Has this ever happened to you?

You’ve spent the day doing some much needed yard work, but you still need to weed the garden. As you begin to grip and pull weeds from the soil, a sharp pain shoots from your elbow and into your forearm. You need to finish the task so you work through the pain for the next half hour. The pain intensifies and your forearm muscles become stiff as you continue to work.

Finally, the symptoms are bad enough that you have to stop working. In the evening, a persistent ache and stiffness in the elbow make it difficult to cook dinner, to turn doorknobs, or to do anything with that arm.

te2The pain in your elbow lingers for several days and worsens when you try to grip anything or twist off the lid of a jar. Typing on your computer and frequently using the mouse cause the pain to move down the forearm with intermittent tingling in the fingers. Driving becomes unbearable, especially when you turn corners. Turning doorknobs and pulling doors open is as bad as the first day.

Your daily activities become so difficult that you decide to visit your physician. After the examination, she says that you have tennis elbow. What, tennis elbow? You don’t even play tennis . . .

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse or trauma. It’s called tennis elbow because the repetitive movements required for ground strokes in tennis are the same movements that lead to inflammation in this area. While it can occur from playing racquet sports, other activities that involve consistent or forceful use of the arm can cause tennis elbow.

Examples include working with machinery, performing office tasks, using a screwdriver, and playing other sports. This condition can significantly limit a person’s ability to perform usual daily activities.



Anatomy of the Elbow

Your elbow joint is formed where the upper arm bone, the humerus, meets the radius and ulna from your forearm. It’s considered a hinge joint, but there is rotational component during supination and pronation of your forearm. Two bony prominences on the inside (medial) and outside (lateral) of the elbow are called epicondyles. The joint is held together by several ligaments and a thick fibrous joint capsule. The motion of the elbow is controlled by the surrounding muscles that generate force when needed to perform functional tasks.


anatomy of the elbow


Tennis elbow is inflammation of the tendons of forearm muscles that attach to the lateral epicondyle. The muscles travel from the elbow along the forearm to the wrist and hand. They work to extend your wrist and fingers during your daily activities. The muscle usually involved in tennis elbow is the Extensor Carpi Radialis Brevis (ECRB). The ECRB helps stabilize the wrist when the elbow is straight during activities such as a tennis forehand or backhand stroke.


Causes of Tennis Elbow

One of the most common causes of tennis elbow is overuse from repetitive movements, particularly twisting of the forearm and extension of the wrist. This injury is generally considered be a result of small tears in the muscle tendon near its attachment to the lateral epicondyle. The forehand tennisand backhand strokes used in tennis are examples of repetitive motions that occur with the elbow extended.

Although tennis and other racquet sports are common causes of this condition, any activity that requires repetitive or vigorous use of the forearm muscles can cause this inflammation.

The repetitive nature of some job tasks can lead to this injury. People who are carpenters, machine workers, painters, and plumbers can be at risk for developing tennis elbow.

Other potential causes including trauma to the elbow and a person’s age, but in some cases, the cause is unknown.



Overview of Tennis Elbow Treatment

Treatment of tennis elbow can be broken into two types: conservative management and invasive techniques. Conservative management of tennis elbow includes rest, activity modification, bracing, medication, exercise, manual therapy, and thermal modalities such as heat or cold. Invasive techniques include steroid injections and surgery.

This article will focus on the conservative treatment techniques. Many conservative interventions are performed by licensed physical and occupational therapists, but here are five ways that you can manage the condition yourself.



1. Rest and Activity Modification

The first step in the treatment of tennis elbow to rest and reduce the strain on the forearm muscles. Rest doesn’t mean that you need to stop all of your usual activities, but you should avoid anything that causes more pain. You should not try to work through the pain with this condition because it will just cause the symptoms to get worse.

You should attempt to identify which activities could be causing your symptoms, then stop or modify the actions required to perform the activity. Even small motions like twisting a bottle cap or opening a jar can be extremely painful. Rest is an important part of the healing process.



2. Straps and Braces and Sleeves, Oh My

Tennis elbow straps and bands are popular devices used manage symptoms and to protect the elbow during daily activities. This market, including braces and support sleeves, has grown significantly over the last decade. The popularity of these devices has been enhanced through their use by professional athletes.

te3Tennis elbow straps and bands can help reduce stress on the elbow muscles that attach to the lateral epicondyle. These straps are worn just below the elbow and the compress the muscles to redirect the force under the strap instead of at the lateral epicondyle and tendon.

To visualize this concept, think of pulling on someone’s necktie. If you pull downward on a tied necktie, the force is felt around the neck and the knot. When you grasp the tie a couple of inches below the knot and pull again, the force focuses at the point you are grasping instead around the neck. Elbow straps function in much the same way.

Elbow braces are designed to immobilize the elbow to prevent motion that could irritate the symptoms. This is not generally recommended because it will cause the elbow joint to become stiff and could lead to the formation of troublesome scar tissue. Elbow sleeves compress the elbow and forearm muscles to give support during activities. They pose less risk than immobilizing braces, but they are effective for everyone.

Using straps, braces, and sleeves can help to reduce stress on the elbow muscles during your daily activities. However, there are a few things to consider. These devices are primarily for situations where you MUST perform actions that cause irritation of your elbow such as job tasks and sports. They can give you a false sense of security and encourage excessive use of the arm.

Another concern is the compressive force created by these devices. Muscle tendons have less blood supply than the muscle belly. Using straps and sleeves to compress this area can reduce the blood flow further leading to slower healing times.



3. Exercise

Although rest is an important part of the recovery process, tendons need tension and movement to heal and stay healthy. This is accomplished with specialized exercises designed to reduce muscle guarding, improve flexibility, and restore strength.

The first phase of exercise is stretching to reduce muscle guarding and to improve flexibility.

The wrist extensor muscles in the forearm tend to tighten in response to the pain associated with tennis elbow. Initially, the lack of flexibility comes from muscle guarding, but when the symptoms are present for long periods, the muscle begins the process of adaptive shortening. Here are a couple of stretching exercises to reduce tightness and to restore proper muscle length.


Standing/Seated Wrist Flexion Stretch

Begin in a standing or seated upright position with the involved arm extended in front of your body, palm facing the floor.

With your other hand, gently press downward on the back of your hand and bend your wrist until you feel a stretch in the top of the forearm.

Make sure to keep your elbow straight and try not to apply too much pressure. The stretch should be gentle and not painful.

Hold the stretch for 10-20 seconds, then release. Perform 3-5 repetitions of this exercise at least 3 times per day.


Reverse Prayer Stretch

Begin in a standing or seated upright position.

Place the backs of your hands together in front of your body, then lower your elbows until you feel a stretch in the back of your wrists, and hold.

Make sure to only move through a pain-free range of motion.

Hold the stretch for 10-20 seconds, then release. Perform 3-5 repetitions of this exercise at least 3 times per day.

The second component of exercise for tennis elbow is strengthening with isometric and eccentric movements. Isometric exercises involve generating resistance with the muscle without allowing motion in the wrist joint. This helps to recruit the muscle fibers and stimulate muscle activity without causing strain in the wrist extensor muscles.

Eccentric movements are the lowering phase where the muscle providing resistance is slowly lengthening and the weight is returned to the start position. This is also called the “negative” phase. Here are a couple strength exercises to restore strength and function.

Seated Isometric Wrist Extension

Begin sitting upright with your arm resting on a table, palm down, and your other hand on top of your involved hand.

Try bending the involved wrist upward, gently resisting the movement with your other hand. There should be little to no movement.

Your fingers may lift off the table, but make sure to focus on trying to bend at your wrist. Keep your shoulder relaxed during the exercise.

Hold to contraction for 5 seconds, then release and repeat. Perform 2 sets of 10 repetitions twice daily.

Progress to 3 sets of 10 repetitions 3 times per day as tolerated.

Seated Eccentric Wrist Extension

Begin sitting in an upright position with one arm resting on a table or your knee, holding a light dumbbell or soup can with your hand hanging off the edge, palm face down.

Use your other hand to pull (curl) your wrist up, then use the involved muscles to slowly lower it back down, and repeat.

Make sure not to rotate your wrist, and do as little work as possible as with the hand that is assisting moving the wrist upward.

Start with 2 sets of 10 repetitions twice daily using 0.5 – 2 lbs, then progress to 3 sets of 10 twice daily.

The resistance should be progressed slowly as tolerated.

Resistance Bar Twist

Begin standing upright holding the end of a resistance bar in your involved hand.

Extend your wrist backward, then grab the top end of the bar with your other hand and twist the bar forward keeping your involved wrist extended.

Keeping your wrists in the same positions, straighten your arms in front of you, then slowly unwind the resistance with your involved hand.
Return to the starting position and repeat.

Perform 2 sets of 10 repetitions twice daily. Progress to 3 sets of 10 repetitions as tolerated.

Make sure to maintain an upright posture and do not shrug your shoulders during the exercise.

It is normal for feel muscle fatigue and mild to moderate soreness in the forearm muscles after this program. However, you should not feel more intense pain over the lateral epicondyle.



4. Manual Therapy

Manual therapy is a physical technique that involves using your hands to manipulate soft tissue structures including muscles and tendons. In the case of tennis elbow, soft tissue mobilization and cross friction massage can be effective in reducing pain and tightness. The primary difference between these two techniques is the direction of force.

Think of the wrist extensor muscles as guitar strings traveling along the neck of the guitar. They extend from the elbow to the wrist and hand. Soft tissue mobilization is performed along the length of the muscles (like sliding down the guitar strings toward the neck of the guitar).

woman holding armCross friction massage is performed perpendicular to the muscle fibers (like strumming across the guitar strings). Soft tissue mobilization is generally a more comfortable technique, while cross friction massage can be painful at first. Both techniques help to improve blood flow and to restore muscle extensibility.

Cross friction massage can help break up any adhesions that might form between the muscle fibers when prolonged inflammation results in tendinosis. When starting cross friction massage, keep your fingers flat on the surface of the forearm. As you strum across the muscle and tenderness subsides, slowly increase the angle of your fingers on the forearm toward a more perpendicular position.

This creates a force that reaches the deeper muscle fibers. You will only tolerate this for a few minutes at a time, but you can use an ice cube to massage the area and decrease pain between repetitions.



5. Thermal Modalities

Hot packs, cold packs, and ice cubes are types of thermal modalities that can be used to manage pain and inflammation in tennis elbow. During the acute phase of this condition, you should avoid using a hot pack. It will most likely cause greater inflammation and pain within a half hour after removal — even if it feels okay during the application. This will present as deeper aching, stiffness, or sharp pain along the elbow and upper forearm.

Hot packs can be used successfully in the chronic phase to improve blood flow and tissue pliability. Cold packs and ice cubes can be extremely helpful for decreasing pain and reducing inflammation in localized areas. They are particularly helpful during the acute phase of the condition.



Tennis elbow is a common musculoskeletal condition that limits your ability to perform your usual daily activities. The conservative management techniques covered in this article are for informational purposes only and are not meant to replace skilled medical care. These conservative techniques should be effective for most mild to moderate cases of tennis elbow. However, you should consult your physician and/or physical therapist if your symptoms persist or become more severe.

Once your symptoms resolve and you return to your previous level of activity, you should continue to perform the exercises at least three times per week. Maintaining strength and flexibility will help you resist future overuse injuries and avoid tennis elbow.



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