What is Tennis Elbow? – Evidence Based Strategies for Treatment and Management
- Brainz Magazine
- Mar 23
- 9 min read
Written by Jon Kilian, Physical Therapist
Jon Kilian is a rehab and strength expert in VA who specializes in injury treatment that bridges the gap between strength and conditioning and traditional rehab. He currently is the practice manager of the clinic where he works and has rehabbed a plethora of musculoskeletal conditions of populations ranging from geriatrics to elite level athletes.
‘Tennis Elbow’ is the layman’s term for lateral epicondylitis, or an injurious state of the extensor tendon(s) of the wrist. Many times, this is coined as ‘tendonitis,’ which is characterized as an acute injury with microtears of the muscle-tendon unit, paired with localized swelling and point tenderness. However, if the problem has been chronic, the injury may have progressed to be more appropriately labeled as “tendinosis,” which is an active, long-term degeneration of this tissue.
It is important to distinguish between the two because they require slightly different paths and starting points of treatment and intervention to be most efficiently addressed. With tendonitis, the goal is to first provide an environment that removes the irritable stimuli and allows healing before loading the tissue to become more resilient. With tendinosis, a particular loading program may be used immediately and for a relatively lengthy amount of time, but it may still require surgical intervention to remove the diseased tissue in worst-case scenarios.
The quickest way to differentiate between these two pathologies is to consider the timeline as well as whether there is active swelling. If the injury was of a quicker onset and has point tenderness and swelling, it probably falls into the category of tendonitis. If the pain has been a longstanding issue that has steadily gotten worse and doesn’t have any significant warmth or swelling over the painful area, it may be more of a tendinosis.
Either way, the goal is to first “put out the fire” and then to create more robust, resilient tissue. While this may seem like a very lengthy and in-depth read, I believe it is important to understand the background and thought processes of treatment if you are to correctly engage in the right path, so I encourage you to persevere through this article.
Tennis elbow typically occurs in people between 35 and 50 years old and is more prevalent in those who, whether by work or sport, are required to extend and twist (pronate/supinate) their wrist repetitively. It is important to note that there are other pathologies that mimic pain around the lateral elbow and need to be considered before blindly treating tennis elbow.
First of all, if the pain is associated with a fall, particularly on an outstretched hand, consult a medical professional for further triage and potential imaging. Secondly, it would be prudent to consider nerve involvement. If the pain can be affected by neck movements, its onset was accompanied by neck pain, or if the pain radiates down to the fingers, it may be more of a radiculopathy (nerve-related or referred pain) of the cervical spine, particularly at the levels of C6 and C7.
Entrapment of the radial nerve in the radial tunnel can also mimic these symptoms. If compression of the area makes the symptoms worse, the injury may fall under more of a radial nerve impingement syndrome. If this is the case, consult a local medical professional before proceeding with care.
One way to increase confidence in the involvement of the common extensor tendon and true tennis elbow is through the use of “special tests.” In and of themselves, though, these tests are not very special and have weak diagnostic capability. However, in conjunction with the other symptoms that have been outlined, they do aid in an educated understanding of potential diagnostics.
Cozen’s test
With the elbow extended or straightened and resting on a surface, pronate, radially deviate, and extend against resistance. A positive test is pain reproduction at the lateral epicondyle. Some would recommend palpating that area throughout the test. Reference the video above for a demonstration of this test. See here.
Mill’s test
This is a passive test, and a partner will be required to carry it out most accurately. With the elbow flexed, the partner will passively pronate and flex the wrist, then maximally extend the elbow. A positive test is indicated by pain reproduction at the lateral epicondyle. Reference the video above for a demonstration of this test. See here.
Maudsley’s test
With the arm fully straight and resting on a table with the palm down, actively extend or lift the middle finger off the table. Add resistance by trying to push it back down. A positive test is indicated by pain reproduction at the lateral epicondyle (involvement of the extensor digitorum muscle). Reference the video above for a demonstration of this test. See here.
Treatment
Once the “tissue with the issue” is identified, the first important step is to ‘put out the fire,’ or decrease pain. Pain is an inhibitor and will affect how the associated musculature is able to activate and stabilize the related joint. Being able to manage this is a fundamental step in successful rehabilitation, which is why it needs to be (mostly) addressed first. First, one needs to identify and decrease aggravating movements and activities. Then, loading of the tissues intelligently can allow for greater resiliency and, therefore, function to be achieved. There will be gray areas, such as when utilizing isometric contractions, as they can help bridge the gap between pain-free contraction, which can simultaneously decrease pain and also address loading of the associated tissue.
Note: It is important and recommended to check with your doctor or local physio before applying any of these techniques in order to be aware of any contraindications or precautions.
Symptom management (“put out the fire”)
While the clinical practice guidelines state “weak evidence” for instrument-assisted soft tissue mobilization (IASTM), this technique has been shown to facilitate healing of injured tissues. When soft tissues are injured, scar tissue may form during the healing process, which reduces tissue elasticity, causes pain and dysfunction, and restricts tissue perfusion, including the supply of oxygen and nutrients (Kim, Sung & Lee, 2017). The goal of IASTM is to cause an acute inflammatory response to “restart” the healing process, stimulate new collagen synthesis, and ultimately enable the tissues to heal in a better environment.
For tennis elbow, Sevier and Stegink-Jansen (2015) demonstrated that this technique significantly reduced reported dysfunction and pain, as well as increased grip strength significantly more than the compared group (eccentric exercise). More importantly, when added to the compared group, it made up for the deficit shown in these measures.
To apply IASTM for lateral epicondylitis, obtain an object that does not have a sharp edge. The most popular pieces used are typically made of stainless steel and can be purchased. However, as a fun fact, throughout history, other objects such as rocks or wood have even been used, showing that it doesn’t necessarily depend on the precision of the instrument (though I would say we have better access to instruments now, and I wouldn’t recommend rocks or wood). For the sake of safety and practicality, I typically suggest either purchasing an official instrument or using the back end of a butter knife. Refer to this video for an example of IASTM for tennis elbow.
General technique
Scrape at an angle of 30 to 60 degrees, parallel along the muscle fibers, to a tolerable pressure where the symptoms are located, for about 20 to 180 seconds.
Decompressive cupping is another technique that can be used to assist in decreasing pain and stimulating an acute inflammatory response in the associated area, which may help facilitate healing. While there are many proposed mechanisms of action for the use of cupping, such as adhesion mobilization, increased blood circulation, and increased lymphatic activation, it is most likely that cupping works as a placebo effect or in line with stress reduction, thereby decreasing perceived pain (Trofa et al., 2020). However, even with limited evidence, a placebo effect is still an effect, and this modality may be useful in decreasing irritable tissues causing pain, allowing for pain free exercise. Refer to this video for an example of cupping for tennis elbow, as well as a sample cupping set that can be purchased for home use.
General technique for cupping
Cupping can be performed as static on static, dynamic on static, or static on dynamic, with comfortable decompressive pressure. When leaving the cups on (static on static), one should not allow them to be left for more than 15 minutes in order to avoid adverse responses. Dynamic on static involves “scraping” the cups along the surface of the irritable tissue with a medium such as lotion for about 1 to 3 minutes. Static on dynamic involves not moving the cups once they are on the irritable tissue, but rather performing active range of motion of the associated musculature underneath the cups.
Taping techniques
Taping techniques can be used to “offload” the aggravated tissues, which could decrease the symptom aggravator and also reduce pain, allowing for a better healing environment and improved function. The clinical practice guidelines state that rigid taping techniques have moderate evidence to decrease symptom aggravation in the short term, though other tapes such as kinesiology tape can be used with varying degrees of efficacy (Lucado et al., 2022). Shown here is a taping technique that can be utilized to manage symptoms and allow for decreased pain with exercise and movement.
Loading to increase resiliency of the tissues
Once the pain is controlled or decreased, one must include exercise in order to cement these changes and take advantage of the previously described treatment effects. The clinical practice guidelines (Lucado et al., 2022) state moderate evidence for a phased approach to exercise, meaning ordering exercises based upon their prioritized or tolerated contraction (isometric, eccentric, or concentric).
The following are some examples of exercises to address tennis elbow, grouped into the main contraction type. These exercises isolate and support the problem area. Inclusion and progression back to systemic movements such as upper body pulling, pushing, pressing, and farmer's carries is an important aspect to consider for returning to full functional capacity.
Isometrics
Wrist extension (manual vs weight - KB)
Hold for 5-10 seconds for 12 -24 reps (total volume of contraction 1-2 minutes)
Eccentrics
Concentrics
Dosing and a gradual return to full previous function is important to consider through this rehabilitative process. I highly recommend consulting a local physio for detailed and hands-on instruction/leadership. Other treatments such as dry needling have been shown to have moderate levels of evidence in management of tennis elbow, and typically a multimodal approach is recommended based on what works for the individual.
Disclaimer: The content written for Brainz Magazine by the author is for information and educational purposes only. It is not intended for medical advice nor does it take the place of medical advice from a qualified doctor or other healthcare provider. The information provided should not be used as a diagnostic tool to suggest, confirm, contradict, or rule in/out any medical diagnoses. Readers should consult with their own qualified healthcare team for individualized health concerns, questions, or treatment.
Jon Kilian, Physical Therapist
Jon Kilian is a leader in where musculoskeletal rehab and strength and conditioning collide for a variety of populations. As a Physical Therapist, he knows how to give the body an environment to adapt and heal from injuries and as a strength specialist he knows how to load them to prevent those injuries from happening again. Kilian has a passion for introducing people to the true strength and resiliency they are capable of and reminding them that there is an athlete inside of us all. His mission: to disseminate information, promote strength, and return independence to the individual.
References:
Dunning, J., Mourad, F., Bliton, P., Charlebois, C., Gorby, P., Zacharko, N., Layson, B., Maselli, F., Young, I., & Fernández-de-Las-Peñas, C. (2024). Percutaneous tendon dry needling and thrust manipulation as an adjunct to multimodal physical therapy in patients with lateral elbow tendinopathy: A multicenter randomized clinical trial. Clinical rehabilitation, 38(8), 1063–1079.
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