Tennis elbow, which in the medical world is referred to as Lateral Elbow Tendinopathy (LET) or lateral epicondylalgia, is one of the most common elbow injuries. As common as lateral elbow pain may be, it can be an absolute nuisance to treat and live with. It doesn’t just affect and cause pain with a tennis backhand but also shaking hands, grabbing dishes, typing, gripping, writing, and you name it. In this article, you’ll learn what tennis elbow is, how to treat it, what you should try first, and elbow prehab exercises to try and avoid this injury in the future.
What is ‘Tennis Elbow’ ?
Tennis elbow refers to pain that is typically on the outside of the elbow and originates in what is known as the common extensor tendon origin, where multiple muscles in the forearm attach to the elbow. It is a condition that affects 1-3% of the general population, both men and women, and most commonly in the 3rd to 5th decade of life. Tennis elbow is more common in manual workers and tennis players, however, we often see it in the clinic after people do a lot of activity that their elbow is not accustomed to. Activities such as home improvement, a new workout routine, or a new hobby/sport.1
In most cases of tennis elbow, the affected fibers are the deep and anterior fibers of the extensor carpi radialis brevis (ECRB) component of the common extensor tendon origin. The ECRB muscle is responsible for extension and radial deviation of the wrist. In tennis elbow, the tendon itself may undergo cellular and matrix changes accompanied by alterations in pain, sensory, and motor functioning. These changes occur because the tendon is overworked and unable to handle the forces placed on the tendon in your day to day activities. There is a chance you have tennis elbow if you have pain to palpation over the lateral epicondyle (see the image above where the red is), pain with gripping, and pain with resisted wrist extension, middle finger extension, or index finger extension.1
So How Do I Manage it?
With any injury, conservative management should always be the first line of defense. Although it could take up to a year in some cases, most people dealing with tennis elbow can get back to regular life without experiencing symptoms or activity restrictions. Addressing tennis elbow early on is key to better long-term outcomes! A model we like to use with tennis elbow cases is the EdUReP Model.2
Education, Unload, Reload, Prevention
Education is one of the most important aspects of managing tennis elbow. A common aggravating motion that someone with tennis elbow may want to avoid is lifting objects with the palm facing down, or gripping heavy objects. In the early stage of tennis elbow, try to avoid activities that reproduce pain and symptoms, and rest your elbow if needed from repetitive movements. So if doing home improvements are aggravating your elbow, take a break from them for a little! You could also use your other hand to try and unload your aggravated elbow. When appropriate, it will be time to reload the common extensor tendon with specific exercises. Last but not least, you will want to continue with a maintenance exercise program to try and prevent experiencing tennis elbow symptoms down the road.2
Should I Get A Corticosteroid Shot In My Elbow?
In this day and age with technology, instant gratification is easy to come by. It is fair to say most people do not enjoy being in pain, and the idea of getting a cortisone injection in your elbow to make your pain go away fast sounds tempting. However, think twice.
“There is strong evidence that corticosteroid medication provides short-term relief of pain but leads to worse outcomes after 6 and 12 months compared to either a wait-and-see approach or physical therapy management, with substantial recurrence rates.”1
It is fair to say the three of us could not agree more with this statement. Unfortunately, most people will only address tennis elbow symptoms when it is a real burden. Getting a cortisone shot can provide immediate relief within a few days, which means no more pain! However, because there is no more pain, there is no reason to do elbow [P]Rehab exercises right? This is the mindset that can lead to tennis elbow coming back and worse long-term outcomes, thus we do not recommend a cortisone shot as the first line of treatment for tennis elbow.
So What Are Tennis Elbow Exercises?
Sample Program For Tennis Elbow
One Size Does Not Fit All
What we know from research focused on tennis elbow is that education and exercise are beneficial. However, there is no consensus on exercise programming for tennis elbow! “Despite clear benefits, the most optimal exercise intensity, duration, frequency, and type of load for rehabilitation of LET have not been established.”1 Below we will cover various elbow, wrist, and hand exercises as well as other exercises we typically program for tennis elbow. If you do not have access to a lightweight dumbbell at home, you can use your other hand for resistance with most of the exercises demonstrated.
In addition to this article, you can download for free a sample acute tennis elbow program HERE that provides our recommended exercise parameters
What we do know is that when the elbow is extremely sensitive and painful in acute cases of tennis elbow, the angry tendon responds well to rest, unloading, and isometric exercises early on. Isometrics produce what is called an analgesic effect that can reduce the pain you feel by altering the nociceptive/pain pathways to your brain.
Isometric Wrist Extension With Elbow Flexion
Demonstrated in this exercise is isometric wrist extension with elbow flexion and slight wrist extension (20-30˚) as this minimizes compression on the involved ECRB tendon. For now, we want to minimize compression on the tendon as it may reproduce symptoms, however, working towards exercises with the elbow extended and the wrist in less extension is a progression when appropriate. Also having the wrist in slight extension maximizes grip strength as the finger flexor muscles are on a slight stretch, which improves the length-tension relationship of the muscles. This is a great starting point for tennis elbow exercises.
Isometric Radial Deviation With Elbow Flexion
The ECRB muscle is responsible for wrist extension AND radial deviation. Radial deviation is another important movement you want to include in your tennis elbow program. Be sure to have a strong grip in your fingers and your thumb!
Isometric Supination With Elbow Flexion
Strengthening the supinator muscle is also important with tennis elbow as it originates on the lateral epicondyle, which is also where the common extensor tendon originates. It is not uncommon for the supinator to be contributing to the tennis elbow symptoms as well. If movements such as opening a door or using a screwdriver bother your elbow, you should definitely include this.
Isometric Gripping With Elbow Flexion And Neutral Forearm
Working on grip strength is essential with tennis elbow. Did you know grip strength is one of the best measures to track with tennis elbow? When performing this for the first time, it is important to perform pain-free gripping and start with a neutral forearm as demonstrated. Remember to start with your wrist in an extended position! Watch the video for other tips with this exercise.
Flexbar Isometric Wrist Extension With Elbow Extension
Flexbar exercises are great for tennis elbow. If you don’t have a flexbar, you can roll up a towel and think about wringing the water out of the towel. You won’t get the same amount of resistance, but the intention is there. This is a progression from isometric wrist extension with elbow flexion, and in my opinion is harder than a dumbbell or using your other hand for resistance.
ALL of the exercise parameters are included HERE in the free download of the acute tennis elbow rehab program. You can find more tennis elbow exercise variations in our PrehabX Exercise Library clicking on diagnosis – tennis elbow tag
When appropriate, it is important to progress towards eccentric exercises. Eccentric exercises are excellent for tennis elbow as they specifically load the affected common extensor tendon. A progressive loading program is required in order for the tendon to undergo positive adaptations so that it can tolerate the demands imposed on it! Eccentrics can be a good starting point for long-standing cases of tennis elbow that have not responded well to other treatments. Eccentrics are also a nice progression from isometrics. Detailed instruction, as well as tips and tricks, are included with every video!
Eccentric Wrist Extension With Elbow Flexion
Eccentric Wrist Radial Deviation With Elbow Flexion
Eccentric Supination With Elbow Flexion
As mentioned earlier, one size does not fit all. There may be some individuals with tennis elbow that only respond well to isometrics, or eccentrics, or neither… now what? Isotonic exercises are another option for tennis elbow. Isotonics are a combination of concentric motion and eccentric motion. An example of this is a bicep curl. For the biceps muscle, the concentric portion of the exercise is curling the weight up while the eccentric portion is lowering the weight back down. Detailed instruction, as well as tips and tricks, are included with every video!
Flexbar Wrist Extension With Elbow Flexion
Pronation & Supination With Elbow Flexion
Wrist Extension With Elbow Extension
Wrist Extension Motor Control
If you’ve been dealing with tennis elbow for quite some time and no matter how you move your wrist into extension it hurts, try this. Working on wrist and finger dissociation with wrist extension can be beneficial. This is also a nice exercise to focus on body awareness at your wrist. You want to limit any radial or ulnar deviation AKA keep your fingers parallel with your forearm. Listen in for tips.1
It is a hot debate if you should stretch with tennis elbow. There is evidence to support stretching to increase the stiffness of tendons through applications such as sustained static stretching, however stretching an angry tendon may not be appropriate or comfortable for people. If you want to learn more about what stretching really does click here. Our thoughts on stretching for tennis elbow – if you like to stretch, if you think it will help, and it doesn’t cause significant pain go for it, but do so sparingly. Stretching alone will likely not resolve your tennis elbow symptoms. You can try the contract-relax method or soft tissue mobilization method below.
Contract-Relax Extensor Mass Stretch
Extensor Mass Soft Tissue Mobilization
Spine & Nerve Mobility
Improving thoracic and cervical spine mobility as well as neural mobility can have positive central effects on the nervous system. This means for someone with tennis elbow that has been experiencing hypersensitivity at their elbow for a long time may benefit from the exercises demonstrated below. Performing these repeated movements, especially the nerve exercises, may decrease the sensitivity and symptoms associated with tennis elbow! Also in this day and age, almost everyone could benefit from having better thoracic mobility!1
Thoracic Spine Foam Rolling
Radial Nerve Glide
It is not uncommon for the radial nerve to be irritated and involved with tennis elbow, especially chronic cases of tennis elbow. It is important to minimize symptoms when performing these two nerve exercises for the first time!
Radial Nerve Tensioner
This a progression from the radial nerve glide. Get very comfortable with the radial nerve glide exercise and have zero symptoms before progressing to this.
Proximal strengthening is something we always program for tennis elbow. You have to realize that it is not always the elbow’s fault. There may be a lack of strength and stability elsewhere that is leading to overuse or compensation at the wrist, which can strain the ECRB tendon. Demonstrated are two of my favorite exercises specific to tennis elbow that work on dynamic wrist stability, grip strength, and strengthening of the shoulder girdle.
Upside-down Kettlebell Overhead Press
Simply holding a kettlebell upside-down demands a lot of grip strength and dynamic wrist stability. I like to program these at least 1x/week just to work on grip strength and as a prehab measure against tennis elbow.
Ultimate Rotator Cuff Row
Performing shoulder external rotation resistance exercises always incorporates isometric wrist extension. The set-up of the exercise imposes a wrist flexion moment. I love this exercise because it strengthens the shoulder blade muscles, the external rotators of the shoulder, and the wrists!
Training Around Elbow Pain
So what do you do if you have tennis elbow and are desperate to work out your upper body?! Try out these exercises! Demonstrated in this video are a few exercises that limit the amount of gripping required, which may decrease stress on the elbow. Finding a way to still exercise not only provides physical benefits but mental as well!
Like we mentioned above, one size does not fit all. There is some evidence to suggest a combination of isometrics, concentrics, and eccentrics lead to better outcomes. It is a matter of finding out what works for you! If you’re having trouble managing your tennis elbow, please seek a consultation with a physical therapist or other healthcare professional. This is not strict medical advice, rather a guide to try and help you to manage this on your own. It is also important to consider other factors in life including the demands of your job, your habits, stress, hobbies, and anything else that could be contributing to your tennis elbow symptoms. Remember, most cases of tennis elbow resolve within a year. Only in rare cases do people with tennis elbow elect to have surgery. It is important to be patient and trust the EdUReP model. If you’re in the greater Los Angeles area and would like to work with us in person, contact us via email.1, 2
Tennis Elbow Phase 1 Rehab Program
Click HERE or the photo to download the FREE Tennis Elbow Phase 1 Rehab Program that includes parameters for two weeks!
- Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: one size does not fit all. J Orthop Sports Phys Ther. 2015;45:938- 949. http://dx.doi.org/10.2519/jospt.2015.5841
- Davenport, TE; Kulig, K; Matharu, Y; Blanco, CE: The EdUReP model for nonsurgical management of tendinopathy. Phys Ther. 85(10):1093 – 1103, 2005.