Tennis elbow affects 1-3% of the population. I’ve got to say that of all the cases I’ve seen, only 2 clients actually played tennis. Some were drummers, some were rock climbers, some played hockey, one was a competitive shooter, so it’s clearly not restricted to tennis.

Patients will generally complain of pain or tenderness on the outer part of the elbow, pain with gripping movements, pain with wrist extension (a common complaint is “I can’t pour milk into my coffee without pain”) and general stiffness of the forearm.

Most textbooks point to the extensor carpi radialis brevis origin as being the culprit but having been in the field, I would argue that any of the extensor origins can act up. Generally, one of these muscles accumulates so much micro trauma that it begins sliding into that grey zone where while not yet macro trauma, it is more than micro. Some think of it as a repetitive stress injury which is not incorrect. Generally, the repetitive motion cause micro tears of the muscles and tendons, just like with normal exercise. The problem being it causes so much due to the frequency that the body doesn’t have time to adapt and it starts to scar and knot inside the muscle and tendon. In 90% of cases, with therapy and rest, it can be treated successfully. In 10% of cases, the damage is so severe that the client must either stop activity or pursue a surgical option to continue.

Various therapeutic protocols exist; shockwave, acupuncture, bracing, steroid injections, strengthening, stretching- all with varying degrees of evidence.

Dr. Johnson of Ohio State University proposed a strength training protocol in 2003. It stated that 3 sets of 10 reps of wrist extensions using 1-2lb weights followed for 4-6 weeks, increasing weight where permitted, would rehabilitate lateral epicondylitis. This should be done in both the elbow extended position and the elbow flexed to 90 degrees.

Croisier et al 2007 demonstrated that eccentric loading for the same condition for 1 month of regular exercise improved symptoms by 89% compared to the control group. Dr. Finestone and Rabinovitch, 2008 also demonstrated similar results but reported that patient compliance is the main issue with this program. If the patient is incompliant, the program will not produce results in the expected amount of time.

Waseem et al, 2012 reviewed the literature on lateral epicondylitis. They review the chemical and physiological responses and the roles of substance P and calcitonin in the tendons. As we understand the biochemical pathways, new avenues for treatment and prevention open up but this is not practical now for the average coach or athlete. They demonstrate that stretching the ECRB tendon with elbow extension and strengthening it 2-3 times daily demonstrates enough evidence to indicate a basic protocol.

So it appears that at this time, 3 stretches 3 times daily before strength work for 30-45 sec has validity as part of a treatment protocol. 3 sets of 10 reps of the two exercises discussed previously 3 times daily also seem to produce measurable effects. This protocol is not difficult to explain to a patient and will likely help with recovery.

The only thing I can add from personal experience is adding some soft-tissue work. In order to break up the scar tissue and adhesions, having the patient work the extensor tendons on a tennis ball or other surface for 5 minutes twice daily and doing some direct soft-tissue work during treatment seems to improve outcomes. When the knot it broken up and strength restored, the patient can quickly return to normal function.

In terms of prehab, for at risk athletes (eg: tennis players, rock climbers, etc.) I would definitely recommend 2-3 sessions/week of doing these exercises to prevent adhesions from building up. You’d rather spend an extra 10 minutes in the gym then have to be sidelined for a month and coming to see a therapist, right? Train hard, train smart guys.