If you’re an outdoor athlete, you’ve probably figured out that tennis elbow isn’t exclusive to tennis players. The pesky problem, known as lateral epicondylosis in the medical community, also torments climbers, skiers, paddlers, and bikers—anyone who grips something with an extended wrist. This tendinopathy, felt as pain or discomfort on the outside of the elbow, is a common overuse injury across sports. But with the right recovery protocol, you could be back in action in as little as eight to 12 weeks.
What Causes Tennis Elbow?
“The elbow is at the mercy of the joints around it. Whatever happens at the fingers, the wrist, and the shoulder dictates what goes on at the elbow,” Vagy says. “The issue is that our grip is strongest when our wrist is cocked back to about 35 degrees. So, in any sport that involves gripping, the muscles on the back of the forearm are constantly activated to hold and stabilize this position.”
The extensor muscles of the posterior forearm all attach to the humerus via the same tendon, which is fixed at a specific location on the outside of the elbow, called the lateral epicondyle. Overuse of these muscles, especially due to poor biomechanics, can stress this tendon and lead to lateral epicondylosis. Pain or discomfort typically occurs near the bony bump on the outside of your elbow, but it can also spread down the forearm and into the wrist. Actively extending the wrist backwards or passively flexing it forward typically exacerbates the pain.
The Recovery Process
Unload Phase: Two Weeks
Most soft-tissue injuries start with an initial phase of pain, inflammation, and stress from overuse, which typically lasts for two weeks after you stop or limit the cause. But elbow injuries are tricky, Vagy says. While tennis elbow was previously thought to be a tendinitis (an inflammatory response), newer research shows that it often lacks an inflammatory component and is better classified as a tendinosis (degeneration of a tendon). In practical terms, that means anti-inflammatories might not help, so you can put away the ice pack.
“For the first two weeks, decrease or stop the aggravating activity,” says Vagy. “I’m not a big fan of telling people to stop doing what they love, but if you continue to do your sport, do it with modification.”
If you’re a climber and certain holds make the pain worse in your elbow—crimps, wide cracks, and pinches all require strong activation of the wrist extensor muscles—switch to holds that keep your wrist in a neutral position and don’t put as much stress on the tendon, like slopers or jugs. If you’re a mountain biker and the intensity and vibration of downhill riding causes more pain, switch to gravel or road biking, and use aero or drop bars to alter your wrist position. “That way you can keep your baseline level of fitness,” Vagy says, “but allow adequate time for the tissues to recover.”
Mobility and Strength Phases: Six to Eight Weeks
After you’ve taken it easy for two weeks, it’s time to get to work. With a problem like shoulder or hip impingement, you’d typically enter a mobility phase to restore range of motion to the joint before moving on to strength training. But elbow tendinopathies typically aren’t associated with a restricted range of motion, Vagy explains. “Strength exercises are actually more important than mobility exercises for the elbow. I’d initiate strength training as soon as possible, because it takes six to eight weeks to truly make changes,” he says.
The moves below include one mobility exercise followed by a strength progression. Start with the soft-tissue release and the first strength exercise. Only move from one strength exercise to the next once you can complete all sets and reps without pain. The correct weight or level of resistance for you will allow you to complete 15 repetitions in good form before hitting fatigue or failure. Once that feels too easy, bump up to the next level of resistance or add around 10 percent more weight.
If you experience an increase in pain or discomfort, see no improvement within six to eight weeks, or have any doubts whatsoever, get checked out by a medical professional.
Once you’re pain-free and back at it, be mindful of the movement patterns that can add stress to the wrist extensors and tendon. Keep up with strength work for maintenance.
Tools You’ll Need
- Armaid Extreme or lacrosse ball
- TheraBand FlexBar or hand towel
- Wrist roller (easy to make at home—more details below)
Tennis Elbow Exercises
What it does: Uses a combination of rolling and active trigger-point therapy to release tension in the extensor muscles on the back of the forearm, which reduces stress on the tendon.
How to do it: Sit in a chair and rest the Armaid (set up with the Orange Roller) on your thigh. Place your arm inside the clamp with the orange ball on the back of your forearm. With your opposite hand, squeeze the handles to apply gentle pressure as you roll your forearm back and forth through the device, feeling for the tightest spots in the muscle. Once you find a knot, extend your wrist, apply more pressure to the device, then straighten your wrist to neutral to actively release the soft tissue. Repeat a handful of times, then move on to a new location.
If you don’t have access to an Armaid, you can use a lacrosse ball instead. Place the ball on a table, rest the back of your forearm on top of it (palm facing up), then use your opposite hand to apply gentle pressure and roll out the extensor muscles as described above.
With either technique, avoid rolling over any bony protrusions or putting too much pressure on sore spots. Stop if you feel any numbness.
Volume: Eight to ten minutes, up to three times per day.
FlexBar Eccentric Twist (Tyler Twist)
What it does: “Research has shown that tendinopathies, especially tennis elbow, improve with eccentric loading, which is when a muscle elongates under load,” Vagy says. This exercise targets the wrist extensors through eccentric loading to strengthen the degenerating tendon that attaches them to the lateral epicondyle on the outside of the elbow.
How to do it: Hold the FlexBar vertically from the bottom with your wrist fully extended back. (Your injured arm should be on the bottom.) Grab the upper end of the bar with your other hand, thumb down, and twist by flexing the upper wrist forward. (Hold the lower wrist in extension against the added resistance.) While maintaining the twist, pivot the bar to horizontal and extend your arms in front of you at shoulder height, elbows straight. Then slowly release the twist in the bar by flexing the wrist on the side of injury. (You can watch a demonstration here.)
If you don’t have access to a FlexBar, you can use a rolled-up hand towel instead, though it’s not as effective.
Volume: Three sets of 15 repetitions, once per day.
What they do: Target the wrist extensors through eccentric loading to strengthen the tendon—a progression of the strength exercise above.
How to do them: Start with the rope wound tight around the bar. Hold the bar in both hands with your arms extended in front of you at shoulder height. (The rope should hang on the opposite side of the bar from your body.) Alternate flexing your wrists forward to slowly lower the weight to the ground. With the weight on the ground, squat down and rewind the rope, unweighted. (You’re working only the eccentric phase here.) Stand up, extend your arms out, and repeat.
Volume: Three sets to failure, once per day.
How to Make Your Own Wrist Roller: Some gyms have these, which are also called forearm trainers, but if not, it’s easy and cheap to make one at home. You’ll need an 18-inch length of dowel, PVC pipe, or broom handle; six feet of rope or cordelette; and a carabiner. Cut the dowel or pipe to length, then drill a hole in the center. Thread the rope through the hole, then tie a stopper knot so it jams. Tie a loop on the opposite end for the carabiner. Thread this through the hole of a plate weight or the handle of a light kettlebell, and clip the carabiner back to the rope. You can also clip the carabiner to any weighted object you might have at home, like a gallon jug of water or a small backpack full of books or rocks. Wrap the handle with athletic tape for additional grip.
Concentric and Eccentric Twists (Palm-Down Wrist Curls)
What they do: Target the wrist extensors through both concentric and eccentric loading to strengthen the tendon—a progression of the strength exercises above.
How to do them: You can do this with a FlexBar or a light dumbbell. For the FlexBar, grip the bar in both hands with your arms extended in front of you at shoulder height. Keep the bar stable with your good arm. On your injured arm, slowly bend your wrist backward against the resistance of the rubber, like you’re revving a motorcycle, then all the way forward for one repetition.
With a dumbbell, hold the weight on your injured side, palm facing down. Bend your elbow to 90 degrees, arm at your side and forearm parallel to the ground. Without moving the rest of your arm, bend your wrist forward to start from the lowest position, then bend your wrist all the way backward to lift the weight. This is one repetition. Slowly lower the weight (over three to five seconds) every time to extend the eccentric phase of the exercise.
Volume: Three sets of 15 repetitions, once per day.
What it does: Corrects movement patterns to reduce stress on the common extensor tendon and prevents injury relapse.
How to do it: Practice gripping with a neutral wrist position across all sports and activities; try to keep your elbow aligned with the wrist. This will take time and a conscious effort before it becomes second nature, but if you avoid the patterns that overwork the extensor muscles and stress the common extensor tendon—and keep up with maintenance exercises—you’ll keep your elbows happy.
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