Tennis elbow is the most common condition in the elbow. Tennis elbow is actually a tendinopathy of the wrist extensors on the outside of the elbow, hence why it is also called lateral epicondylitis. The development of tennis elbow is through overloading of the wrist extensors, typically either through activities that require a lot of gripping or repetitive wrist extension. While tennis elbow is commonly experienced by tennis players, it is also common in weight lifters, baseball/softball players, and construction workers.
The treatment of tennis elbow should begin by evaluating the load being placed on the wrist extensions. Since tennis elbow is considered an overload syndrome, it may be appropriate to temporarily decrease the load on the tendons to allow them to heal and adapt. The most common ways to modify the load on the wrist extensors are to decrease the frequency, duration, intensity, or a combination. The goal of modifying the load isn’t to completely off-load the tendon (which can have negative consequences on its own), but to find a load that the tendons can tolerate.
For example, if we have a weight lifter using kettlebells. We could modify the loading by only using kettle bells once or twice a week (frequency) and/or decreasing the weight that is being lifted (intensity). Another example of how to modify load, would be to limit the time that someone does an activity. We may limit the amount of hammering to 15 to 30 minutes before taking a break (duration).
The overall goal of treatment for tennis elbow should be to increase the tissue load tolerance of the wrist extensors. Manual therapy, mobilization, and exercise have all been shown to help improve tennis elbow. While only exercise has been shown to increase tissue tolerance, manual therapy and wrist mobilizations can help make loading the elbow more tolerable. Clinically, combining isometric exercise (holding the wrist still against resistance) with instrument assisted soft tissue therapy (Graston) has been particularly effective in decreasing the pain on the elbow.
Some other common treatment strategies include corticosteroid injections, ultrasound, and orthoses (tennis elbow straps), however these treatment options are not supported by the research. Ultrasound and orthoses have not been shown to be more effective than sham treatments or a wait-and-see approach. Corticosteroid injections were a popular treatment approach when the pathology of tennis elbow was thought to be inflammatory (new research has shown that inflammation is not the main driver of tendon pain). Corticosteroid injections usually have good short term results compared to conservative care, however, injections can cause a higher rate of reoccurrence of tennis elbow.
Since exercise is the only treatment shown to increase the ability of tissues to tolerate load, the rehab program for tennis elbow is of vital importance. The rehab program for tennis elbow should consist of a progressive loading program, generally starting at isometric exercises, then concentric/eccentric exercises, and ending on sport specific movements.
Isometric exercises are movements where the wrist remains still while resisting a load. These isometric holds should first be performed with the wrist in a neutral position, but can then be held with the wrist in flexion or extension. The benefit of starting with isometric exercises is that they have been shown to be pain relieving. Generally this exercises should be performed for 45 second holds for 5 sets, but will depend on the individual.
The next progression would be to begin concentric and eccentric (often called negatives) exercises, which would be wrist curls. Isolated eccentric (commonly called negatives) exercises have been a popular exercise option for tennis elbow, however, it doesn’t appear that they are more beneficial than combined concentric and eccentric exercises. So to make sure the wrist is being strengthened in all movements, we recommend doing both concentric and eccentric wrist curls.
The final progression of the rehab program would be to reintroduce sport specific movements. This would include starting to swing the tennis racket again for someone who is a tennis player or increasing the weight for a weight lifter.
Tennis elbow is an overload syndrome of the wrist extensors that can be experienced by anyone. The primary treatment strategy should be to modify loading on the wrist extensors, but manual therapy, wrist mobilizations, and a progressive rehab program can be effective at decreasing pain and increasing tissue tolerance.