Updated: Jul 8
Lateral Epicondylitis or Tennis Elbow refers to pain on the outside of your elbow. It is located where your wrist extensor muscles insert into your humerus. Here is an image to give you a better idea:
These muscles primarily perform wrist extension (bending backwards as if doing a push up), but they are also responsible for finger extension which helps with gripping and supination (turning your palm to the sky). An excellent breakdown of the anatomy is provided by the American Academy of Orthopaedic Surgeons on their website here.
The role in gripping is often misunderstood, so let’s break it down in more detail. Lay your arm down next to you with your palm facing down. Try to make a fist. You will probably extend your wrist naturally to do so, because these muscles play a role in tensing and stabilizing grip strength.
The condition is referred to as lateral epicondylitis or lateral epicondylalgia because the affected area is known as your lateral epicondyle. However, it has taken on the name of tennis elbow because it is frequently seen in tennis players. The cause of the injury can be traumatic, but it is usually repetitive stress that your body is unprepared to handle. While it is commonly seen in tennis players, it is not uncommon in people working in manual labor, artists, people working at a computer, weight lifters, or other athletes including baseball and softball players. It is estimated that 1-3% of Americans will suffer from tennis elbow.
As I mentioned before, the injury is typically due to overuse in an unprepared tissue. Imagine that it is spring and you go out for the first time to play tennis. You play for a couple of hours and hit numerous backhands. You wake up the next morning and your outer elbow is hurting a lot. You stressed the muscles and tendons in a way that they were not prepared for and they reacted by becoming irritated and breaking down.
Poor mechanics and conditioning of the forearm muscles are important factors, but other areas of the body can be implicated as well. Imagine that your shoulders are tired from playing tennis, so instead of using your shoulders on backhands, you start flicking the ball more with your wrist. Because of your deconditioned shoulder muscles, you are putting more stress on the wrist extensors. Look at this picture below. The athlete is using his whole body to create power for this backhand shot. Larger muscles such as his glutes, obliques, lats, and other structures are creating power that is being transferred through the arm. This creates less stress on the elbow, but it requires better conditioning of the rest of the body.
Tennis Elbow Symptoms
The primary symptom of tennis elbow is pain at the outer elbow as previously mentioned. However, sometimes weakness is the main limitation. Breakdown of the muscles and tendons can lead to decreased strength, which can manifest in difficulty with daily activities. If there is pain, your body may try to protect itself by decreasing muscle activation as well. Imagine that it hurts to lift something. Your body may simply refuse to engage the painful muscles, forcing you to give up or utilize a different strategy to lift the object.
Symptoms are typically found on the dominant side, as most people do more using that arm. Of course, if you work in a job where you primarily use your non-dominant arm, this may not be the case. Symptoms are usually only on one side, so many people will try to get by simply using their non-dominant arm. While this is an effective short-term strategy, you are not fixing the problem. In fact, your dominant arm is probably getting weaker and you risk overusing your non-dominant arm!
Pain can be from a variety of activities, but a common movement that people find difficult is twisting a door handle. The gripping motion combined with twisting puts significant strain on the muscles involved with lateral epicondylitis. Pain is usually limited to active movements such as gripping, lifting, and twisting, but it can occur at night or with rest in aggravated conditions.
Tennis Elbow Treatment
Treatment for tennis elbow or lateral epicondylitis can be difficult. The main difficulty is that it takes significantly longer to heal than most people think. The University of Michigan reports that many cases take 6-12 months to heal with some people requiring 2 years! This is obviously the extreme side of recovery, but I have seen people struggle with tennis elbow for months. Part of the problem is that people typically wait until symptoms are unbearable before seeking treatment. This allows for more tendon breakdown. It takes much more time to heal tendon damage compared to the time it took for the damage to occur. People also try to come back from this injury too quickly, usually based on the sporting season. If you hurt yourself in March while you first played, you may try to rush back for a big tennis tournament or a vacation where you want to play for a couple of days with friends. Tendons respond to gradual loading (we will discuss this more later on), not peaks and valleys.
As I mentioned earlier, other body parts can be the cause of stress on the elbow. If you have limited mobility of your shoulders, spine, or other structures, you may rely on your elbow and wrist to compensate. Also, if you have decreased strength in these areas, then the smaller wrist extensors muscles take on excessive load. Finally, many persistent tennis elbow conditions are thought to have a neurological component. Your nerves originate from your cervical spine and run down to your fingers. One of the main nerves in your arm, the radial nerve, runs directly through the involved muscles and structures around your lateral epicondyle and elbow. You can see the radial nerve in an image from teachmeanatomy.com here:
Many times, what we think is a muscular problem can be a nerve entrapment. Unfortunately, it can be difficult to ascertain where the nerve is trapped. Sometimes, a pinched nerve in your neck can cause symptoms in your arm or hand without you realizing that the neck is the actual problem. A healthcare professional should perform a thorough assessment to rule out neck, shoulder, and other involved structures.
Regarding treatment, manual therapy can be effective initially to decrease muscular guarding of the area. Our bodies remember pain, and part of the symptoms you are feeling can be a result of our body not allowing the wrist extensors to relax. Trigger point dry needling is particularly effective in these cases, as it creates a twitch response in the affected muscle. This twitch is a strong contraction that results in the relaxation of the muscle, which can improve pain and mobility quickly.
Tennis Elbow Exercises
As I mentioned before, tendons respond well to gradual loading. If you are in significant pain, then aggressive exercise may be too much for you to handle. However, you do want some load so that the tendons can receive stimulation and blood flow. You also want to prevent further weakening of the muscles and tendons.
Isometric exercises are a great starting point for lateral epicondylitis. Isometric refers to a muscular contraction where there is no change in the length of the muscle. These exercises have been shown to promote blood flow and healing of tendons without as much wear and tear on the injured muscles. Isometrics should be performed to the point of some discomfort to truly engage the muscle and tendon, but sharp pain is not a good idea. Simply extending your wrist into a desk or other structure and holding for 10-30 seconds can be a great starting point. Gripping of a tennis ball or similar structure can help as well to engage the muscles in a functional way.
Eventually, you can progress to loaded wrist extension and carrying heavier weight as you start to feel less pain and increased strength. It is important to remember that these muscles also help with supination (turning your palm towards the sky) so some rotational exercises are important. A simple exercise is taking a light weight or hammer and moving it back and forth into pronation and supination as you can handle, pictured below courtesy of statorthopedicrehab.com
As I mentioned before, tendons respond to a slow ramping up and maintenance of exercise. You want to be consistent and gradual with your progressions to provide strengthening, but not overly stress the tissue.
How to Prevent Tennis Elbow
Preventing tennis elbow can be tricky, as it requires diligence and a whole-body approach. An assessment from a healthcare professional can be beneficial to see if any mobility or strength limitations exist that might stress the lateral elbow and the wrist extensors. It is also important to monitor your activity and gradually progress. If you have been unable to play tennis for a long time, go easy the first few days back. You have to manage your workload even if it feels like you are doing well. Waking up the next day in pain is not worth an extra 15 minutes of tennis.
It is important to look at yourself as an athlete. Too many people think that sports like tennis or golf are easy and do not require preparation. This could not be farther from the truth. These are repetitive sports that put a lot of demands on your body and you need to train for them. Your workout to prepare for tennis is not to play tennis, it should involve an individualized exercise program in the gym or at home to prepare your body.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about tennis elbow or lateral epicondylitis and how it works. If you want to learn more about elbow injuries, check out our elbow page. I would continue to stress prevention if at all possible, so reach out to a healthcare provider for an assessment to go over any injury risks. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you are located near our office in Sterling, Virginia please reach out for a physical therapy assessment! If you have any questions email me at firstname.lastname@example.org or follow me on Instagram or Twitter @drdannydpt.