Tennis Elbow involves irritation or micro-tearing of the tendons connecting the forearm muscles to the bony bump on the outside of the elbow. This overuse injury typically affects the tendons that help extend the wrist and fingers. Although named for tennis, the condition commonly results from any repetitive gripping or twisting motions that strain the forearm muscles. Rehabilitation uses specific exercises to manage discomfort, restore strength, and ensure the tendon can tolerate daily stresses.
Initial Steps Before Beginning Rehabilitation
A professional diagnosis is necessary before beginning any exercise program to ensure symptoms are caused by lateral epicondylitis. In the initial, acute phase, the primary goal is to calm irritated tissues by temporarily stopping painful activities. Applying ice to the outer elbow for 15 to 20 minutes several times a day can help manage discomfort, and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce pain.
Exercises should not be started until the sharp, intense pain has subsided and the arm can tolerate gentle movement. A good readiness check is when the pain level is consistently manageable, and the elbow does not feel worse after light use. Attempting to push through significant pain in the early stages can aggravate the tendon and delay healing.
Gentle Mobility and Stretching Techniques
The first phase of active rehabilitation focuses on improving the flexibility and range of motion in the wrist and forearm, which helps reduce resting tension on the affected tendon. These movements are performed slowly and gently, aiming for a stretch sensation without causing any sharp, stabbing pain.
Wrist Extensor Stretch
To perform the wrist extensor stretch, extend the affected arm straight out in front of you with the palm facing down. Use your opposite hand to gently pull your fingers downward toward your body until you feel a stretch along the top of your forearm. Hold this position for 20 to 30 seconds and repeat the stretch two or three times.
Wrist Flexor Stretch
The wrist flexor stretch targets the muscles on the underside of the forearm to maintain balance and flexibility. Extend the affected arm straight out with the palm facing upward. Use your other hand to gently pull your fingers backward toward your body, feeling the stretch on the inner forearm. Hold this stretch for 20 to 30 seconds, and perform a few repetitions daily.
Forearm Rotation
A simple rotational movement, known as forearm pronation and supination, can also encourage mobility. Keep your elbow bent at your side at a 90-degree angle. Slowly rotate your forearm so the palm faces up (supination), then slowly rotate it so the palm faces down (pronation). This movement can be done 10 to 15 times, focusing on a smooth, controlled range of motion without a weight.
Protocol for Forearm Strengthening
Once mobility is restored and gentle stretching is tolerated, the next stage involves targeted strengthening, focusing on eccentric loading. Eccentric exercise involves contracting a muscle while it is lengthening. This type of loading is highly effective for tendon repair as it helps restructure the collagen fibers within the injured tendon.
Eccentric Wrist Extension
The primary exercise for strengthening the wrist extensors is the eccentric wrist extension using a light weight, such as a soup can or a small dumbbell. Sit down and rest your forearm palm-down on a table, allowing your hand to hang off the edge. Use your unaffected hand to lift the weight by bending your wrist upward.
Then, remove the unaffected hand and slowly lower the weight back down to the starting position using only the affected wrist, taking approximately four to five seconds to complete the downward movement. The slow, controlled lowering is the eccentric phase that provides the therapeutic load to the tendon. A standard starting protocol is to perform three sets of 15 repetitions, three times per week, with a 30-second rest between sets.
Towel Wring
Another beneficial movement is the towel wring, which targets grip strength and general forearm conditioning. Hold a small, rolled-up towel horizontally with both hands. Using only your wrists and forearms, twist the towel as if you are wringing water out of it, alternating the direction. Perform this twisting motion for 10 to 15 repetitions in each direction.
Gradual progression is necessary, and the weight should only be increased when you can complete the exercise sets with mild to moderate discomfort that does not linger afterward. If the current weight becomes too easy, increase the resistance by a small amount, such as a half-pound, and restart the progression with the new weight.
Safety Guidelines and Activity Modification
Throughout rehabilitation, it is important to distinguish between tolerable muscle fatigue and harmful pain signals. Mild discomfort during or immediately after exercise is often acceptable for tendon loading. However, any sharp, stabbing, or intense pain that causes you to stop the movement immediately signals that you should reduce the intensity or take a day of rest.
Modifying daily activities is equally important for preventing re-injury, even after the pain has lessened. For those who work at a desk, adjusting the mouse position or using an ergonomic keyboard can reduce the strain on the wrist extensors. When lifting objects, try to keep the elbow bent close to the body and lift with the palm facing upward, which shifts the load away from the irritated tendon.
For athletes, checking equipment is a useful modification, such as ensuring a proper grip size on a tennis racket or reducing the string tension. A gradual return to strenuous activities is always advised, beginning with a warm-up and slowly increasing the duration and intensity of the task. Continued adherence to the eccentric strengthening exercises can help maintain tendon health and prevent a recurrence of the condition.