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Tennis Elbow Rehabilitation

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 (see full article for an explanation of the anatomy).

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.

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.

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:

  1. 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.
  2. 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.
Photo: Forearm strengthening - step 1
Photo: Forearm strengthening - step 2

A Typical Progression Schedule

DayLoad12 x 6 repetitions22 x 8 repetitions32 x 10 repetitions4Rest53 x 8 repetitions63 x 10 repetitions74 x 8 repetitions83 x 12 repetitions9Rest104 x 10 repetitions114 x 12 repetitions124 x 14 repetitions134 x 16 repetitions14Rest

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

Photo: Forearm strengthening - step 1
Photo: Forearm strengthening - step 2

A Typical Progression Schedule

DayLoad152 x 6 repetitions162 x 8 repetitions172 x 10 repetitions18Rest193 x 8 repetitions203 x 10 repetitions214 x 8 repetitions223 x 12 repetitions23Rest244 x 10 repetitions254 x 12 repetitions264 x 14 repetitions274 x 16 repetitions28Rest

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:

  1. The forearm is placed facing down supported by a table, with the elbow straight. The wrist and hand should overhang the table.
  2. 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.
  3. 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.
Photo: Eccentric contraction of the extensor tendons - step 1
Eccentric contraction of the extensor tendons - step 2

A Typical Progression Schedule

DayLoad292 x 6 repetitions302 x 8 repetitions312 x 10 repetitions32Rest333 x 8 repetitions343 x 10 repetitions354 x 8 repetitions363 x 12 repetitions37Rest384 x 10 repetitions394 x 12 repetitions404 x 14 repetitions414 x 16 repetitions42Rest

Once this progression has been followed successfully, the next stage is a gradual return to functional and sporting activities.