What is Tennis Elbow?
Tennis elbow, also called lateral epicondylitis, is a condition that causes pain and inflammation on the outside of the elbow. It is mainly seen in athletes and laborers and is associated with activities that involve repetitive strain on the wrists caused by gripping and extension movements.1 Exercises that lengthen the muscles and tendons under tension, called eccentric exercises, play a major role in the recovery and strengthening of forearm muscles.2 NHS provides information on the duration and frequency of exercises to be repeated.8 There are videos on different exercises for elbow pain given by the Chartered Society of Physiotherapists.
Anatomy and physiology
Key structure affected - Extensor carpi radialis brevis (ECRB) tendon.
Other forearm muscles involved- Extensor carpi radialis longus and extensor digitorum.The primary cause of tennis elbow is repeated injury to the forearm, resulting in strain, inflammation, and degeneration of the muscles surrounding it.
Eccentric exercise protocol
Eccentric exercises are done as part of guided physiotherapy to treat tennis elbow. The exercises are divided into 3 phases.3
| Modality | Aim | Action | Dose | Goals | Consideration |
| Active warm-up | To increase blood flow and movement of soft tissue | Treadmill walking | Up to 10 minutes at a comfortable pace (2 mph on a flat incline) | 10 minutes | - |
| Phase 1 | To promote healing and reduce pain by using low-grade exercises | Wrist/Elbow exercises-1. Rest your arm on the table with your wrist hanging off the edge and your palm facing down, holding a dumbbell in your hand. Slowly move the dumbbell to the starting position after lifting it with the other hand.2. Repeat the above exercise with palm facing up | 3 sets of 10 reps once a day | Perform wrist extension and elbow movement with no pain | Avoid activities that aggravate the symptoms |
| Phase 2 | To slowly increase strength and resistance in the tendon with controlled stress | Resistance-based exercises -1. Holding the dumbbell in the affected arm, both palms facing each other, and moving the dumbbell inwards by curling.2. holding weight, raising and lowering the wrist.Holding it down isometrically for 5-10 seconds. | 1-5lbs, 3 sets of 10 reps, once a day | Both eccentric and concentric exercises with 5 lbs, 20 reps each day, without pain | When the muscle soreness lasts for less than 24 hrs after the start of it, pain is low with advanced resistance |
| Phase 3 | Using moderate to heavy loads, increasing strengthening and resistance in the muscles | Advanced resistance exercises-1.Take a heavy weight to do wrist curl.Holding for longer2. Controlled push-up with slow lowering using the forearm muscles | Elongate lower arm, use heavy dumbbell, 3 sets of 10 reps, once every other day 3 sets, 5-8 reps | Advanced strengthening exercises without pain | Temporarily reduce resistance exercise and focus on strengthening exercises by extending of your lower arm |
| Education and awareness | Increase understanding of activities that worsen the pain and how to modify tasks and activities to reduce stress on muscles. | Activities assessment | Modify activities to minimise injury | Sports-specific retraining / activity-specific |
Additional consideration
- Pain Monitoring: assessment of pain before, during, and after exercise should be graded with scales (between 0-10). The scale is used as a guide for assessing pain before, during, and after exercise by a person doing them at home. 0 to 3 – minimal pain, 4 to 5 – acceptable pain, 6 to 10 – excessive pain. Pain scaling between 0-5 is acceptable after exercise; however, if the pain increases beyond 5, reduce the number of repetitions, slow the speed, and give resting intervals
- Introducing rest intervals and reducing the frequency of activities that increase the pain.
- Cold Therapy- ice packs post-exercise reduce inflammation and pain. Ice pack for 15 minutes and ice massage for 5 minutes3,5
- Using braces or counterforce straps, the strap is placed about 2 finger widths below the painful area, and tension is adjusted to achieve comfort. Wearing them only while doing sports/ work or performing insulting activities
- Soft tissue therapy- deep friction massage, soft tissue massage for 3-5 minutes to release wrist extensor muscles
- Home instructions-following the therapist’s guide on load and time of load. Avoid repetitive wrist and elbow movement, using larger handles on utensils, tennis rackets and tools, mindfully doing exercises, using good posture at work, do not maintain fixed postures for prolonged period, using vertical mouse to promote neutral wrist posture and consulting a sports trainer on modification of equipment and to correct faulty mechanics3
- Joint mobilisation techniques- focuses on pain-free grip while gliding the elbow away from the body for five seconds, 6-10 repetitions. The second technique involves the use of a mobilisation belt using the same direction of force mentioned in the first technique, with an extended elbow
- Additional strengthening exercises, specifically for back muscles and shoulders to avoid excessive strain on the elbow. These include isotonic and isometric exercises for the scapula
- Elastic bands are used to create resistance, with elbows resting by the side, and pulling the bands in a rowing motion
- Sleeping on the stomach side, extending the affected arm with or without a weight in hand
Differential diagnosis
Lateral elbow tendinopathy can often be misdiagnosed with Common cervical radiculopathy, radial tunnel syndrome, ligament pathology, and referred pain from wrist injuries.6
People with tennis elbow can also have additional problems like cervical radiculopathy,
radial nerve irritation, and intra-articular pain7
Sometimes, therapists may opt to perform additional tests to check for involvement of nerves.
Side effects
- Reduced proprioception and symptoms may persist for a long period.
- High recurrence
- Motor and sensory system deficits in the non-injured forearm
These side effects can be reduced with progressive loading, assessing nerve involvement, and introducing exercises for the non-injured arm.8
FAQs
What can I do if I have elbow pain?
Reduce or stop doing activities that increase pain, take over-the-counter pain medicines, and use ice and heat packs
When do I see a doctor?
If the pain continues after 2 weeks of at-home measures
How do I do exercises at home?
There are instructions given on the NHS website and videos on the Chartered Association of Physiotherapists’ webpage
When do I visit the physiotherapist?
Your GP or doctor will advise you if you need a physiotherapist or not after around 6 weeks of evaluation
Can I do eccentric exercises at home?
Yes, eccentric exercises can be done at home under the guidance of a therapist.
Summary
Among strengthening programs, eccentric strengthening has been commonly used to treat tennis elbow8 and is effective when done along with concentric exercises. Treatment of tennis elbow depends on individual presentations and response to treatment. The outcome of these exercises depends on dosage, duration, and design of the exercises, which vary with different people.9 Eccentric exercises have been shown to reduce pain and increase muscle strength, especially in chronic tennis elbow cases.10
References
- Buchbinder, Rachelle, et al. ‘Shock Wave Therapy for Lateral Elbow Pain’. Cochrane Database of Systematic Reviews, edited by Cochrane Musculoskeletal Group, vol. 2009, no. 1, Oct. 2005. DOI.org (Crossref), https://doi.org/10.1002/14651858.CD003524.pub2.
- Hody, Stéphanie, et al. ‘Eccentric Muscle Contractions: Risks and Benefits’. Frontiers in Physiology, vol. 10, May 2019, p. 536. DOI.org (Crossref), https://doi.org/10.3389/fphys.2019.00536.
- Day, Joseph M., et al. ‘A COMPREHENSIVE REHABILITATION PROGRAM FOR TREATING LATERAL ELBOW TENDINOPATHY’. International Journal of Sports Physical Therapy, vol. 14, no. 5, Sept. 2019, pp. 818–29. DOI.org (Crossref), https://doi.org/10.26603/ijspt20190818.
- Malanga, Gerard A., et al. ‘Mechanisms and Efficacy of Heat and Cold Therapies for Musculoskeletal Injury’. Postgraduate Medicine, vol. 127, no. 1, Jan. 2015, pp. 57–65. DOI.org (Crossref), https://doi.org/10.1080/00325481.2015.992719.
- Ahmad, Z., et al. ‘Lateral Epicondylitis: A Review of Pathology and Management’. The Bone & Joint Journal, vol. 95-B, no. 9, Sept. 2013, pp. 1158–64. DOI.org (Crossref), https://doi.org/10.1302/0301-620X.95B9.29285.
- Faro, Frances, and Jennifer Moriatis Wolf. ‘Lateral Epicondylitis: Review and Current Concepts’. The Journal of Hand Surgery, vol. 32, no. 8, Oct. 2007, pp. 1271–79. DOI.org (Crossref), https://doi.org/10.1016/j.jhsa.2007.07.019.
- Stasinopoulos, Dimitrios, and Mark I. Johnson. ‘“Lateral Elbow Tendinopathy” Is the Most Appropriate Diagnostic Term for the Condition Commonly Referred-to as Lateral Epicondylitis’. Medical Hypotheses, vol. 67, no. 6, Jan. 2006, pp. 1400–02. DOI.org (Crossref), https://doi.org/10.1016/j.mehy.2006.05.048.
- Sany, Shabbir Ahmed, et al. ‘The Effectiveness of Different Aerobic Exercises to Improve Pain Intensity and Disability in Chronic Low Back Pain Patients: A Systematic Review’. F1000Research, vol. 11, Feb. 2022, p. 136. DOI.org (Crossref), https://doi.org/10.12688/f1000research.75440.1.
- Peterson, Magnus, et al. ‘A Randomized Controlled Trial of Eccentric vs. Concentric Graded Exercise in Chronic Tennis Elbow (Lateral Elbow Tendinopathy)’. Clinical Rehabilitation, vol. 28, no. 9, Sept. 2014, pp. 862–72. DOI.org (Crossref), https://doi.org/10.1177/0269215514527595.
