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Building Lateral Elbow Resiliency


I'm currently self-managing "tennis elbow" on my left arm so I figured this would be a great time to put together a post on training through lateral epicondylar pain and building resiliency! As mentioned in previous posts, even if you do everything PERFECT from a technique, programming, nutrition and recovery perspective, some sort of injury or pain during training is unavoidable if you are competitive or pushing yourself. In the statistically likely scenario that I, or one of my athletes, encounters lateral elbow pain along their strength journey, I am documenting the culmination of knowledge I have acquired so far in conquering tennis elbow as a roadmap to navigate any future episodes.


I recently started experiencing soreness to the touch on my left lateral elbow. There was no acute event in my training that I'm aware of that caused it. Earlier this year I successfully self managed through lateral elbow pain on my right arm and it has not been bothering me since for several months now (knock on wood).


Disclaimer: I am not a medical professional or physical therapist, and I might not be YOUR coach or know YOUR specific circumstances. The following information is provided to give you broad concepts that you can hopefully apply to your specific situation.


LATERAL EPICONDYLAR WHAT NOW?


Lateral Epicondylitis Is A Misnomer!

Pain in the lateral region of the elbow has been called everything from "elbow tendonitis to "lateral epicondylitis." The terms "epicondylitis" and "tendonitis" have the suffix -itis which suggests that the cause of pain is due to inflammation of the tendons that join the forearm muscles on the outside of the elbow (1). However, research does not support this claim, so the terms " lateral epicondylar pain" or "lateral elbow tendinopathy" have been proposed instead for pain in this region. To keep things simple, we will refer to pain in the lateral epicondyle of the humerus simply as... tennis elbow :)


Attribution: Henry Vandyke Carter, Public domain, via Wikimedia Commons


So What If It Is A Misnomer?

The name of a condition is also indicative of the treatment. Typical treatments for inflammation include rest, ice, and the use of non-steroidal anti-inflammatory drugs (NSAIDs). While these can certainly provide short-term relief, the use of rest, ice, and NSAIDs alone are not enough if you want to create a more resilient elbow that can endure whatever life or your particular training activity has to throw at it. To create resiliency in the elbow for the long-term we'll need to:

  1. Create healthy shoulder and wrist joints

  2. Create strong supporting musculature around the scapula, wrist, and forearms

  3. Manage movements, exercises, and loads used during training

  4. Modify applicable lifestyle factors

SELF-MANAGEMENT


Tennis Players

Half of tennis players, competitive or not, will likely experience some sort of lateral elbow pain over the course of their careers. Management of lateral elbow pain can be accomplished through the use of double-handed grips or use of racquets specifically designed to be "arm-friendly" (3).


Manual Laborers

If you perform repetitive tasks involving hands, wrists, or elbows as part of your daily life or occupation there are multiple options (2):

  • Take frequent breaks from activities that require extensive hand/wrist motions.

  • Reduce or avoid lifting objects with the arm extended.

  • Reduce repetitive gripping and grasping with the hand and wrist.

  • Decrease the overall tension of gripping.

  • Avoid the extremes of bending and full extension.

  • When using tools, increase the gripping surface by wearing gloves or adding padding. Use a hammer with extra padding to reduce tension and impact. Hold heavy tools with two hands.

Gym Goers or Strength Athletes

Many lifters who experience lateral elbow pain develop symptoms as a result of the grip used on pulling exercises like deadlifts, pull-ups, or barbell rows. Using alternate grips or straps can help reduce the symptoms temporarily. Other lifters experience pain from pressing motions like the bench press which also challenge the wrists, forearms, elbows, and shoulders. This is further compounded when the person also trains a low-bar squat and deadlift in addition to bench pressing. If the person is interested in developing strength in the BIG 3 movements, avoiding tennis elbow altogether may not be possible but it can be managed through adjustments in technique, loading, and overall programming.


EXERCISES FOR RESILIENCY


If you are reading this post you are likely not interested in just managing the pain, but also conquering it and developing a more resilient kinetic chain between the wrists and shoulders to avoid pain in the future. The following are the exercises I have been using for increasing work capacity of the lateral elbow tissues along with improving the entire kinetic chain that affects those tissues. These can be done during the onset of tennis elbow symptoms or pre-emptively to minimize risk.

  1. Wrist Extensions

  2. Wrist Supinations

  3. External Rotations

  4. Lateral Raises

Use these to help strengthen the shoulder, scapulae, wrist, and forearms to improve function and reduce pain. All of these movement should be performed in a slow and controlled manner. A demonstration of each exercise is provided below, except for lateral raises. Everybody knows what lateral raises are, right?


Wrist Extensions




Wrist Supinations



External Rotations



Lateral Raises



Additional exercises that I have not personally used in my training but help build the rotator cuffs include:

  1. Prone Angels, Prone External Rotations, Prone T's, and Prone Y's

  2. Empty Cans, Full Cans


IMPLEMENTATION

Each of the exercises above can be performed for 3 to 4 sets of 6 to 12 repetitions at RPE 7 to 9. Do this for 2 to 4 weeks depending on how your symptoms improve. Focus on progressively loading each movement by either slowing down tempo or increasing external load. Perform each of the 4 exercises 3 to 4 times per week with 2 to 3 minutes of rest between each set.


Depending on the severity of your symptoms you may need to use regressed versions of the above exercises based on pain. Below are two regressions that can be executed depending on the severity of your symptoms. If you cannot perform 6 repetitions of the above exercises with a 2.5 pound dumbbell or red resistance band without pain below a 4 out of 10, then execute Regression 1 for 2 to 4 weeks followed by Regression 2.


Regression 1 - Isometrics

Each of the exercises above can be performed as an isometric for 3 to 4 sets for 30-45 seconds at RPE 7 to 9. Do this for 2 to 4 weeks depending on how your symptoms improve. Focus on progressively loading each movement by first increasing time under tension up to 45 seconds before increasing external load. Perform each of the 4 exercises 3 to 4 times per week with 2 to 3 minutes of rest between each set. Substitute lateral raises with one of the "prone" or "can" exercises in subsequent training blocks.


Regression 2 - Eccentrics

Each of the exercises above can be performed as a loaded 3-second eccentric for 3 to 4 sets of 6 to 12 repetitions at RPE 7 to 9. Do this for 2 to 4 weeks depending on how your symptoms improve. Focus on progressively loading each movement by first increasing time under tension up to 3 seconds before increasing external load. Perform each of the 4 exercises 3 to 4 times per week. Substitute lateral raises with one of the "prone" or "can "exercises in subsequent training blocks.


If after 4 to 8 weeks of executing the above regressions you still have lateral elbow pain symptoms, proceed with executing the full movements at the reps, sets, and RPE, described in the beginning of "IMPLEMENTATION." If you cannot execute the full 6 repetitions with a 2.5 pound dumbbell, go back to Regression 1.


MONITORING PROGRESS

Keep a log or journal and track if there is a reduction in pain, frequency of pain, or duration of pain. If you find improvement in any of these areas, then you should be reassured that you are moving in the right direction and should continue progressing these exercises.


Reduction in Pain

If on the onset of pain you are experiencing 6 out of 10 pain during certain activities and it decreases to 4 or less, that is a sign your symptoms are improving.


Frequency of Pain

All other things being equal, if the quantity of pain experiences notably decreases during the activities that cause it, that is a positive outcome and sign that you should continue progressing the resiliency plan.


Duration of Pain

All other things being equal, if pain that would last say 30 seconds decreases to 15 seconds, that is another positive sign that you should continue developing elbow resiliency!


If you find yourself able to eliminate the pain all-together, congratulations! Keep executing the exercises 2 to 3 times per week in a progressive manner to prevent future episodes of tennis elbow.


If you find yourself unable to escape the pain and it is consistently above 4 or 5 out of 10 pain, then consider seeking guidance from a medical professional or physical therapist.


THANK YOU!

Tennis elbow can be anything from a moderate annoyance to very debilitating. My hope is that this post helps you navigate through your lateral epicondylar pain in a logical and proactive manner. If you found this post helpful, be sure to like, share or comment below!


REFERENCES

  1. https://en.wikipedia.org/wiki/Lateral_epicondyle_of_the_humerus

  2. https://www.uptodate.com/contents/elbow-tendinopathy-tennis-and-golf-elbow-beyond-the-basics

  3. https://supertennisracquet.com/best-tennis-racquets-for-tennis-elbow/\

  4. https://e3rehab.com/blog/rotatorcuff/

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