Remember! Our guides are to be used following an assessment with a qualified medical professional. Do not attempt these exercises if you have not been given a formal diagnosis, or given consent to complete these exercises by a Physical Therapist.

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Tennis Elbow Physical Therapy Guide

What Is Tennis Elbow?

Tennis elbow or “Lateral Epicondylytis” is a painful condition that most commonly occurs as a result of overusing the extensor tendons of the forearm and elbow joint (a tendon is a structure which connects a muscle to the bone). The tendon most commonly affected is that of the Extensor Carpi Radialis Brevis tendon. As the name suggests, tennis elbow can often be caused by playing tennis and other racquet sports, but it is mainly the result of a number of other physical activities that involve repetitive gripping and wrist movement. As a result, it is often a condition, which affects those who complete manual work.

Tennis elbow is a common condition which affects around 2 – 3% of the population every year. In the United Kingdom this means that there are a million new cases of tennis elbow every year!

What Is Really Happening In There?

Overuse movements such as manual labor, typing on a keyboard or racquet sports, repeatedly damage the forearm extensor tendons. This causes “micro trauma” to the tendon whereby minute tears disrupt the integrity and strength of the structure. To add insult to injury, the blood supply is diminished around the site of injury, and as such it struggles to heal on its own. This is when an acute injury becomes a chronic one, and action needs to be taken.

What Causes It?

Tennis elbow is a chronic overuse injury. The injury itself has normally been developing over the course of months or years of disuse, and pain commences when the tendon simply can’t take any more! As a result, there isn’t typically a single episode of trauma; most people report a pain coming on over the course of a few weeks, unable to distinguish an exact time.

It is common in sports / occupations that involve repeated wrist extension (whereby the back of your hand goes upwards). In tennis, the tendon is often damaged during a players backhand where they unknowingly overly flick their wrist. In the workplace, it can be something as simple as typing on a computer for long periods of the day. This is because tasks that require wrist stabilisation (such as gripping), or wrist extension movements, a considerable load may be placed on the Extensor Carpi Radialis Brevis tendon over long periods of time.

What Are The Symptoms?

Lateral elbow pain is typically presented as pain on the outside of your upper forearm, just below your elbow – the pain may also travel down your forearm towards your wrist in more severe cases. The peak incidence is between the ages of 40 and 50 years old; however, the condition can affect any age group.

The most common symptoms are:

  • Pain when lifting objects or simply bending your arm.
  • Pain when writing or gripping small objects, for example, when holding a pen or clicking a mouse
  • Pain when twisting your forearm or wrist – for example, when turning a door handle or opening a jar
  • Pain and stiffness when fully extending your arm
  • Grip strength decreased
  • Reaction times decreased

What Are My Treatment Options?

There are many treatment options available to people who suffer with tennis elbow!

Rest & Time

It is imperative that you stop doing the thing(s) that caused the elbow pain to begin with and avoid activities that agitate it further. This can be a wide variety of things from tennis, twisting open jars or even typing on a keyboard. There are no specific activities to avoid, as it is completely subjective; everyone is different. Throughout your rehabilitation programme you must make note of what to avoid via trial and error. Any time that you feel something is causing the pain to flare up, or if you feel your elbow getting “hot” you must take care of the injury site and stop the activity. Perhaps the worst thing you can do for this type of injury is to “work through the pain”, tendons do not heal in this way and it will only set you back more time if you do.

Physical Therapy

Although rest is a vital component of the recovery process, it doesn’t mean the affected limb has to be completely immobilised. In fact, tendons need to be placed under tensile loads to grow and stay healthy. The difficult part is finding the specific movements in which you place the tendons under load, and strengthen the wrist extensor muscles in your forearm. As previously mentioned, the tendons in your body have very poor circulation, and as a result healing of tendons does not automatically happen. Something must be done to encourage this process. That something is Exercise!


Exercise is the most important component for your recovery and one that must not be avoided.

Tensile load needs to be placed through the affected muscle to enable it to grow!

These exercises should be done daily; they will take approximately 20 minutes, but will greatly improve your pain, prognosis and recovery time.

Tennis Elbow Exercises

1) Eccentric Wrist Curl

This is the number one exercise prescribed by Physical Therapists and health care professionals in the health industry. It places a tensile load through the affected tendons whilst slightly stretching them, causing them to break down scar tissue, encouraging an inflammatory response to the area. The position of your arm can be modified to make the exercise easier or harder. To make the exercise harder you simply straighten your elbow further.

How to do it:

  • Place your affected arm on a steady surface with your hand and wrist hanging over the edge, palm facing the floor.
  • Hold a small weight, or place some form of resistance through the hand (holding a can of beans).
  • Slowly let your wrist bend towards the floor (the slower the better).
  • Once you reach the bottom, use your good arm to lift the weight back up.

Repeat for 10 reps, 3 sets. Try to do this 3 times per day.

2) Tyler Twists

The Tyler Twist exercise is the latest evidence based exercise in the treatment of lateral elbow tendonopathies. It requires the use of a Theraband Flexbar, which can be purchased here!

It works upon the same principles as before, the extensor tendons are stretched whilst a tensile load is slowly placed through them.

How to do it:

  • Grasp the Flexbar with your injured arm near to its base and extend your wrist.
  • Grasp the upper end of the bar with your non-affected arm so that it faces away from you.
  • Twist the bar with the top hand as you stabilise with the bottom hand.
  • Hold both wrists steady as you extend both elbows in front of you. The wrist on your injured side should be extended whilst the other wrist is flexed.
  • Slowly release the bar with your injured side, while maintaining tension with the uninjured side.
  • The more twisting motion you can apply with your uninjured side to begin with, the better the resistance will be for the injured side.

Repeat 10 reps, 3 sets, try to do this 3 times per day.  

3) The Zottman Curl

This exercise works in the same way as the eccentric wrist curl except its main function is to stress the Biceps and Brachialis muscles. The wrist movement at the peak of the movement brings about wrist and forearm stabilisation on the eccentric portion of the exercise, and that is where we target the site of injury.

How to do it:

  • Stand with a weight in your hand with your palms facing forward.
  • Curl the weight up towards your shoulder as high as you can.
  • Now turn your wrists over so that your palms are now facing the floor.
  • Slowly lower your arms back to the starting position.

Repeat 10 reps, 3 sets. Try to do this 3 times per day.

4) Supination / Pronation

Your forearms also contain the muscles that are responsible for pronating and supinating your wrist (the movement you would use to turn a door knob back and forth). These muscles can become weak in patients with tennis elbow and so it is a good idea to strengthen when possible.

How to do it:

  • Begin with your affected arms elbow resting on your thigh with your thumb pointing towards the ceiling
  • Hold a small weight in your hand
  • Slowly rotate your palm up and then down so that your palm faces the ceiling, and then the floor

Repeat 10 reps, 3 sets. Try to do this 3 times per day.

5) Isometric Extensions

Once you can feel your pain improving and you are better able to complete tasks that you weren’t previously able to do, then you can progress to isometric exercises of the wrist. Isometric exercises are used in strength training but differ from eccentric. During isometrics the joint and muscle length do not change during contraction. Examples of this are poses in body building or pushing against an immoveable object such as a wall. For this exercise you will need a Theraband, which can be found here!

How to do it:

  • Rest your injured forearm and hand on your knee whilst holding a theraband that is wrapped around your foot.
  • Keep your forearm steady in a palm down position
  • Hold the position in its neutral position for 10 seconds.

Repeat 5 reps, 3 sets. Try to do this 3 times per day.

6) Deep Transverse Frictions

 Deep transverse frictions are a treatment to speed up the recovery process tendon injuries like tennis elbow, which is used by Physical Therapists, but can be performed by the patients themselves. The purpose of deep friction massage is to maintain the mobility within the soft tissue structures of the tendons and prevent adherent scars forming. The massage is deep and must be applied transversely to the specific tissue involved (the extensor tendons near your elbow). The movement encourages realignment and lengthening of these wrist extensor muscle fibres and will improve your recovery rate.

Many professionals find it preferable to use foam rollers or Muscle Stick rollers, which can be found here!


Untreated tennis elbow can last anywhere between 3 months and 2 years, with high chances of the condition returning if you do not heed advice such as this. Medical research suggests that Physical Therapy and exercise are the most effective way of treating the condition, most patients show significant improvement after 6 weeks of treatment however it can take up to a year to show full improvement.

To reduce your chances of getting Tennis Elbow again, you must continue to strengthen and stretch your forearm muscles. Taking breaks from activities that involve long periods of tendon loading will also prevent tendon micro-trauma and if you feel some pain coming on, you must try and cease that activity immediately.