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Tennis Elbow Management

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Kim Jackson, Ewa Jaraczewska, Tarina van der Stockt, Robin Tacchetti, Tony Lowe, Jorge Rodríguez Palomino and Stacy Schiurring

Introduction

The management approach of tennis elbow (TE), also known as Lateral Epicondyle Tendinopathy (LET), is adapted from the general principles of tendinopathy rehabilitation. Rehabilitation should be multimodal to achieve long-term goals and meet individual needs.

The different causes and effects of tennis elbow were explored in the assessment course, including central sensitisation, muscle and tendon structural changes, and mechanical abnormalities. Hence, all these aspects must be investigated in the history taking and objective examination and considered when designing a rehabilitation programme.

Characteristic of Tennis Elbow

Tennis Elbow is a degenerative condition characterised by increased thickness in the common extensor tendon. [1] It affects upper limb functions, particularly when gripping. [2] Pain with hand grip is the most common presentation with TE. As a result people with TE demonstrated their most powerful grip at a reduced wrist extension angle when compared with healthy individuals. [2] They also present with less reaction time in wrist muscle activity [1], particularly the extensor carpi radialis brevis (ECRB) muscle. [3]

Rehabilitation Framework

The use of multimodal care is effective in managing Lateral Epicondyle tendinopathy. [4] This includes (1) education, (2) tissue loading management, (3) exercises, (4) manual therapy, (5) steroid injection and (6) taping. These management strategies can be used and tailored depending on the patient's needs, the clinician's clinical reasoning, and the decision shared between the patient and clinician. Since exercises are the best management option available now, TE management should be centred around exercises. [5]

1. Patient Education

Patient education is ''a planned learning experience using a combination of teaching, counselling, and behaviour modification techniques which influence patients’ knowledge and health behaviour.''[6]

Educating patients on their health management should focus on reaching a shared decision, stimulating patients' compliance with treatment and improving self-efficacy. [7] Patient education should include an explanation of the nature of LET as a degenerative tendon condition involving structural changes to the common extensor tendon, changes in pain processing, and motor system impairment, rather than a simple inflammatory process.[3] This understanding helps patients make sense of why recovery takes time and why a progressive, active approach to rehabilitation is more effective than rest or passive treatment alone. Patients should be advised that a minimum of 12 weeks of progressive loading is typically required, and that short-term pain relief strategies such as corticosteroid injection, while sometimes appropriate following shared decision making, are associated with higher recurrence rates and poorer long-term outcomes compared to physiotherapy.[4]

General health factors that influence tendon health and recovery should be discussed routinely with patients. The following have been shown to reduce tendon load tolerance and delay recovery, and should be addressed as part of a comprehensive self-management plan: smoking, obesity (particularly abdominal obesity), high consumption of processed or fatty foods, physical inactivity, poorly controlled diabetes, poor sleep hygiene, and high stress levels[3][8]

Where relevant, patients should be encouraged to address these factors alongside their rehabilitation programme, framed not as blame but as modifiable contributors to tendon health that are within their control.

According to Buchanan et al., patient education regarding movement should include the following:[9]

  • Avoid extremes in the end range of motion in extension and flexion.
  • Avoid repetitive hand and wrist motions, and take breaks from such activities when necessary to perform them.
  • Avoid letting heavy items hang with the arm in full extension; perform work or weight-lifting partially bent with the elbow.
  • Use two hands to hold heavy tools and a two-handed backhand in tennis.
  • Limit repetitive grasping and gripping motions.
  • If a movement causes the pain to return, avoid it, and report to your clinician's office.

2. Tissue Loading Management

Reduction of load on the tendon is an effective management strategy which has to go hand in hand with building tissue resilience to allow for gradual progression to the target load by training the mechanical properties of the tendon. A good way of altering the load is to ask the patient to work under their pain threshold and engage them in exercises that load the tendon below the level of exaggerated pain. [10][11]

Pain and swelling will occur in response to increased load, which is known as ''reactive tendinopathy''. Reducing pain is essential in this phase through pain management measures and de-loading. Identifying the contributing factors to pain and tendinopathy can help modify the tendon's loads. A sudden increase in load by movements involving repetitive wrist extension from a pronated forearm and an extended elbow can trigger pain and inflammation in the common extensor origin. Educate your patient on lifting objects with a flexed elbow and a supinated forearm to de-load the inflamed tendon.

3. Exercises

Exercise therapy is the most effective management strategy for LET and should be central to the rehabilitation programme.[12][13] While exercise interventions improve outcomes compared to passive interventions, the overall effect size appears small and the certainty of evidence remains low.[14] The evidence on optimal load, speed of movement, number of repetitions, duration of contraction, and exercise type remains inconclusive — no single exercise type has consistently outperformed others.[14][15] Multiple exercise types have been studied, including eccentric, concentric, isometric, and combined approaches, and all have demonstrated meaningful improvement in pain and function.[14][15] Providing an exercise that the patient can tolerate and will adhere to is therefore likely more important than the specific type chosen.[12]

The classical model for exercises in tendinopathy rehabilitation is eccentric contraction as a standard protocol, especially with Achilles and Patellar Tendinopathies. [5] Eccentric exercises are considered an effective measure for tendon overuse injuries and prevention of re-injuries. [16] They are also better in preparing patients/athletes for return to function or athletic activities when compared to concentric exercises. [17] Tendons' response to eccentric exercises in Achilles tendinopathy was observed after twelve weeks of training. [18] However, other studies found no difference in tendon response between concentric and eccentric exercises. [19] The evidence on load, speed of movement, number of repetitions, duration of contraction and type of exercise remains inconclusive. [19]

Eccentric exercise has been the most extensively studied approach in LET and was historically considered the standard protocol, drawing on its established role in Achilles and patellar tendinopathy rehabilitation.[17] While eccentric exercise as an adjunct to other interventions has demonstrated improvements in pain and muscle strength, it does not consistently outperform concentric or combined approaches in LET specifically, and should not be presented as the only or superior choice.[14][20]

Isometric exercise is a clinically useful starting point for many patients with LET for two reasons. First, the ECRB tendon (the primary tendon involved in LET) functions as a static wrist stabiliser during gripping and hand use, making isometric loading functionally relevant.[15] Second, isometric contractions have been shown to have a hypoalgesic effect both locally and at remote sites during and after contraction, which may help manage pain during early rehabilitation.[21][22] Current evidence suggests isometric exercises should be performed for up to 60-seconds with maximal tolerable resistance, repeated five times, once daily, with pain provoked only to a level the patient deems acceptable.[23] However, the optimal isometric protocol for LET has not yet been definitively established and further research is needed.[23]

Gradual progression of exercises is essential to increase tendon tolerance to loads. The following are different ways to progress your exercises:

  • Elbow and forearm position: begin with a flexed elbow and forearm in supination, then progress by increasing the elbow extension angle.
  • Fingers flexion vs. extension: Start with fingers in flexion and progress to extension to load the long extensors.
  • Adding weights: whether by an exercise band or dumbbells
  • Bilateral movement. Many people report bilateral symptoms, supporting the evidence of the association of central sensitisation with TE. [24][25]
  • Functional training exercises and targeting the whole upper limb.
  • Weight-bearing exercises

Pain during exercise remains a debated topic and there is currently no definitive evidence that pain-free exercise is superior to exercise involving some discomfort, or vice versa.[26] In highly irritable presentations, working below the pain threshold is advisable to avoid symptom flares. As irritability reduces, some discomfort during loading is acceptable and may support tissue adaptation. The most important factor is that the patient understands the rationale and remains engaged with the programme. Shared decision making around acceptable pain levels during exercise supports self-efficacy and long-term adherence.

4. Manual Therapy

Pain and functional impairment associated with TE should be managed with manual therapy.[27] Manual therapy recommendations include Mulligan's mobilisation with movement, Cyriax physiotherapy, Maitland mobilisation, and neural mobilisation.[28][29]

Mobilisation with movement can be utilised with other measures to reduce pain and facilitate exercises. Rehay et al. [30] investigated the effect of Mulligan's mobilisation with movement in TE and found a significant reduction in night pain and pain on VAS up to 3 months after application of treatment and an increase in pain-free grip strength. Another study found the same approach superior to wait and see and corticosteroid injection. [4]

[31]

5. Steroid injection

Corticosteroid injection has good outcomes only in the short term ( up to six weeks). The long-term outcomes are poor, and it was found to be linked to high recurrence rates.[4][32] [33] One study found increased pain and reduced grip strength in an intermediate follow-up after corticosteroid injection. [34] However, the short-term benefit of pain relief can be sought to encourage patients' engagement with the exercise programme.

6. Taping

Taping has a good placebo pain relief effect and pain-free grip strength in patients with chronic TE. [35] A study compared the effect of kinesio taping with exercises to sham tape with exercises and exercise only groups on patient-rated tennis elbow evaluation (PRTEE), visual analogue scale (VAS), grip strength, and the disabilities of the arm, shoulder and hand (QuickDASH) scales. The results of the study support the combination of Kinesiotape and exercises. [36]

A prospective, randomised single-blinded trial that compared bracing or kinesio taping in the management of lateral elbow tendinopathy by Çelik et al.[37] indicated that both techniques positively affect pain severity, grip strength and functionality of patients with lateral elbow tendinopathy.

[38]
[39]
[40]


References

  1. ↑ 1.0 1.1 Manickaraj N, Bisset LM, Kavanagh JJ. Lateral epicondylalgia exhibits adaptive muscle activation strategies based on wrist posture and levels of grip force: a case-control study. Journal of musculoskeletal & neuronal interactions. 2018 Sep;18(3):323.
  2. ↑ 2.0 2.1 Heales LJ, Vicenzino B, MacDonald DA, Hodges PW. Forearm muscle activity is modified bilaterally in unilateral lateral epicondylalgia: A case‐control study. Scandinavian journal of medicine & science in sports. 2016 Dec;26(12):1382-90.
  3. ↑ 3.0 3.1 3.2 Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. British journal of sports medicine. 2009 Apr 1;43(4):252-8.
  4. ↑ 4.0 4.1 4.2 4.3 Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Bmj. 2006 Nov 2;333(7575):939.
  5. ↑ 5.0 5.1 Dimitrios S. Exercise for tendinopathy. World J Methodol. 2015 Jun 26;5(2):51-4.
  6. ↑ Forbes R, Mandrusiak A, Smith M, Russell T. Training physiotherapy students to educate patients: a randomised controlled trial. Patient education and counselling. 2018 Feb 1;101(2):295-303.
  7. ↑ Ndosi M, Johnson D, Young T, Hardware B, Hill J, Hale C, Maxwell J, Roussou E, Adebajo A. Effects of needs-based patient education on self-efficacy and health outcomes in people with rheumatoid arthritis: a multicentre, single blind, randomised controlled trial. Annals of the rheumatic diseases. 2016 Jun 1;75(6):1126-32.
  8. ↑ Zhang C, Jia Z, Li J, Wang X, Yang S. Impact of lifestyle and clinical factors on the prognosis of tennis elbow. Scientific Reports. 2024 Feb 6;14(1):3063.
  9. ↑ Buchanan BK, Varacallo MA. Lateral Epicondylitis (Tennis Elbow). 2023 Aug 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 28613744.
  10. ↑ Mascaró A, Cos MÀ, Morral A, Roig A, Purdam C, Cook J. Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. Apunts. Medicina de l'Esport. 2018 Jan 1;53(197):19-27.
  11. ↑ Keating C, Bodnar R, Joseph J, Knapp S, Lepage M, Solger G.Effectiveness of Painful Loading in Lateral Elbow Tendinopathy on Pain Outcomes: A Systematic Literature Review. Orthopaedic Practice 2020; 32(4):208-214
  12. ↑ 12.0 12.1 Lucado AM, Day JM, Vincent JI, MacDermid JC, Fedorczyk J, Grewal R, Martin RL, Dewitt J, Paulseth S, Dauber JA, Szekeres M. Lateral elbow pain and muscle function impairments: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of hand and upper extremity physical therapy and the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of orthopaedic & sports physical therapy. 2022 Dec;52(12):CPG1-11.
  13. ↑ Campos MG, Maia LB, Mascarenhas RO, Lourenco BM, Henschke N, Oliveira VC. Effectiveness of non-invasive therapies on pain, maximum grip strength, disability, and quality of life for lateral elbow tendinopathy: a systematic review and meta-analysis. Brazilian Journal of Physical Therapy. 2024 Mar 1;28(2):100596.
  14. ↑ 14.0 14.1 14.2 14.3 Karanasios S, Korakakis V, Whiteley R, Vasilogeorgis I, Woodbridge S, Gioftsos G. Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials. British journal of sports medicine. 2021 May 1;55(9):477-85.
  15. ↑ 15.0 15.1 15.2 Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: one size does not fit all. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):938-49.
  16. ↑ Arampatzis A, Peper A, Bierbaum S, Albracht K. Plasticity of human Achilles tendon mechanical and morphological properties in response to cyclic strain. Journal of Biomechanics. 2010 Dec 1;43(16):3073-9.
  17. ↑ 17.0 17.1 Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clin Orthop Relat Res. 1986 Jul;(208):65-8
  18. ↑ Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow-up. Br J Sports Med. 2004 Feb;38(1):8-11, discussion:11
  19. ↑ 19.0 19.1 Rees JD, Lichtwark GA, Wolman RL, Wilson AM. The mechanism for efficacy of eccentric loading in Achilles tendon injury: an in vivo study in humans. Rheumatology. 2008 Jul 22;47(10):1493-7.
  20. ↑ 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. Journal of clinical medicine. 2021 Sep 1;10(17):3968.
  21. ↑ Naugle KM, Fillingim RB, Riley III JL. A meta-analytic review of the hypoalgesic effects of exercise. The Journal of pain. 2012 Dec 1;13(12):1139-50.
  22. ↑ Senarath ID, Chen KK, Weerasekara I, de Zoete RM. Exercise‐induced hypoalgesic effects of different types of physical exercise in individuals with neck pain: A systematic review and meta‐analysis. Pain Practice. 2023 Jan;23(1):110-22.
  23. ↑ 23.0 23.1 Stasinopoulos D. Isometric Exercise for the Management of Lateral Elbow Tendinopathy. Journal of Clinical Medicine. 2022 Dec 22;12(1):94.
  24. ↑ Manickaraj N, Bisset LM, Ryan M, Kavanagh JJ. Muscle Activity during Rapid Wrist Extension in People with Lateral Epicondylalgia. Medicine and science in sports and exercise. 2016 Apr;48(4):599-606.
  25. ↑ Nijs J, Van Houdenhove B, Oostendorp RA. Recognition of central sensitisation in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy. 2010 Apr 1;15(2):135-41.
  26. ↑ Smith BE, Hendrick P, Bateman M, Holden S, Littlewood C, Smith TO, Logan P. Musculoskeletal pain and exercise—challenging existing paradigms and introducing new. British journal of sports medicine. 2019 Jul 1;53(14):907-12.
  27. ↑ Elkeblawy MA, Grace MO, Hashish MA. Effect of Manual Therapy Approaches in Management of Tennis Elbow: A Review Article. Delta University Scientific Journal. 2025 Apr 1;8(1):220-7.
  28. ↑ Kulaybi YA, Faqihi FA, Khubrani YM, Areshy AA, Kulybi TY, Khobrani NA, Alhafaf AM, Maashi TM, Basodan TS, Moraya RM. The Role of Manual Therapy in the Management of Tennis Elbow: A Narrative Review. Journal of International Crisis and Risk Communication Research. 2024;7(S5):811.
  29. ↑ Jain C, Goyal M, Kothiyal S. Efficacy of neural mobilisation and Maitland accessory mobilisation in patients with tennis elbow-randomised controlled trial. Journal of Bodywork and Movement Therapies. 2024 Apr 1;38:525-33.
  30. ↑ Reyhan AC, Sindel D, Dereli EE. The effects of Mulligan’s mobilisation with movement technique in patients with lateral epicondylitis. Journal of back and musculoskeletal rehabilitation. 2019 May 10(Preprint):1-9.
  31. ↑ Mulligan MWM for tennis elbow. Available from: https://www.youtube.com/watch?v=thUlPbCX4fU
  32. ↑ Lenoir H, Mares O, Carlier Y. Management of lateral epicondylitis. Orthopaedics & Traumatology: Surgery & Research. 2019 Dec 1;105(8):S241-6.
  33. ↑ Pai GM, Acharya AM, Bhat AK, Navaneeth PK. An Update on Tennis Elbow. Journal of Orthopaedic Trauma and Reconstruction. 2024 Jul 1;1(2):30-4.
  34. ↑ Olaussen M, Holmedal O, Lindbaek M, Brage S, Solvang H. Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ Open. 2013 Oct 1;3(10):e003564.
  35. ↑ Cho YT, Hsu WY, Lin LF, Lin YN. Kinesio taping reduces elbow pain during resisted wrist extension in patients with chronic lateral epicondylitis: a randomised, double-blinded, crossover study. BMC musculoskeletal disorders. 2018 Dec;19(1):193.
  36. ↑ Giray E, Karali‐Bingul D, Akyuz G. The Effectiveness of Kinesiotaping, Sham Taping or Exercises Only in Lateral Epicondylitis Treatment: A Randomised Controlled Study. PM&R. 2019 Jan 4.
  37. ↑ Çelik Ö, Şencan S. Bracing or kinesio taping in the management of lateral elbow tendinopathy: A prospective, randomised single-blinded trial. J Bodyw Mov Ther. 2023 Oct;36:235-243.
  38. ↑ KT Tape: Tennis Elbow. Available from: https://youtu.be/DgwQSPQv_Zo
  39. ↑ Meglio TV. https://youtu.be/8n5qKX8mctU. Available from: https://youtu.be/8n5qKX8mctU
  40. ↑ KT Tape: Tennis Elbow. Available from: https://youtu.be/GOwqNDP40TQ
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