TENNIS ELBOW

Tennis elbow = lateral epicondylitis. It’s a tendinopathy of the forearm extensors, usually ECRB, from overuse and poor loading mechanics. Physio treatment is about calming the tendon, then rebuilding its tolerance to load.

1. *Figure out the irritants*

Physios check:

- *Pain location*: Outside of elbow, worse with wrist extension, gripping, lifting with palm down.

- *Load history*: Sudden increase in typing, manual work, racket sports, or lifting? Tendons hate sudden load spikes.

- *Wrist and shoulder mechanics*: Weak wrist extensors, poor forearm control, and stiff shoulders make the elbow overwork.

- *Differential*: Rule out radial nerve irritation, elbow joint issues. True tennis elbow is tender right over the lateral epicondyle.

2. *Acute phase: reduce irritability*

If it’s hot, sharp with gripping, keep it calm for 1-2 weeks.

- *Load modification*: Reduce aggravating activity, not stop it completely. Complete rest makes tendons weaker.

- *Grip modification*: Use a larger grip on tools/rackets, avoid tight gripping. Neutral wrist position during activity.

- *Isometric holds*: Wrist extension isometrics at 70% effort, 5x45s holds. Isometrics reduce pain and maintain strength without aggravating.

- *Manual therapy*: Soft tissue work on forearm extensors, joint mobilizations if elbow/wrist is stiff.

3. *Loading phase: rebuild tendon tolerance*

Once pain is <3/10 during activity, start progressive loading.

- *Eccentric wrist extension*: Slow lowering from wrist extension using the other hand to assist. 3x15 reps daily. This is the gold standard exercise.

- *Progressive resistance*: Add weight gradually - start with 0.5-1kg, build up. Use a hammer or light dumbbell.

- *Forearm strengthening*: Supination/pronation, grip strengthening with putty or hand gripper.

- *Shoulder and scapular control*: Weak lower traps/serratus makes the arm work harder. Rows, face pulls, wall slides help.

4. *Functional phase*

Get you back to typing, lifting, racket sports without flare-ups.

- *Sport/work-specific drills*: Gradual return to tennis strokes, hammering, typing. Start with low volume, short duration.

- *Load management*: Follow the 10% rule - don’t increase activity volume by more than 10% per week.

- *Technique check*: For tennis/golf, poor backhand mechanics or grip size are common culprits.

5. *What doesn’t fix it long-term*

Cortisone shots help short-term pain but weaken the tendon and increase re-tear risk. Rest alone doesn’t work - tendons need controlled load to remodel. Ultrasound and laser have weak evidence compared to exercise.

Timeline

- Mild cases: 6-8 weeks with consistent loading

- Chronic cases >3 months: 3-6 months. Tendons remodel slowly.

*Key rule*: Pain during exercise is okay up to 4/10 and should settle within 24h. If it’s worse the next day, you overloaded it.

Return-to-activity test: Pain-free grip strength 80% of other side, 15 eccentric wrist extensions with load, and can do daily activity without next-day flare.

Is your pain worse with gripping, typing, or lifting? That tells me whether we need to focus more on grip modification or loading progression.

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