• Tennis Elbow: Lateral Epicondylitis

    What is Tennis Elbow?

    Tennis Elbow (Lateral Epicondylitis) is a common cause of elbow pain. Tennis Elbow is characterised by pain over the outer side of the elbow, which may radiate down the forearm. Despite the name, Tennis Elbow does not just afflict tennis professionals. In fact, this common elbow problem (it affects about 3% of the population) is most often associated with work-related activities, although racquet sports players are more prone to the condition and account for approximately 5% of all sufferers. Tennis Elbow is equally common in men and women, peaking in prevalence between the ages of 30 and 50.


    Tennis Elbow usually begins as inflammation of the extensor tendons of the forearm as they attach to the Humerus (upper arm) bone, just above the elbow joint and function to bend the wrist back (extend). Typically this inflammation is caused by prolonged gripping activities such as hammering, driving screws, weight lifting, playing certain musical instruments, typing, canoeing, digging in the garden, driving and, of course, racquet sports.
    If these activities are continued, then the inflammatory nature of Tennis Elbow can give rise to a chronic tendon problem that is characterised by pain, weakness and degeneration of the tendon. This elbow problem can then be very persistent and much more difficult to treat.

    Signs & Symptoms of Tennis Elbow

    Tennis Elbow is very easy to diagnose. There is pain when the Lateral Epicondyle (outermost part of the elbow) is touched, and also if the elbow is straight and the hand is moved forward and back at the wrist. The elbow pain is made worse by gripping activities and, in some cases, simple things like turning a door handle or picking up a kettle can cause intense pain.

    Tennis Elbow is differentiated from osteoarthritis of the elbow joint by x-ray investigation. Rheumatoid disease would usually affect more than one joint and is confirmed by blood tests. Pain in the elbow region can be referred from a problem in the neck or shoulder and these should be thoroughly examined in order to eliminate them before a diagnosis of Tennis Elbow is made.

    Tennis Elbow Treatment

    • Consult a sports injury expert
    • Use anti-infammatory gel for pain relief
    • Apply ice packs/cold therapy
    • Wear a compression strap to reduce painful stresses
    • Use resistance bands for strengthening exercises

    Since severe Tennis Elbow is an inflammatory condition, the obvious treatment would be a short course of non-steroidal anti-inflammatory drugs ( NSAIDs), prescribed by a doctor. Anti-inflammatory gel can also be helpful to relieve tennis elbow pain. Some doctors may even inject the affected area with a corticosteroid (a naturally occurring substance which can settle down inflammation).

    Ice packs are a cheap and effective treatment for tennis elbow, applied for ten minutes every couple of hours (never apply ice directly to the skin). A cryotherapy cuff is the most effective method of providing ice therapy and is the professional’s choice. It can provide continuous ice cold water and compression for 6 to 8 hours to significantly reduce pain and inflammation.

    In addition to anti inflammatory treatments, it is important that the patient reduces the strain on the painful area, otherwise the treatments can simply mask the pain while the condition gets worse. Ideally the patient should rest from aggravating activities for around two weeks to allow the inflammation to settle down. If it’s not possible to rest completely then a elbow compression strap is very effective at reducing the stress on the painful area, whilst allowing the user to continue with activities. A wrist splint may also help reduce excessive movement of the wrist, allowing the inflammation to resolve. Often desk jobs where a lot of typing is carried out can aggravate this condition and a wrist splint or support to reduce the amount of wrist extension needed can serve as a long term solution to this overuse injury.

    Once the severe elbow pain has subsided rehabilitation under the supervision of a Chartered Physiotherapist can cure the problem and prevent a recurrence. A progressive strengthening programme using resistance bands has been shown to be the best long term approach to tennis elbow.

    In some cases of tennis elbow, conservative treatment can prove ineffective. This usually occurs in very longstanding cases, where the pain has been present for more than six months and where provocative movements can’t be limited or modified. In these cases, the inflammatory nature of the condition gives way to a chronic degeneration of the tendons of the extensor muscles.

    This degeneration can be further exacerbated by long term use of NSAIDs and corticosteroid injections. For this reason, these should be avoided in longstanding cases. In these chronic, degenerative cases, where conservative treatment has not helped, then an orthopaedic surgeon may consider surgery to cure the problem.


    Tennis Elbow Rehabilitation

    Controlling the Inflammation

    The success of rehabilitation of tennis elbow is dependent upon first controlling the inflammation at the insertion of the extensor tendons into the Humerus bone, on the outside of the elbow joint.

    Depending on the severity of the condition, this may be alleviated simply by rest or with the use of anti-inflammatory medication or a corticosteroid injection. In some longstanding cases, where there is degeneration of the extensor tendons, anti-inflammatory medication, especially corticosteroid injections, should be avoided. This is because they can hinder tissue healing and in fact cause more degeneration.

    In severe cases, where a corticosteroid injection has been given, some doctors insist on a 10 day rest period before rehab is initiated. Unless this is adhered to the following exercises are likely to aggravate the problem or cause long term weakening of the tendons. If the progression is timed correctly, all of the exercises should be pain free.

    Restoring Muscle Extensibility

    Prior to progressive strengthening, it is normal to restore full muscle extensibility by performing some simple stretching exercises for the forearm and wrist. This involves gentle stretching of the extensor tendons that attach to the inflamed area, which are located in the outer part of the forearm and are responsible for bending the wrist back.
    They are stretched by simply straightening the elbow and bending the wrist forwards. This helps to regain flexibility and realign the scar tissue which is present in the affected area, thus making it stronger.

    To do the exercise, keep the elbow straight and bend the wrist forwards. Use the other hand to gently push a little further. You should feel a mild stretch on the back of the forearm. The stretch should be held for about 30 seconds and should be completely pain free.

    This exercise should be undertaken daily for the duration of the rehabilitation period.

    Once the stretch can be done comfortably, a carefully supervised strengthening programme for the wrist extensor muscles can commence.

    Forearm Strengthening

    The progressive strengthening is usually undertaken utilising an ‘eccentric contraction’ and is referred to as an eccentric program. An eccentric contraction is defined as a contraction where the muscle is lengthening, as opposed to a concentric contraction where the muscle is shortening, or an isometric contraction where there is no change in the muscle length.

    There is nothing magical about eccentric muscle strengthening in the role of alleviating tendon problems but it is often a neglected component of strengthening regimes. The key is the controlled progression of exercise, which encourages adaptation in the tendon that produces healthier tissue and increased tensile strength. Research has shown that eccentric muscle contractions generate more tension than isometric or concentric contractions, often involving the “”braking”” motion of a movement. By using eccentric work in rehabilitation a muscle group can be efficiently strengthened and more capable of withstanding daily and sporting stresses.

    However, it’s crucial that the load and number of repetitions are carefully recorded and progressively increased, as the movements become more pain free. This ensures that the overload on the tendon is carefully controlled and gradually increased.

    Finally, to progress, the speed of the exercise is increased, making the exercises more functional for work activities.

    Tennis Elbow Rehabilitation: Phase 1 (weeks 1 to 2)

    IMPORTANT: These exercises should only be started once the pain has settled. There should be no pain during or following these exercises. These exercises should be carried out under the supervision of a Chartered Physiotherapist.

    The exercises begin with working the extensor muscles of the wrist, in the outer part of the forearm, against a Light Resistance Elasticated Band.

    To work the extensor tendons of the wrist eccentrically:

      • The forearm is placed facing down supported by a table, with the elbow straight. The wrist and hand should overhang the table. The Elasticated Band is looped under the foot and over the fingers, infront of the knuckles.
      • Keeping the fingers straight, slowly lengthen the band by carefully raising, or ‘extending’, at the wrist.
        The wrist should start at the extreme of wrist flexion (wrist bent forward) and finish at the extreme of wrist extension (wrist bent back), before being lowered slowly in a controlled manner, back to the starting position.

    The lowering against resistance is the eccentric muscle contraction component.

    A Typical Progression Schedule

    Table 1
    Day Load
     1 2 x 6 repetitions 
     2 2 x 8 repetitions
     3 2 x 10 repetitions 
     4 Rest
     5 3 x 8 repetitions
     6 3 x 10 repetitions
     7 4 x 8 repetitions
     8 3 x 12 repetitions 
     9 Rest 
     10 4 x 10 repetitions
     11 4 x 12 repetitions
     12 4 x 14 repetitions
     13 4 x 16 repetitions
     14 Rest
    Day Load    
    1 2 x 6 repetitions 8 3 x 12 repetitions
    2 2 x 8 repetitions 9 Rest
    3 2 x 10 repetitions 10 4 x 10 repetitions
    4 Rest 11 4 x 12 repetitions
    5 3 x 8 repetitions 12 4 x 14 repetitions
    6 3 x 10 repetitions 13 4 x 16 repetitions
    7 4 x 8 repetitions 14 Rest

    Tennis Elbow Rehabilitation: Phase 2 (weeks 3 to 4)

    As the exercises are gradually progressed, phase 2 uses a higher Resistance Band.

    A Typical Progression Schedule

    Day Load    
    15 2 x 6 repetitions 22 3 x 12 repetitions
    16 2 x 8 repetitions 23 Rest
    17 2 x 10 repetitions 24 4 x 10 repetitions
    18 Rest 25 4 x 12 repetitions
    19 3 x 8 repetitions 26 4 x 14 repetitions
    20 3 x 10 repetitions 27 4 x 16 repetitions
    21 4 x 8 repetitions 28 Rest

    Tennis Elbow Rehabilitation: Phase 3 (weeks 5 to 6)

    During the final two weeks of the progression, pain and normal daily activities should be near full recovery, allowing further resistance to be added in the form of free weights. The weight used shouldn’t be too heavy and all exercises should still be pain free.

    To work the extensor tendons of the wrist eccentrically:

    • The forearm is placed facing down supported by a table, with the elbow straight. The wrist and hand should overhang the table.
    • A small weight is placed in the hand and the exercise is to slowly lower the weight by carefully lowering, or ‘flexing’, at the wrist.
    • The wrist and weight can then be assisted to the starting position using the opposite hand – this eliminates the ‘concentric’ component of the exercise to ensure pure eccentric work.

    A Typical Progression Schedule

    Day Load    
    29 2 x 6 repetitions 36 3 x 12 repetitions
    30 2 x 8 repetitions 37 Rest
    31 2 x 10 repetitions 38 4 x 10 repetitions
    32 Rest 39 4 x 12 repetitions
    33 3 x 8 repetitions 40

    Tennis Elbow Prevention

    Tennis elbow is caused by gripping activities, and gripping either too hard or for too long can bring on the pain. Make sure the item that you are gripping, whether it’s a tennis racquet, bike handles, a hammer, or a canoe paddle, is the correct size for your hand. If it is too small it will cause you to grip too hard. If you play a racquet sport for the first time in a long while or you have to decorate a room in one weekend, make sure you take regular breaks and stretch the muscles which work over the wrist by doing ‘limp wrist’ and ‘policeman halting traffic’ type stretches.

    For those who have suffered from golfers elbow in the past it may be a good idea to wear a compression strap or elbow support. These work by reducing the strain on the painful area by preventing the wrist muscles from contracting fully during sporting and work activities.

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