Assessing and Treating Tennis Elbow

By Ben Benjamin, PhD
March 7, 2016

Assessing and Treating Tennis Elbow

By Ben Benjamin, PhD
March 7, 2016

The most common elbow injury is a strain to the common extensor tendon which controls the wrist, but begins at the elbow. This injury is commonly known as "tennis elbow." Tennis elbow earned its name because many tennis players suffered from this injury.

This is an injury which is not exclusive to those who play racket sports. It is very common in people who use their hands and wrists a great deal in their occupations. The involved muscles are used frequently to grip and lift objects.

You use them when you open doors, paint a wall, screw and unscrew jar lids and turn a screwdriver. Most people with this injury experience pain with activities such as shaking hands, washing dishes, wringing a cloth or lifting a teapot.

Tennis Elbow Anatomy

Tennis elbow means that there is a slight tear or inflammation of one particular muscle tendon unit, frequently near where it connects to the bone at a place medically known as the teno-periosteal junction.

Among the muscles at the outside of the elbow joint, there are two very closely associated muscles: the extensor carpi radialis brevis (See Figure 1) and extensor carpi radialis longus (See Figure 2). Both of these muscles share the common tendon which attaches to the bone at the outside of the elbow (the humerus), the tendon fibers of the longus extend a little further up the attachment to the bone than do the brevis.

Of the various sites of injury the most common is in the common tendon close to its attachment to the bone. The pain is felt at the lateral aspect of the elbow with activities involving the wrist joint and may extend from the outside of the elbow into the forearm as far as the wrist.

To locate the exact area of attachment, lean sideways against a wall and bend your arm as though you were going to shake hands with someone. Push your elbow against the wall. The knobby bone you feel pressing into the wall is called the lateral epicondyle of the humerus and is the area where the common tendon attaches to the elbow. This is often the site of the injury.

A little probing with your finger will confirm that this is the spot or you may find it a little lower down the arm in the tendon itself. The muscle bellies of the brevis and longus and their tendons pass down the forearm. The brevis attaches at the back of the hand just beyond the wrist joint while the longus continues on into the fingers.

In addition to the teno-periosteal junction the injury may also occur in the main part of the tendon, called the body of the tendon, or at what's called the musculo-tendinous junction, which is where the tendon and the muscle join each other. The final place of injury with a tennis elbow may be in one or both of the muscle bellies of these two muscles.

How and Why?

This bothersome and frequently long-term injury is extremely common. It regularly afflicts people who lift heavy objects, scrub floors, wait tables, and, of course, play racquet-sports. When racquet enthusiasts get tennis elbow, it's usually because the muscle-tendon unit is fatigued due to repetitive stress or a sudden excessive strain applied to the muscle tendon unit.

It can also occur by falling onto the elbow or bumping the elbow against a wall or another surface with some force. This causes a sudden muscle contraction which tears a few of the fibers of any part of the muscle tendon unit. An inflammatory response occurs. Then adhesive scar tissue develops, often becoming chronic.

Tennis elbow may occur suddenly. The pain may be so severe that you may be forced to stop what you are doing. Tennis elbow may also come on slowly in a milder form initially and then become severe. In this case, the tendon has suffered many minor micro-tears over a period of time by particular repetitive activities, eventually resulting in a severe, painful tennis elbow if you continue to use it.

Where the common tendon attaches at the outside of the elbow it is in close proximity to several other muscles and tendons which control the wrist and fingers. The close proximity of these structures makes it likely that extraneous scar tissue formation which accompanies this injury will bind several structures together.

This binding together with scar tissue inhibits the individual function of the different structures making healing more difficult.


Ask the client to straighten the elbow and bend their wrist upwards as if they were a policeman saying, "Stop." Now, place the other hand at the back of their upturned hand and attempt to push the upturned hand forward while they resist. Use slight force, at first; as it is usually all that is needed to reproduce the pain. Pain at the outer side of the elbow during this test with associated weakness indicates a tennis elbow is present.  The pain causes the weakness.


This method for treating any soft tissue injury must always be combined with the appropriate rehabilitative exercises. Friction therapy is designed to break up the unwanted and unnecessary scar tissue which accompanies most soft tissue injuries causing them to become chronic. The rehabilitative exercises are necessary to prevent the reformation of adhesive scar tissue and to rehabilitate the injured muscles and tendons.

This friction technique is best done in a sitting position. Bend the client's arm at a 90-degree angle and supinate the forearm. While holding the forearm with one hand, place the thumb tip or index finger of your other hand at the lateral edge of the lateral epicondyle of the injured elbow. To check that your hand placement is correct, move your thumb medially onto the tendon and ask the client to raise and lower the hand, as in the test. If you are in the right place, the tendon will tighten under your thumb or index finger. Press down on the tendon attachment at the elbow and apply friction in a medial direction only. Repeat this for 5 to 10 minutes with interruptions as needed for the client's comfort. After frictioning, massage the entire arm extensively, especially the extensor surface of the forearm.

Exercise Therapy

These two exercises which are done throughout the day will limit the formation of extraneous scar tissue and help it to change from a matted network of fibrous tissue into a useful, pliable scar.

  1. Stand or sit with the injured arm stretched out in front at approximately shoulder height. Throughout this exercise keep the elbow straight. The starting position is with the palm facing the floor. Gently wave your hand up and down as if you are saying goodbye. This should be done for about 30 or 40 repetitions. The more often you do this movement throughout the day, the better.

  2. Extend the arm in front of you at approximately shoulder height with the elbow straight. Move the arm so that the wrist is directly in front of the center of your chest. In this exercise, the hand is pulled back as if you are a policeman saying "Stop." Now, place the palm or fingers of your other hand at the back of your wrist. Gently press down with the good hand on the back of the wrist while maintaining the position. Hold the pressure for five seconds and repeat 8 to 10 times. Do this 4 to 5 times a day. In time, you will be able to push harder and harder as the strength returns to the muscle. Do not push so hard that you create pain. Then stretch your wrist as in the photograph.