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  • Writer's pictureLionel Pannunzio PT / SCS

Lateral Epicondylitis (aka Tennis Elbow)


Tennis elbow can happen to anyone who repeatedly uses their elbow, wrist, and hand for their job, sport, or hobby.

Most people who get tennis elbow don't play tennis! In fact, less than 5% of all cases of tennis elbow occur in people who play tennis.

What exactly is Tennis Elbow or Lateral Epicondylitis ?

Tennis elbow is a Painful condition caused by overuse of the "extensor" muscles in your arm and forearm, particularly where the tendons attach to rounded projections of bone (epicondyles) on the outside or lateral aspect of the elbow.

The muscles you use to grip, twist, and carry objects with your hand all attach to the "lateral epicondyle" at the elbow. That's why the movement of the wrist or hand can actually cause pain in the elbow.

Prolonged use of the wrist and hand, such as when using a computer or operating machinery and, of course, playing tennis with an improper grip or technique can lead to tennis elbow. It can happen to athletes, non-athletes, children, and adults.

It occurs more often in men than women, and most commonly affects people between the ages of 30 and 50.

Signs and Symptoms

Symptoms of tennis elbow can occur suddenly as a result of excessive use of the wrist and hand for activities that require force, such as lifting, twisting, or pulling.

More commonly, though, symptoms of tennis elbow develop gradually over a period of weeks or months as a result of repeated or forceful use of the wrist, hand, and elbow.

Repetitive (and often too forceful) typing combined with slouched posture at the computer can also cause lateral elbow pain

Your symptoms may include:

  1. Pain that radiates into your forearm and wrist

  2. Difficulty doing common tasks, such as turning a doorknob or holding a coffee cup

  3. Difficulty with gripping activities

  4. Increased pain when you use your wrist and hand for lifting

  5. Stiffness in the elbow

  6. Weakness in the forearm, wrist, or hand

For an "acute" case of tennis elbow one that has occurred within the past few weeks it's important to treat as early as possible. Left untreated, tennis elbow may become chronic and last for months and sometimes even years


1. Tendinopathy

The most common cause of Lateral Elbow Pain is the result of a  Tendinopathy.

Tendinopathy means the condition can occur after a single incident (acute injury) or after repetitive irritation or "microtrauma" (chronic injury).

2. Acute:

Tennis elbow can also sometimes occur after straining , banging or knocking your elbow.

3. Oversuse:

Tennis elbow is often an overuse injury.

It occurs when the muscles and tendons in your forearm are strained due to a repetitive or strenuous activity.

Most often, lateral elbow pain is the result of repetitive trauma to the tendons  that can result in a gradual breakdown of the tissue.

Please note that we don’t use the term tendonitis because “itis” means inflammation like in an acute ankle sprain.

This is more a problem in the architecture of the tendon, a mechanical problem within the tendon and not an inflammatory process.

4. Rotator cuff and scapular Muscle Weakness:

Other factors contributing to this type of pain are weakness in the rotator cuff and scapular musculature.

Since the act of gripping or lifting a weight, requires not only gripping action of your forearm muscles but also the action of the scapular muscles and rotator cuff, it makes complete sense that weakness in these muscles will place more stress on the wrist / forearm muscles .

It was reported  up to 25-35 % decrease in shoulder strength in individuals with lateral epicondylalgia.

5. Fatigue:

In Patients that  spend long hours in the same position  fatigue of the upper extremity muscles may play an important role in the development of elbow pain.

Typing or mouse use for long periods of time without interruption may predispose to fatigue of the wrist extensors and pain.

6. Faulty Mechanics during : Functional Activities

Improper lifting / pulling / pushing / carrying techniques especially if done repetitively can be the source of the “overuse” factor described in lateral elbow pain patients .

Treatment Guidelines

Traditional conservative treatments for LE include cross friction massage, electrical and thermal modalities, bracing, and therapeutic exercise.

Interestingly, a systematic review and meta-analysis of interventions for LE noted a lack of evidence to support treatments other than exercise.

Here is our approach to this condition which has a high rate of success

Reduce tone in affected muscles

Pain in the elbow will also cause tightening of  the surrounding muscles and creates high density of the wrist extensor muscles .

Clients can benefit from some type of manual therapy or self Myofascial release to decrease pain on this muscles.

Strengthening of Elbow and Forearm Muscles

Especial emphasis should be put in restoring the strength of the wrist extensors first Isometrically, strength without movement and close to the body  advancing to normal functional  movements once pain is under control. ( concentric and eccentric type of exercises)

Strengthening beyond the Elbow

Restore muscle strength in the whole kinetic chain starting with the scapular muscles, rotator cuff muscles.

Several studies have shown that focusing on the position of the scapula with a proper activation of scapular and RC muscles increased grip strength and reduced pain in people with lateral epicondylalgia.

Therefore, a lot of focus will be on the  Lower and Middle Trapezius strengthening ( scapular muscles ) to improve adduction of the scapula.

Finally shoulder internal and external rotation for rotator cuff strengthening will assure a strong proximal support for the activity of the wrist and hand and less stress on the affected area

Education in Functional Activities

Improper lifting / pulling / pushing / carrying techniques especially if done repetitively can be the source of the “overuse” factor described in lateral elbow pain patients .

Patient education that emphasizes proper posture  and proper technique for these movements in the rehabilitation treatment is mandatory to assure a more neutral role of the wrist extensor during these activities

Treatment Examples

1. Self-myofascial Release Technique

Pain in the elbow will also cause tightening of the surrounding muscles and creates high density of the wrist extensor muscles. Lateral elbow pain patients can benefit from some type of manual therapy or self Myofascial release to decrease pain on this muscles.

This video shows a couple of self-myofascial techniques to release tension in posterior compartment of the forearm.

I. Pinch and release: place lacrosse ball over tight muscle and move the wrist into flexion to cause a stretch of the affected muscle.

II. Lacrosse ball rolling: similar to foam rolling, this technique seems to increase intramuscular temperate and blood flow due to friction or alter muscle‐spindle length or stretch perception.

III. Combining both is even a better approach

2. Strengthening - Painful Phase

When the elbow hurts a lot it is difficult to exercises, therefore we have to build up resilience in the whole upper extremity.

For the reasons explained above, We like to use resistance training for reducing painful symptoms and for improving the work capacity of the tendon.

The first exercises we prescribe to tennis elbow patients are:

I. Isometric Holds

In my experience Isometrics holds are an excellent start point for pain management and strengthening at the same time.

A few tips here: Keep wrist in neutral, don’t grip hard , aim for 10 seconds of any amount of weight you can hold without pain.

Then try to advance either the weight or the time holding up to 20 seconds.

Besides Strengthening the elbow it is very important to restore muscle strength in the whole kinetic chain starting with the scapular muscles, rotator cuff muscles. Tennis elbow has been related to weakness in the base of these muscles.

II. Rows

Any type of Row variation is acceptable, in this case is bent-over Row with heavy weight

III. The “W” Exercise

This exercise creates a scapular stabilization and posterior cuff strengthening

3. Strengthening - Restoring Grip Strength

Limited capacity of the wrist extensors can predispose individuals to muscle strains and lateral elbow tendinopathy.

The forearm muscles help control the wrist, elbow and forearm movements .

We can differentiate two muscle groups:

  • The anterior group composed by the flexors and pronators .

  • The posterior group includes the wrist extensors and supinators on the back side of the forearm and attach on the outside of the elbow (lateral epicondyle).

Once we have control on the previous exercises now is time to move on.

Resistance training exercises that target these muscles can help treat Tennis elbow deficits.

Here are a few of the exercises we use in the first stages of strengthening.

IV. Wrist Extensor Eccentric and Concentric / Eccentric Strengthening


This type of exercise helps build strength and lengthening of the Muscle-Tendon unit. To perform this variation use a weight you can tolerate well , handle yourself the weight at the top position and lower it down slowly and with control. Recommended 2-3 sets of 5-8 reps .


This a regular wrist curl variation, for this one you can a heavier weight and go up and down all the way with control to emphasize the “time under tension” to build strength Recommended 2-3 sets of 10-12 reps

V. Flexbar

This exercise has shwon to work well with patient with lateral elbow pain. Follow the instructions in the video for proper workout. .

VI. Rotator Cuff Strengthening

We chose the side-lying variation because it activates scapula and cuff in a neutral grip position contributing to the build up of muscle capacity.


  • Tennis elbow is usually a Overuse condition that once chronic can cause debilitating pain in the elbow and inability to grasp objects

  • It is associated with poor posture, prolonged typing and weakness of the forearm muscles

  • Treatment requires a progressive and comprehensive approach to restore strength not only in the elbow but also and more important in the rotator cuff and scapular muscles. This point is usually neglected reason why many treatments fail.

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston,  where he treats Soccer Player, Runners and Athletes of all ages

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Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”

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