Tennis elbow is the bane of many. This condition is felt in the tendon on the outside of the elbow, usually when gripping or lifting. Because this is a tendon injury, it will be very close to the bone and tender to poke. The pain should remain local (no more than two fingers width in area and not radiate or refer). ‘Maudsley’s test’ is used to determine this – support the bent arm with fingers held straight. If there is pain near the elbow when resisting the middle finger being pushed down, it suggests tennis elbow.

Maudsley’s test isn’t infallible but we don’t need a precise diagnosis; a reasonably accurate assessment should suffice.

A brief nerdy history into tendon-ouchies 

A bird doesn’t need a degree in engineering or a pilot licence to fly and you don’t need to become an expert in biology to fix your tennis elbow, but a bit of background info won’t hurt (unlike the affliction we are trying to deal with).  Don’t let the name fool you. Not all tennis related injuries around the elbow are ‘Tennis elbow’ and tennis is not the only cause. In fact forearm problems are not limited to sports people and teenage boys and there are many ways to encounter them (injuries, not teenage boys). 

The clinical name ‘lateral epicondylitis’ has caused confusion about how best to treat the condition. The suffix ‘itis’ means an inflammation, as in tendinitis. Despite ice and anti-inflammatories seeming to help, the inflammatory process of tendons has been questioned in the past (to put it mildly) and it is commonly called ‘tendinosis’. This term was first used in the 1940’s by some German researchers and it resurfaced in the mid 80’s. The ‘osis’ suffix means a degenerative, diseased or abnormal process or state. In turn, this has changed the recommendations in how we avoid such manifestations. Again, the evidence supporting that this is a degenerative condition is weak. In fact there is little understanding of the mechanics in how or why the thing hurts in the first place. 

Tendinopathy may be the best current description, which falls between the previous two. It describes a disorder that includes pain, impaired function, tenderness and swelling. Swelling may be caused by the movement of water into the tendon matrix rather than just inflammatory products. However, your time will be better spent understanding the treatment options than fretting over what name is most appropriate.

Tendons are usually pretty tough – they can take far more load than the muscles they attach to, so you’ll not overload them with slow or static movements. However, they can be irritated by direct impact or a sudden change of activity. Excessively playing on your phone or laptop, a feature-length spell of gardening or decorating would do the job just as well as going back to the gym full throttle after a short holiday or lay off. There are no set levels. As someone gets stronger, they will be exposed to greater loads but also be better able to tolerate them. Despite our uniqueness, we are not all that different from one another. So carefully plan the frequency and time between your sessions based on your ability, conditioning and needs!

How to deal with it in the early stages

You’re going about your business and then all of a sudden, there is a localised pain or burning sensation on the outside of your elbow. This can be reoccurring or from a single instance. You are at this exact moment presented with a one time, not to be repeated offer. Stop the session or activity right there and then and if you’re lucky, the pain will go after 5-10 days. Sounds like a crappy deal when you could quite easily train through it. Until you find out the hard way what the alternative is. Trust me – this may seem drastic, but if nothing else comes of it then you had a good result.

At this acute stage, the collagen and neuromuscular structures likely remain intact. There will probably be a non-inflammatory thickening of the tendon. This is your body’s way of spreading the load over a wider area – it reduces the stress and increases the stiffness. 

Do not stretch it out – this would only make things worse by adding more compressive forces to the problem. Simply back off on the training for the 5-10 days, and give long enough between sessions to allow things to settle down. 

No rest for the wicked

Complete rest is unnecessary and could make things worse. Boxers take most damage when retreating and tendons are similar. Tendons unloaded for prolonged periods (> 24 hours) become stress-shielded. This induces the same sort of cell and matrix change as the overloaded pathological state. Load is both catabolic and anabolic to tendons – remaining in an ever-changing goldilocks zone maintains their mechanical integrity and makes them less prone to overload or injury.

Instead of total inactivity, reduce your training volume, frequency and intensity. Avoid high loads, faster paced or springy movements and any direct massage or poking. This will allow the tendon to adapt and its cells to become less reactive and the matrix to revert to a more normal structure. 

Training needs to be increased gradually to prevent relapse. There are some less obvious exercises to avoid while the injury recovers. Shoulder pressing, cleans, squatting with a low bar or narrow grip, pull ups or lat pull downs and close grip benching all involve compressive and tensile loading that can irritate the area.

There are other exercises that can cause problems, but the key here is know what brings on your symptoms. Identifying your trigger may be as simple as allowing a day or two between high or very high tendon loads. This is one of the reasons training diaries are so useful, so track your volume, frequency and gradually increase things. 

It is too soon to use eccentric loading (i.e. negatives – this could easily overload the tendon) but isometric (static) exercise is recommended during this phase, partly to help maintain strength whilst training loads are reduced but mostly to help relieve the pain (like a natural anaesthetic). 

Isometric work

An isometric contraction sounds oxymoronic, but describes a movement or exercise when a muscle resists a load without changing length. Avoid stretching or squashing the area, so put the muscle in its ‘mid-range position’. Bend your arm at 90 degrees and hold a light weight using only 25-50% of your strength (this is how hard you’re squeezing the muscles, not how heavy the weights should be).

Hold this for 40-60 seconds (this is why you can’t squeeze too hard) and repeat 4-5 times throughout the day.

Give it the finger 

Sit down and rest the elbow on your thigh. Place an elastic band around your thumb and middle finger. Open and close your hand for three sets of ten reps. You can experiment with other fingers or combinations as long as the thumb is always one of them.

How to deal with it in later stages

Tennis elbow can affect your workouts and be uncomfortable, but in the early phase it feels more of a niggle than anything debilitating. Most people try to ignore it and train through it. 

Once you get into your workout and you’re warmed up, the pain probably all but vanishes and doesn’t reappear until after the session. However, when it does, it likely feels worse than before and interferes with the healing process. At this chronic stage, things will take a while to recover and action is required. The affected area may feel quite knobbly or nodular. The tendon becomes stiffer and its recovery and capacity to handle load are altered. Recovery is still possible, but it is less likely the longer you let it carry on.

Stretching the area may now be appropriate, along with direct or even aggressive massage, trigger pointing and general poking. We can also add in eccentric training. 

Eccentric training

Eccentric doesn’t mean you need to move into a flat with a load of cats and wear a tea cosy on your head. Instead, you emphasise the lowering phase of a lift. Slowing this portion is thought to increase collagen production in abnormal tendons. For whatever reason, this has no effect on normal tendons and so can’t be used preventively. Used correctly, this will help short and long term pain, function and see you return to normal activity.

Use the reverse bicep curl, which is the same as a regular bicep curl but you use an overhand grip. It doesn’t matter if you decide to use bar, dumbbell, cable or machine. 

Start relatively light with 3 sets of 15 reps. Lifting the bar should be done at normal pace, bringing the bar just past 90 degrees and using no more effort than necessary. However, the lowering phase should take 3-4 second. There is no need for a pause at the top or bottom of the lift.

Repeat twice daily and on training days, it should be your first warm up exercise. Increase the weight whenever possible, but focus on the lowering phase and keep the reps high.

Heavy slow resistance training

All going well, things will start to feel better. Over the next 12 weeks (yes, I know it takes forever, but it is not to be rushed) the reverse curls should be dropped down to 2-3 times a week with at least 24-36 hours between sessions. Gradually increase the weight and decrease the reps, but do not go below sets of 6. The eccentric phase can be less emphasised and eventually the exercise can be eliminated. Now you can begin your return to regular sport and more complicated and explosive exercises can be added back to the routine.

Use the right approach

Going straight to DEFCON 1 with your treatment plan is not only ineffective, but you are potentially escalating the severity of the injury in proportion to the aggression of your remedial exercises. 

The early stages of tennis elbow is easily aggravated by exercise and is usually painful. At this point it needs to be treated gently but not rested either. Avoid heavy loads, fast movements and any exercises that may compress the area. Don’t poke, prod or stretch the area directly. Add in the isometrics and the band exercises. All being well, you can expect a good recovery in the next 6 weeks.

If the early phase is ignored or there have been repeated bouts, you can assume you are in a later stage of tendinopathy. Whilst still uncomfortable, training has probably been negatively affected but no longer feels as though it is making things worse (it’s just not really going away either). Now the massage and stretching can be a little more targeted, plus you can add in the eccentric training which gradually leads you back to regular workouts. This is a more advanced phase, so expect healing to take anywhere between 3-12 months – a long time, but be grateful it will heal at all.

It likely that there are different areas of the tendon at various stages of injury or healing. It is best to tackle the early stages first, then treat the chronic areas second.

Maybe it will just go away on its own..

We all train hard and have better things to do than be waiting for every ache or pain to sort themselves out. Minor niggles get ignored and serious ones are given just a couple days off before it’s business as usual. 

Feeling that this is all too long winded so you’ll just carry on with your sessions until it goes away could be a big mistake. The more repeated or prolonged the bouts of injury, the harder it becomes to recover from.

Tennis elbow may sound like the paper cut of training injuries, but we can easily push our luck by being impatient. The irony is that rushing to improve and achieve our goals is counterproductive as it does not give our tendons the time to adapt. Whilst injured, progress creeps forward or gallops backwards.

If the tendinopathy is allowed to degenerate further, there will be a breakdown of the matrix, cell death and less collagen. It’s probably been going on so long or so often that you don’t even notice your training is suffering and by now it is quite likely to not even hurt all that much anymore but the pain behind tendinopathies has been an enigma from the start. 

You are not out the woods by any stretch of the imagination. Although spontaneous ruptures are possible, 97% of them will occur in the final phase of tendinopathy. Two thirds of these cases were pain free until the time of this catastrophic breakdown of tissue and function. Surgery is now the only viable option but in all likelihood it will be unsuccessful as the damage and morphology is now irreparable. Often normal training can resume post recovery, but it will take some exercises completely off of the table and be an everlasting weak spot.

Injuries are a general nuisance; they can slow you down and hurt. But when the effects are irreversible, they really do suck. This is why training should be carefully planned. 

Generally people do not need more information – knowing what to do and doing it are not the same thing. This advice is only going to be useful if you acknowledge the injury and manage your condition properly. Easier said than done when it actually happens, but the quicker you take action, the quicker you stop training on credit and the less you need to pay back in the end.


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