengthening for 2-3 sets of 8-15 repetitions, 3 times per week. As an optional add-on, you can pair this with wrist flexion strengthening.
2. Supination and pronation strengthening with a weight or household object for 2-3 sets of 8-15 repetitions, 3 times per week.
If you’re using a band, strengthening of the pronators is optional.
Grip strength and endurance, aiming for 2-3 sets of 30-60 seconds of total work, 3 times per week.
If you also wanted to focus on your shoulder, neck, and thoracic spine because you play sports or have other symptoms associated with those areas, two optional exercise categories include shoulder strengthening and thoracic mobility.
The shoulder strengthening exercises can be performed for 2-3 sets of 10-15 repetitions or 30-60 seconds of total work, 3 times per week prior to the wrist and forearm exercises.
The thoracic mobility exercises can be performed for 1-2 sets of 6-8 repetitions per side as part of your workout or periodically throughout your day.
Since your overall health and well-being can have an affect on your lateral elbow symptoms and function, taking steps to a healthier lifestyle can be a beneficial component of recovery.
You can incorporate adjunct treatments that alleviate pain, but they’re not the focus of rehab, especially if they’re high cost or high risk.
Regardless of what you decide to do, it’s important to tailor the plan to your individual goals and needs. There is no quick fix for lateral elbow tendinopathy, so it’s helpful to set realistic expectations and plan for the process to take a minimum of 3 months.
Don’t forget to check out our Tennis Elbow Rehab Program!
Want to learn more? Check out some of our other similar blogs:
Golfer’s Elbow, Improving Elbow Range of Motion, Triceps Tendinopathy
Thanks for reading. Check out the video and please leave any questions or comments below.
