You’ve never played tennis. But every time you grip a pan, turn a doorknob, or shake someone’s hand, the outside of your elbow screams. It started 3 months ago and hasn’t improved. You’ve taken ibuprofen. You’ve rested. You got a cortisone injection, it felt better for 3 weeks, then came back worse.
Lateral epicondylitis, tennis elbow, has nothing to do with tennis for most patients. It’s a repetitive strain injury of the forearm extensor tendons where they attach to the outside of the elbow. It affects 1-3% of the general population, with peak incidence at ages 35-55 (British Medical Journal, 2006). In Malaysia, it’s particularly common among factory workers, office workers who mouse extensively, cooks, and anyone who performs repetitive gripping tasks.
Here’s the problem with standard treatment: rest reduces pain temporarily, but the tendon hasn’t healed, it’s just stopped being aggravated. Cortisone injections suppress inflammation, but a 2013 Lancet study found that cortisone-treated tennis elbow had WORSE outcomes at 1 year than no treatment at all. The injection masks pain, the patient resumes aggravating activities, and the tendon deteriorates further.
OT addresses the actual tendon pathology with eccentric loading, fixes the activities that caused it, and braces the elbow during recovery. Success rate: 85-90% resolution without surgery (Journal of Hand Therapy, 2019).
Tennis elbow not healing? OT fixes the cause, not just the pain.
Why Tennis Elbow Happens
The extensor carpi radialis brevis (ECRB) tendon anchors to the lateral epicondyle of the elbow. Every time you grip, lift, or twist with your forearm, this tendon loads. With repetitive loading beyond its capacity, the tendon develops:
- Micro-tears in the tendon fibres
- Failed healing response, the body tries to repair but produces disorganised, weak tissue (tendinosis, not tendinitis)
- Chronic degeneration, the tendon becomes progressively weaker and more painful
This is why rest alone doesn’t cure tennis elbow: the tendon needs specific loading (eccentric exercise) to stimulate proper healing. Without it, the degenerated tissue remains degenerated.
Common causes in Malaysia:
- Repetitive mouse use (5+ hours daily)
- Factory assembly work (repetitive gripping and twisting)
- Cooking (wok tossing, chopping, stirring)
- Cleaning (wringing mops, scrubbing)
- Construction (hammering, drilling)
- Badminton, golf (the actual sports causes)
The OT Treatment Programme
1. Eccentric Exercise (The Core Treatment)
Eccentric exercise, slowly lowering a weight, is the gold standard treatment for tennis elbow. A 2014 study in the British Journal of Sports Medicine found that eccentric exercise produced 81% improvement in pain and function at 12 weeks.
The Tyler Twist (using a FlexBar):
- Hold the FlexBar vertically with the affected hand at the top, wrist extended
- Twist the bar with the unaffected hand at the bottom
- Hold both ends and slowly let the affected wrist lower (eccentric phase)
- Repeat 15 times, 3 sets, once daily
Alternative without FlexBar:
- Wrist extension eccentric: Hold a light weight (0.5-1kg), rest forearm on table with hand over edge, palm down. Slowly lower the weight by bending wrist down (3-second eccentric phase). Use the other hand to lift the weight back up.
- 15 repetitions, 3 sets, once daily
Progression: Increase weight by 0.5kg every 2 weeks if pain-free during exercise. Mild discomfort (3-4/10) during exercise is acceptable; sharp pain is not.
2. Bracing
Counterforce brace: A strap worn 2-3cm below the elbow that reduces load on the ECRB tendon during gripping activities. Cost: RM30-100. The OT fits the brace at the correct position and tension.
Wrist cock-up splint: In severe cases, a wrist splint reduces wrist extensor activity, resting the tendon more completely. Worn during aggravating activities or at night.
3. Activity Modification
The OT identifies which activities are perpetuating the tendon damage:
| Activity | Problem | Modification |
|---|---|---|
| Mouse use | Sustained wrist extension + grip | Vertical mouse, forearm support, frequent rest breaks |
| Carrying bags | Sustained grip load | Forearm carry, rolling bags |
| Cooking (wok) | Heavy grip + wrist flicking | Lighter pan, two-hand technique, reduce wok tossing |
| Wringing cloths | High grip force + twisting | Press instead of wring, use a towel wringer |
| Opening jars | High torque through the ECRB | Jar opener, rubber grip, open with opposite hand |
| Keyboard typing | Sustained wrist extension | Negative-tilt keyboard, wrist rest |
4. Ergonomic Assessment
For work-related tennis elbow, the OT assesses the workstation:
- Mouse position (should be close to the body, not reached forward)
- Keyboard height (elbows at 90 degrees, wrists neutral)
- Tool handle sizes (too small increases grip force)
- Repetition frequency (need rest breaks?)
5. Manual Therapy
The OT provides:
- Deep friction massage over the ECRB origin (reduces adhesions)
- Mobilisation with movement (Mulligan technique), specifically effective for tennis elbow
- Muscle release for the forearm extensors
- Neural mobilisation if radial nerve involvement is suspected
Treatment Timeline
| Week | What Happens | Expected Progress |
|---|---|---|
| 1-2 | Assessment, bracing, activity modification, begin eccentric exercise | Pain reduction with activity modification |
| 3-6 | Progressive eccentric exercise, continued bracing | 30-50% pain reduction |
| 6-10 | Increase exercise resistance, graduated return to activities | 60-80% pain reduction |
| 10-12 | Full activity reintroduction, brace weaning | 80-90% resolution |
Total sessions: 6-10 over 10-12 weeks. Cost: RM720-2,000.
When Surgery Is Needed
Surgery (tendon debridement) is reserved for cases that fail 6-12 months of consistent conservative treatment. Only 5-10% of tennis elbow cases eventually require surgery. Post-surgical OT rehabilitation takes an additional 8-12 weeks.
Frequently Asked Questions
Should I avoid all gripping activities? No, complete rest doesn’t heal the tendon. Reduce aggravating activities and use the brace during necessary gripping tasks. The eccentric exercises provide the specific loading that stimulates tendon healing.
How is tennis elbow different from golfer’s elbow? Tennis elbow (lateral epicondylitis) affects the outside of the elbow, the wrist extensors. Golfer’s elbow (medial epicondylitis) affects the inside, the wrist flexors. Both are treated with OT using similar principles but different exercise protocols.
Can tennis elbow come back after treatment? Yes, if the activities that caused it resume without modification. The OT’s activity modifications and ergonomic changes are long-term, not temporary. Maintaining the eccentric exercise programme 2-3 times per week after recovery prevents recurrence.
The Tendon Won’t Heal on Its Own. It Needs the Right Load.
Rest removes pain. Cortisone masks pain. Neither heals the tendon. Eccentric exercise rebuilds the tendon, but only when combined with activity modification that stops the ongoing damage. OT provides both.
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