Physical Therapy Guide to Tennis Elbow (Lateral Epicondylitis)
Most people who get tennis elbow don't play tennis! In fact, less than 5% of all tennis elbow cases occur in people who play the sport. Tennis elbow can happen to anyone who repeatedly uses their elbow, wrist, and hand for their job, sport, or hobby. Physical therapists help people with tennis elbow gently heal the affected areas, build muscle strength, and avoid further injury. And, according to a new study, choosing physical therapy for tennis elbow outperforms steroid injections and is cost-effective.
Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To locate a physical therapist in your area, visit Find a PT.
What Is Tennis Elbow (Lateral Epicondylitis)?
Tennis elbow is a painful condition. It results from overuse of the muscles in your arm and forearm (extensors). It occurs in the tendons that attach your muscles to the rounded projections of bone on the outside of the elbow (the lateral epicondyle). It affects the muscles you use to grip, twist, and carry objects with your hand. The resulting pain may be felt in the elbow when moving the wrist or hand.
Using the wrist and hand for long periods can lead to this condition. Examples include working on a computer or operating machinery. It can happen to athletes, nonathletes, children, and adults. It gets the name tennis elbow because playing tennis with an improper grip or technique can contribute to it. Tennis elbow occurs more often in men than women. It most commonly affects people between ages 30 and 50.
Signs and Symptoms
Symptoms of tennis elbow can occur suddenly or with repeated use over a long period.
Excessive use of the wrist and hand for activities that require force can cause sudden injury and pain. These include activities such as lifting, twisting, or pulling. For example, pulling strongly on a lawnmower starter cord can injure muscle fibers around the elbow and cause the sudden onset of tennis elbow.
More commonly, though, tennis elbow develops gradually over weeks or months. It results from repeated or forceful use of the wrist, hand, and elbow over time. For example, a grocery store cashier may develop tennis elbow from punching computer keys with too much force and lifting grocery bags many times over a long period.
Symptoms of tennis elbow may include:
- Pain that travels (radiates) from the outside of your elbow into your forearm and wrist.
- Increased pain or difficulty when using your wrist and hand for everyday activities. These can include turning a doorknob, holding a coffee cup, gripping objects, or opening a jar.
- Elbow stiffness.
- Weakness in the forearm, wrist, or hand.
How Is It Diagnosed?
Tennis elbow most often occurs due to repeated movements. Other muscles and joints in the area may be affected as well. Your physical therapist will assess your elbow. They also will assess other areas of your body that may be affected or contributing to your pain.
They will perform special tests that detect any muscle weakness that might have led to the problem in the first place. Your physical therapist may ask you to gently tense or stretch the sore muscles. This will help them pinpoint the exact location of the problem. In some cases, they may refer you for an X-ray to aid the diagnosis.
How Can a Physical Therapist Help?
For the first 24 to 48 hours after acute onset of your pain, your treatment may include:
- Resting the arm by avoiding certain activities and modifying the way you do others.
- Applying ice treatments to the affected area.
- Using elastic bandages or supports to take the pressure off the painful muscles.
Your physical therapist will decide if a brace or support to protect your muscles will aid your healing.
After the First 48 Hours
Your physical therapist will begin a treatment program specific to your needs to speed your recovery. They may use treatments such as:
- Manual (hands-on) therapy.
- Special exercises to relieve pain.
- Ice or heat treatments, or both.
They also will design an exercise program to help correct muscle weakness that you can continue at home.
Your physical therapy program will include:
Improving mobility. Your physical therapist may use manual (hands-on) therapy, such as massage or other techniques. This treatment helps to reduce tightness in the soft tissue and joints to enable your joints and muscles to move more freely with less pain.
Improving strength. Lack of muscle strength can lead to tennis elbow. Sometimes the weakness is in the muscles of the wrist and forearm. In many cases, the problem stems from weakness of the supporting postural, or "core," muscles. In fact, you might find that you need to improve your overall level of fitness to help manage your elbow condition. Your physical therapist will work with you to determine the type and amount of exercise that is right for you.
Physical therapists prescribe several types of exercises during recovery from tennis elbow:
- In early treatment, when the pain is most intense, your physical therapist may perform gentle passive exercises for you. They will carefully move your wrist and elbow without straining the involved muscles.
- As your symptoms improve, you can begin to perform active exercises yourself, moving your wrist and elbow without assistance. Your physical therapist will guide you, to ensure your safety.
- As the muscles become stronger and your symptoms lessen, you may begin using weights or resistance bands to further increase your strength. Your physical therapist will carefully monitor your exercises to help you make progress and avoid reinjury.
Patient education. Your physical therapist can help you retrain your muscles so that you use them properly. For example, when you lift a heavy grocery bag, you should contract the muscles around your shoulder blade and trunk to provide support for your arm muscles. Your physical therapist will teach you how to do activities in a way that lessens stress on your arm to help you avoid future injury.
Your physical therapist will help you stay active by teaching you how to modify your activities to avoid pain and injury. Sometimes it's necessary to make changes at work, on the playing field, or at home. Your physical therapist can help you make changes to your work site, your computer setup, kitchen devices, sports equipment, and even your gardening tools to lessen the strain on your hand, wrist, and forearm. They will emphasize the importance of taking stretch breaks, so that your muscles get frequent rest from repeated movements and positions.
For an "acute" case of tennis elbow (one that arose in the past few weeks) it is important to get treatment as early as possible. If left untreated, tennis elbow can become chronic and last for months or even years. This is especially true if treatment focuses only on relieving pain and not on correcting the muscle weakness and bad habits that likely led to the condition.
Research has shown that physical therapy can help people with tennis elbow improve their pain and function. In a recent study, researchers calculated the economic impact of choosing physical therapy for tennis elbow over steroid injections. They found that doing so saves $10,739, including all the hidden costs of your time, pain, missed life events, and the dollars paid for services.
If your tennis elbow is severe, your physical therapist may recommend that you consult with another health care provider for more testing or additional treatment. In rare cases, a cortisone injection or surgery might be needed. Your physical therapist can help you determine whether you need a referral to another health care provider.
For Tennis Athletes
Playing tennis may contribute to tennis elbow for several reasons. Sometimes the problem results from overtraining. In other cases, the weight of the racquet or its grip may need to be adjusted. For others, the problem may stem from improper form, poor overall fitness, or a lack of strength in the supporting or "core" muscles of the trunk and shoulder blades. Your physical therapist can analyze the source(s) of your specific condition. They will work with you to make any needed adjustments to your form, training, or equipment. This will help to ensure your safe and effective return to sport.
Can This Injury or Condition Be Prevented?
You can help prevent tennis elbow by staying fit, using proper techniques in your sport or job, and using equipment that is designed well for your body type and activity level. Your physical therapist can show you how to achieve these goals.
If you had tennis elbow in the past, you may be at risk for reinjury if:
- Tendons did not have time to fully heal.
- Muscle strength and joint mobility were not fully restored.
- You have poor/improper hitting skills and racquet technique.
Returning to sports or activities before you have fully recovered can result in elbow pain that persists. It also can mean your elbow can be more easily or often reinjured. A physical therapist can help determine when you are ready to return to your activities and sports. They also can help make sure that your elbow, forearm, and wrist are strong and ready for action.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating athletes or people with musculoskeletal problems.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedics or sports physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists in your area with these credentials and clinical expertise on Find a PT, a tool built by the American Physical Therapy Association.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family, friends, or other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with tennis elbow.
- Be prepared to describe your symptoms in as much detail as possible during your first visit. Make a note of what makes your symptoms better or worse.
The American Physical Therapy Association believes that consumers should have access to information to:
- Inform their health care decisions.
- Prepare them for their visit with a health care provider.
The following resources offer some of the best scientific evidence related to physical therapy treatment for tennis elbow. They report recent research and provide information on the standards of practice both in the United States and internationally. They link to a PubMed* abstract (which also may offer free access to the full text) or other resources. You can read them or print out a copy to bring with you to your health care provider.
Yoon SY, Kim YW, Shin IS, Kang S, Moon HI, Lee SC. The beneficial effects of eccentric exercise in the management of lateral elbow tendinopathy: a systematic review and meta-analysis. J Clin Med. 2021;10(17):3968. Article Summary on PubMed .
Landesa-Martínez L, Leirós-Rodríguez R. Physiotherapy treatment of lateral epicondylitis: a systematic review. J Back Musculoskelet Rehabil. 2021 August 4. Article Summary on PubMed.
Kim YJ, Wood SM, Yoon AP, Howard JC, Yang LY, Chung KC. Efficacy of nonoperative treatments for lateral epicondylitis: a systematic review and meta-analysis. Plast Reconstr Surg. 2021;147(1):112–125. Article Summary on PubMed.
Weber C, Thai V, Neuheuser K, et al. Efficacy of physical therapy for the treatment of lateral epicondylitis: a meta-analysis. BMC Musculoskelet Disord. 2015;16(1):223. Article Summary on PubMed.
Peterson M, Butler S, Eriksson M, Svärdsudd K. A randomized controlled trial of exercise versus wait-list in chronic tennis elbow (lateral epicondylosis). Ups J Med Sci. 2011;116:269–279. Article Summary on PubMed.
Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164:1065-1074. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information. PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
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