Step-by-Step Guide to Tennis Elbow Treatment: A Hand Therapist’s Approach

Lateral epicondylitis—aka tennis elbow—is the bane of many patients (and let’s be honest, many therapists too). Whether your patient is an actual tennis player or just a weekend warrior who got a little too enthusiastic with yard work, this stubborn condition requires a well-rounded treatment approach. As an occupational therapist and certified hand therapist, I’m here to walk you through a comprehensive, step-by-step guide to treating tennis elbow effectively.

Tennis Elbow Treatment Step 1: Understand the Why

Tennis elbow is a degenerative condition, not just an inflammatory one. The extensor carpi radialis brevis (ECRB) muscle takes most of the damage, leading to microscopic tears at its origin on the lateral epicondyle. Your goal? Reduce pain, restore function, and strengthen the tissues to prevent re-injury.

Source: Cleveland Clinic https://my.clevelandclinic.org/health/diseases/7049-tennis-elbow-lateral-epicondylitis

Step 2: Eccentric Strengthening – The Game Changer

Eccentric exercises have been shown to remodel degenerated tendons effectively. Here’s how to do it:

1. Wrist Eccentric Drops: Have your patient hold a small weight (1-3 lbs) with their wrist extended. Slowly lower the wrist into flexion over 4-5 seconds, then use their non-affected hand to bring it back up. Repeat 10-15 times.

2. TheraBand FlexBar Twists: This is one of my favorites! Using a FlexBar, patients perform the “Tyler Twist” for controlled eccentric loading of the wrist extensors.

3. Forearm Supination/Pronation Eccentrics: Strengthen the entire kinetic chain by incorporating controlled supination and pronation with light resistance.

Step 3: Don’t Ignore the Shoulder

A weak shoulder leads to increased stress on the forearm. Addressing proximal stability helps long-term outcomes and should always be apart of tennis elbow treatment.

• Scapular Retraction with Theraband: Focus on lower traps and rhomboids.

• External Rotation with a Dumbbell: Strengthens the rotator cuff to improve overall arm mechanics.

• Closed Chain Shoulder Stability: Exercises like wall slides or weight-bearing activities help improve proprioception.

Step 4: Hands-On Manual Therapy for Instant Relief

Manual therapy is your secret weapon for reducing pain and improving movement.

• Soft Tissue Mobilization: Target the ECRB and surrounding extensor mass.

• Cross Friction Massage: Stimulate circulation at the tendon’s origin.

• Joint Mobilizations: Address any radial head restrictions that could be contributing to dysfunction.

• Neural Glides: If radial nerve irritation is present, add nerve glides to prevent neural tension.

Step 5: Dry Needling (If You’re Certified!)

If you have the certification, dry needling can be a powerful tool.

• Target the ECRB and surrounding extensor group to release trigger points and stimulate healing.

• Consider needling the triceps and posterior deltoid if compensatory patterns are present.

• Follow with movement! Always reinforce dry needling with active motion and strengthening.

Step 6: Home Exercise Program – Keeping Progress Going

Patients need to stay consistent outside the clinic. Here’s what to send them home with:

• Daily eccentric wrist flexion exercises (slow and controlled!)

• Forearm stretches: Hold for at least 30 seconds to lengthen tight tissues.

• Radial nerve glides: Prevent nerve entrapment from irritating symptoms.

• Ice massage for pain relief: Short bursts of direct ice application can reduce pain flares.

Tennis elbow requires a strategic blend of strengthening, manual therapy, and patient education. By focusing on eccentric loading, proximal stability, and proper soft tissue work, you’ll be setting your patients up for long-term success. As they progress with decreased pain, slowly increase weight, rep or dynamic movements to continue to challenge your patient and get them back to full function.

Throughout treatment, educate the patient on ergonomics and/or adaptive equipment. One of my favorites in an ergonomic mouse, by simply repositioning the hand to neutral it decreases the load of gravity on the extensor wad and decreases prolonged pronation,

If you’re a new therapist, don’t overcomplicate it—stick to the fundamentals, educate your patients, and remember that consistent, progressive treatment wins every time.

Let me know how you’re treating tennis elbow in your clinic—Baytide Health is always up for a great therapy discussion!