Tennis Elbow

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Most elbow issues such as tennis elbow and Golfer’s elbow are overuse injuries. Ironically, golfers tend to get tennis elbow and tennis players tend to get Golfer’s elbow. There are a number of variables that will predispose you to this type of injury. Suddenly increasing your activity level or changing your grip can set you up for injury. Or, if you are missing range of motion in your shoulder or wrist, your body will find what it needs in the elbow which becomes another form of overuse.

So what is tennis elbow exactly? First off, it’s a muscle that controls the wrist, not the elbow. Repetitive wrist extension leads to microtearing of the muscle or tendon, or both. This is basically what happens when you work out but at a pathologic level. Any given muscle has a certain capacity to tolerate stress applied to a point. If too much stress has been applied to an area before it has a chance to adapt, it becomes irritated, inflamed, and potentially torn. Much like a rope with a heavy weight attached. The more weight you attach, the more strain on the rope. When the weight passes the ropes capacity, it begins to fray and eventually snaps. That is why the stronger a muscle, the more resilient it is.

There are different grades of tears, but most start as microtrauma or microtears like in this picture:

The difference between the rope and your forearm is that it is living tissue and has the ability to repair. Macrophages, satellite cells, and fibroblasts are critical components of muscle recovery. Macrophages clean up the area and eat the dead cells. Satellite cells, who normally lay dormant between the muscle and basement membrane, act to stimulate new muscle cell development. Fibroblasts lay down a connective tissue, like scaffolding that allows the muscle to have a structure to build on.

Generally, with a strained muscle or tendonitis, you want to calm down the tone, use the muscle in a non-provocative manner for blood flow, and take the muscle and joint through range of motion. Then when it is feeling better, you want to progressively load the muscle to prevent another injury.


To calm the tone down, you want to apply a stimulus to the affected area. This can be in the form of massage, cupping, scraping, etc. We do not 100% understand why this works but what we do know is that layers between skin and muscle are rich with different types of receptors. They are able to sense pressure, temperature, compression, light touch, stretch and vibration. The current thinking is that activating these receptors sends a single to the nervous that enables the affected muscle to relax. The modalities classically used basically do exactly that; massage, cold/hot packs, compression braces, and vibrating massagers. Perhaps this is what we have been doing this whole time. Regardless, if we stimulate the painful area, people generally feel better and move better afterwards.

Next you want to use the muscle as pain free as possible. If it is an injury that just happened, it’s probably wise to rest it for a few days until you can actively move it without sharp increases in pain. Once you are out of the acute phase, focus on eccentrics. That means the negative phase of motion. Picture a bicep curl; when you are lowering the weight slowly back to your hips, that is the negative, or eccentric phase. For tennis elbow, that means doing wrist extension, then lowering the weight slowly. Remember the satellite cells that lay dormant? They are activated through exercise and begin the muscle rebuilding process. High repetition and low load sets are recommended as it is less provocative and encourages circulation.


Now that there is blood flow to the area, you should take the joint and muscle through full range of motion as long as it does provoke high levels of pain. For tennis elbow, this comes in the form of a wrist extensor stretch:

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When the symptoms of tennis elbow reduce to pre-injury status, it’s time to load the muscle. Focus on all phases, isometric, concentric, and eccentric. Play with variable such as repetitions and weight to continue to challenge the muscle. Add strengthening to the neighboring joints such as elbow and shoulder. The stronger and more stable the muscle and joint is, the greater its capacity to handle load and volume associated with sports.