This article will focus on non-traumatic pain on the outside of the elbow, often called “tennis elbow”. Although we discuss athletes who develop pain while lifting weights, the overall approach applies to anyone with this issue.
This type of elbow pain often results from overuse and requires a combination of training adjustments and setting appropriate expectations for recovery. If you are looking for a more general guideline to our approach on managing pain, start here.
What it is
The elbow joint consists of the upper arm bone known as the humerus, and the two forearm bones: ulna and radius. It allows for flexion and extension as well as pronation and supination of the hand. The muscles that contribute to pain along the outside part of the elbow share a common tendon that originates from the lateral epicondyle of the humerus. These muscles work to extend the wrist and fingers.
Pain in this area is often diagnosed as “tennis elbow”, or lateral epicondylitis. However, most people developing this issue did not get it from playing tennis, and the ending “-itis” implies the presence of inflammation, which is not the predominant issue in this condition. The term lateral epicondylalgia is preferred in the clinical world, since “-algia” simply implies “pain” — but most people still refer to it simply as tennis elbow.
Lateral epicondylalgia causes pain along the outside of the elbow, especially when gripping or extending the wrist and fingers. It typically results from overuse of the common extensor tendon. As such, the approach will resemble our general guide to tendinopathy.
Tendon pain and loss of function/strength affect both training and activities of daily life, such as typing and getting dressed. Overuse relates to the balance of stress from training volume, load, and intensity, versus the ability to adapt and recover from those loads. We often don’t consider activities like typing as a “training stimulus”, but they still involve low-level stress that, when combined with stress in the gym, can exceed the tendon’s capacity to recover.
What to do
Since this pain often relates to an overall amount of stress that exceeds the tendon’s capacity, treatment involves adjusting how we’re stressing the area, while building it up to better handle what we want to do in training and in life. Complete rest of the area is therefore not a good idea: even though it may result in less pain in the short term, it does nothing to build the tendon’s capacity to handle a return to normal life and training demands in the future.
Overuse injuries cannot be solely addressed by adding more rehab exercises since, by definition, we are already above the capacity of what the tendon can handle. So, we must change other aspects of current training to help things calm down, so that our specific rehab exercises can then provide the desired effect.
Working “around” the issue
Among lifters, lateral epicondylalgia often results from training programs with a high volume of exercises involving a “power grip” like deadlifts, pull-ups, lat pulldowns, and heavy loaded carries, but can be triggered by pressing movements as well. If there has been a recent increase in the intensity, volume, or frequency of these exercises, we need to temporarily lower those back down to where pain is manageable. Common examples of triggers for elbow pain among lifters include:
- Intensity: training at loads closer to 1-rep max strength, or pushing closer to failure
- Volume: Adding additional pulling exercises such as lat pulldowns or rows, or the addition of multiple new sets on existing exercises
- Frequency: This often arises after adding an extra training day. An athlete going from a 3-day split to a 4-day split, or an athlete who has not been training first starting out and going from zero days a week to two or three
Some combination of these is often the culprit, requiring a temporary adjustment in the overall level of training stress back down to what is tolerable.
A simple short-term modification is the use of straps with pulling movements to help offload the area. This modification is not automatic permission to use heavier weights, but is intended to relieve the area while finding a tolerable load. Athletes can also try different grips and hand positions to change how the stress is being applied. For example, instead of using a straight bar for lat pulldowns, we can use “mag grips” or other tools to change hand positions.
If there are other exercises like back squats or bench press that don’t involve the power grip and pulling that are still problematic, similar changes can be made. For squatting, this can involve switching from a low bar squat to a high bar, safety squat, or other specialty bar. Bench presses can be modified to use a wider or narrower grip, or even a reverse grip to continue pressing in the short term. As symptoms improve, the preferable squat and bench techniques can be gradually reintroduced.
Increasing Capacity
After these initial training modifications allow the area to “calm down”, we then introduce more targeted exercises for rehab. Tendinopathies are usually managed with heavy, slow training in order to rebuild tendon strength and capacity. We can think of tendons like ropes: if you are trying to tow something with a rope, you don’t yank on the rope and then pull, but rather take the slack out and gradually increase force.
We use both tempo and intensity, but the starting point will depend on the current level of pain. The specific number of repetitions does not matter as much, so we typically begin with:
2-4 sets of 8-10 repetitions at RPE 8, using a 3-0-3 tempo (3 seconds up, 3 seconds down)
Addressing tendinopathies is rarely a pain-free process, but the pain should remain tolerable, and should generally not involve severe flare-ups during or after training. Our general guideline for specific rehab exercises is to not exceed 4/10 pain during sessions. On day 1 you can assess the starting weight that works best for you, and progress as tolerated.
We recommend starting with the following exercises to find your entry point:
Eccentric wrist extension
(insert video of using unaffected side to assist with wrist extension)
Wrist extension to neutral
Wrist extension through full range of motion
The priority involves using sufficiently heavy weights, and moving sufficiently slowly to target the area. Perform these exercises 2-3 times a week at the start of the workout. This allows you to focus on the area that needs the most attention, but also serves as a warm up that can improve tolerance later in the workout. If you find that these exercises significantly flare up pain, the initial weight might be heavier than the area is ready to handle.
Other “rehab” exercises
While wrist extensions serve as the core exercise for lateral elbow pain, training other functions like supination, pronation, and gripping can also help rebuild strength.
Pronation and supination are typically done using a weighted instrument like a hammer and the athlete begins by holding the object in the middle of the handle and rotating their forearm through the full range of motion. As this becomes easier, the athlete can choke down on the handle to increase the challenge of the movement.
Wrist flexion exercises using dumbbells can also be helpful to increase the overall capacity of the forearm for movement. Athletes can also use grip trainers with a challenging, but tolerable resistance. For each of these, 2 days per week using 2-3 sets of 10 repetitions at RPE 8 is often sufficient.
(insert pic of captains of crush)
Finally, loaded carries using different grips can further increase capacity outside of the barbell-based power grip. Specific sets, reps, and RPE matter less than simply using a variety of challenges. We often start with what is most accessible in the gym. For example:
- If the gym has hex dumbbells, a farmer’s carry holding the dumbbells on the end caps
- If there are bumper plates, using a “pinch grip” to hold the plates and walk
- Hold a kettlebell from the bell portion upside down.
What matters most is having multiple variations than any one specific variation.
Putting it together into a program
There isn’t an absolute “right” program for every athlete, as symptoms are often unique to how the athlete is training leading to overuse and under-recovery. However, there are basic principles that can improve the odds of success. When structuring a program for the typical barbell athlete, it often looks like this:
1. Most tolerable heavy slow wrist extension exercise
2-4 sets of 8-10 reps at RPE 8, using 3-0-3 tempo
Progressing weight and range of motion as tolerated
2. Most tolerable squat movement
As prescribed in the current program using a grip or apparatus that minimizes symptoms
3. Most tolerable pressing movement
As prescribed in the current program using a grip or apparatus that minimizes symptoms
4. Hinge or pulling exercise
Using straps or a different grip/apparatus as needed
The athlete may need to adjust weight or tempo in order to minimize pain when directly training the area. In general, pain should not exceed 4/10 severity during the session or for about 24 hours afterwards.
5. Accessory forearm exercise
Choose from the list above for pronation/supination, wrist flexion, or loaded carries with a different grip. For the first two exercises, use a full range of motion, slow and controlled approach to the exercise for 2-3 sets of 8-10 at RPE 8. For loaded carries, find the most tolerable grip and play with carries.
On speed and intent of movement
While we’ve focused on powerlifting-style athletes, another factor that can contribute to pain is the speed and intent of movement. This often happens if an athlete introduces movements like kipping pull-ups or clean pulls into their program, or dramatically increases the volume of an exercise with higher speed. We use a similar approach here, but also need to control and gradually reintroduce speed as pain improves. While we have emphasized the “heavy, slow” aspect of rehab, but if an athlete is trying to move fast again, we also need to include this in their training.
A movement should involve little to no pain at a slower, controlled pace before reintroducing speed and explosiveness. If an athlete can perform pull-ups or deadlifts with a normal tempo, we can start introducing faster movements at lighter loads. As lateral epicondylalgia is an overuse issue, we can also occasionally test where the upper limit for tolerance exists.
For example, if an athlete is starting to experience symptoms with clean pulls at 70% of the weight they were using prior to starting rehab, that can serve as the ceiling in the short term. Training volume can be programmed at a weight (accounting for sets and reps) below that threshold to get some reintroduction to the intent of movement again without exacerbating symptoms. After some exposure at a lower level, we can test again and find a new ceiling for what is tolerable.
Setting Expectations
Tendinopathy typically involves overuse and decreased tendon capacity. The goal of rehabilitation and training is to adjust the amount of stress and allow for adaptation. During typical progression, symptoms do not suddenly disappear, but rather the amount of weight that triggers pain gradually increases over time. Our goal is to reach a point where the capacity of your elbow to handle load is well beyond the demands of your training. It is often helpful to track the loads and volumes that bring on symptoms to monitor progression. If at first you experience pain with 225 lbs on a deadlift, increasing that threshold to 315 lbs before you experience pain, this represents a significant improvement.
You may also find that all exercises do not progress at the same rate. It may be that lat pulldowns start feeling better before deadlifts. Each exercise should be progressed based on its individual tolerance. However, it is worth addressing how often the limits should be tested. If pain starts improving, but each session you are increasing the weight until you feel pain, you are likely pushing too hard. The goal should be to leave training sessions with your elbow feeling better, not maximizing the workout at the expense of lingering pain. As your elbow improves, you can gradually return to true “effort-based” training. If you experience pain greater than 4/10 during or 24 hours after a session for two sessions in a row, then the volume on the primary lifts needs to be decreased.
It is also advantageous to keep the heavy slow training in for at least a month after pain has subsided. Instead of starting the workout with those exercises, they can be performed as accessory movements on other days, or at the end of the workouts. This allows for some continued, specific exposure while the rest of training transitions back to “normal”.
There is no specific timeline for resolution of pain, and it will depend on the current overall volume of training, the severity of pain, and how often workouts are pushed enough to bring on pain. Tendinopathies do require patience in their approach and you will be much better allowing things to calm down and building specific capacity in the area, rather than seeking the limit of how much you can tolerate during each individual session.
Passive treatments and interventions
Unfortunately, there is no good evidence for passive treatments like icing, scraping, or using braces and elbow supports in managing this issue. The primary treatment strategy is load management and increasing capacity.
However, if you find relief from any of these strategies, it is okay to use them as long as that is not all you are doing. Stretching also falls into this category. We do not advocate for stretching as a necessary part of the program, but if you find relief from stretching, you can certainly include it as part of your training.
Other treatments like surgery do not appear more effective than basic conservative care. The same can be said for corticosteroid injections and platelet rich plasma (PRP). Unlike the above passive treatments, these invasive treatments add additional risk, and generally do not recommend their use.
If you are struggling with this issue, our pain and rehabilitation team is available to consult with you and design an individual program for your needs.
