Lateral Epicondylitis (Tennis Elbow): Beyond Rest and Rehab

Lateral Epicondylitis (Tennis Elbow): Beyond Rest and Rehab

Introduction

Lateral Epicondylitis, or tennis elbow, is a syndrome affecting the common extensor tendons that join the extensor carpi radialis brevis muscle and lateral epicondyle. Due to its location and propensity to cause pain with resisted wrist extension, finger extension, or hand gripping, it is often self-limiting. 

According to the RACGP, around 1-3% of the Australian population experience Lateral Epicondylitis. However, there is still no universally defined and recognised treatment modality. Research into surgical and non-surgical treatment approaches remains divided, with recommendations ranging from rest to arthroscopic surgery.

Rest and rehabilitation are essential steps in treatment, whilst some research demonstrates that combining rehabilitation with bracing is even more effective than either treatment alone. Hence, a holistic management approach that considers a role for bracing solutions may be beneficial in inspiring an effective therapeutic rationale that yields positive outcomes for patients. 

 

Understanding Lateral Epicondylitis

The most common causes of Lateral epicondylitis include overuse of the extensor carpi radialis brevis muscle, direct trauma to the tendon, and elbow overextension. The risk of developing it depends on overall health, fitness, and bodily response to injury. Whilst traditionally associated with athletic-based injury and overuse, tennis elbow also commonly develops in the workplace, with computer users, service staff, and manufacturing workers being among the most at risk.

Lateral Epicondylosis often presents signs of tendon degeneration, such as the presence of fibroblasts, vascular hyperalgesia, and disorganised collagen. In tendinopathy, the collagen bundles are angulated, have varying diameters, and sometimes have “bubbles,” leading to changes in the structural integrity of the tendon that present implications for functional capability and use.

The condition is known to cause elbow pain, reduced grip strength, and reduced range of motion. Patients typically report worsening pain with wrist dorsiflexion and extension (especially with resistance) and when gripping items. 

While the pain is mainly self-limiting, it can negatively affect daily life and interfere with everyday tasks such as cooking, cleaning, carrying shopping bags, and even typing. 


Holistic Management Approach

Lifestyle Modifications

Patients with tennis elbow pain should adopt certain lifestyle modifications, such as taking breaks to rest their hands and avoiding activities that aggravate their symptoms. 

Current recommendations include

  • Elevating the elbows with a gel pad or some kind of cushion while typing. Holding the wrist in a cocked position keeps the lateral epicondyle tendons in contraction, worsening symptoms.
  • Taking frequent breaks throughout the workday or daily activities like cleaning or cooking to rest the elbow or do some gentle stretches.
  • Patients should avoid lifting heavy objects alone in warehouse, hospitality, and retail settings, especially if the task is repetitive.
  • Avoiding or adjusting activities that cause the pain to flare up. For example, if carrying a shopping bag in the hand hurts, they should try carrying it on the shoulder instead.
  • Assess chair and screen height—radiculopathy in the neck can cause or worsen symptoms. The patient should ensure their monitor is at eye level and take steps to prevent slouching (e.g., strengthening and stretching the back).
  • If repetitive or strenuous tasks involving the hands are unavoidable, the patient can reduce elbow strain by wearing an elbow brace or strap. 


Physical Therapy

Rest to mitigate trauma and strain is a necessary intervention, but stretching and strengthening are essential in assisting recovery and preventing future flare-ups. Stretching helps improve ROM and reduce muscle tension, providing better support to the tendons and surrounding structures at the epicondyles to minimise the risk of recurrence and further degeneration. 

In these regards, eccentric exercises are considered to be the most effective. Your patient can also benefit from working on their grip strength, as lateral epicondylitis often makes it challenging to grip items and may weaken the grip due to disuse. 

Key exercises to incorporate into the rehabilitation routine include:


Wrist extension stretch 

  • The patient should stand upright with their affected arm outstretched in front of them.
  • They should lift their hand so their palm faces outwards.
  • Then, they should use their free hand to gently deepen the stretch as far without impacting comfort.


Wrist flexion stretch 

The same principle as the wrist extension stretch, but with the palm facing down. 


Resisted extension and flexion 

As your patient heals and pain levels begin to subside, they may progress to resisted wrist flexion and extension. They should start these exercises with their elbow at 90 degrees and their forearm resting flat on the table. Over time, as their strength improves, they can gradually increase the elbow angle or perform the exercise without the table. 


Forearm pronation and supination

  • The patient should rest their forearm on a table.
  • They should hold a light weight (up to 1 kg) in their affected hand with their wrist free of the table edge and their palm facing inward. 
  • They should slowly rotate their wrist so the weight is parallel to the floor, palm facing up. 
  • Then, they should slowly rotate their wrist in the other direction so their palm faces the floor.


Pain Management

Ice and heat

Ice is a crucial element in the initial management of pain, with particular importance in helping to numb the affected area and reduce inflammation at the onset of injury. Heat can help boost circulation through the area, relieving muscle tension and assisting the healing process.


Pain relief medications

NSAIDS can be helpful to support long-term pain management and have long been posited as crucial components to clinical treatment rationales for tennis elbow.  As we continue to promote and encourage the adoption of more holistic care programs for tennis elbow management, it is crucial that pharmaceutical practices are balanced and complemented by active treatment modalities like rehabilitative exercise and bracing. Generally, pain medication is best reserved for the initial stages of the disorder so that the patient can carry out unavoidable daily tasks and follow their exercise plan in relative comfort without experiencing significant debilitation of physical ability.


Acupuncture

There is limited robust research on the effectiveness of acupuncture for this condition. However, acupuncture is generally recognised for its analgesic effects on ailments such as migraines and back pain. It has few side effects if conducted by an experienced practitioner with the proper level of education (in Australia, a Bachelor’s Degree is required). Hence, patients can pursue this option - though it should not be their only conservative therapy.


Cortisone injections

Cortisone injections can be great for pain relief in the short term. However, they have been found to have adverse chronic effects on connective tissue health. One study found that while the effects of cortisone were comparable or even better than physiotherapy in the short term, they were associated with a much higher recurrence rate in the long term.


The Role of Bracing in Recovery

Bracing is critical to improve proprioception, pain levels, gripping ability, and range of motion in lateral epicondylitis cases. Depending on your patient’s condition and preferences, they may benefit from either of the below brace designs.


A counterforce strap for tennis elbow

Man doing an overhead press with light weights. He is wearing Bauerfeind's EpiPoint Elbow Strap

Our EpiPoint Strap incorporates a 5-point gel pad that you or your patient can adjust to target specific areas of concern. The counterforce effect has long been documented in elbow tendinosis treatment, with research showing it can be as effective as physical therapy and even improve its effectiveness in the long term. In essence, the counterforce effect redistributes strain and pressure away from the injured tendon and onto surrounding healthy tissues, reducing load and facilitating healing.


An elbow compression support

Woman walking on the beach. She is wearing Bauerfeind's EpiTrain Elbow Brace

Compression supports like the EpiTrain have multiple notable benefits largely driven by the innovative use of flat knit to exert medical-graded compression at the injured site. Medical levels of compression are effective in cases of tennis elbow to stimulate the elbow flexor and extensor muscles, improve proprioception, and enhance blood circulation through the area. Anatomical Epicon gel pads provide a massaging effect and, in conjunction with the compression knit, lower the strain on the injured tendon. 

In a controlled trial of the EpiTrain for lateral epicondylitis, researchers found that:

  • Wearing the brace reduced the participants’ pain by 50 units.
  • After 14 days, over 80% of participants could return to work with no restrictions.
  • Joint mobility increased from 80 to 141 degrees in that period.
  • At the end of the trial, 68% of patients in the EpiTrain group were “cured” compared with 13% of patients in the control group.

In more severe or chronic cases, the EpiTrain can be combined with a specialised strap to improve its counterforce effect and further reduce symptoms. 


A wrist splint for lateral epicondylitis

Wrist splints have also been found to be effective for tennis elbow. Their immobilising effect on the wrist prevents strenuous positions and movements that could slow recovery or aggravate symptoms. One randomised study found that a wrist splint was roughly as effective as an elbow strap for treating lateral epicondylitis.

In most patients, the choice between a wrist splint or elbow support is a matter of preference. Some may find a splint too limiting, while others may prefer its level of rigid support over a soft compression sleeve that focuses on improving muscle activity.


Long-term Prevention Strategies

Prevention strategies for lateral epicondylitis recurrence are principally similar to conservative treatment modalities. The patient should continue working on forearm strength and flexibility, ensuring they stretch the extensor muscles during repetitive tasks, warm up that area prior to exercise, and stretch after exercise. As they progress, exercise plans can continue to be tailored for optimal prevention

Patients can also benefit from continuing to wear their compression brace or strap during repetitive work tasks. In sports, a Sports Elbow Support or Compression Sleeve may help them regain confidence in their elbow use and minimise the risk of recurring or new injuries. 

Above all, it is important for them to avoid slipping back into poor ergonomic habits that would have contributed to the development of the disorder. 


Conclusion

Lateral epicondylitis is a common condition without a defined and understood effective treatment method. Empirically,  holistic approaches involving a combination of pain management, anatomical support, and physical therapy have proven to be effective in yielding optimal outcomes for patients that address the primary manifestation of the condition whilst establishing practices to ensure successful prevention of recurrence. 

 

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