What type of exercises are recommended for a patient with lateral epicondylitis?

Recommended Exercises for Lateral Epicondylitis

Eccentric strengthening exercises should be the cornerstone of your exercise prescription for lateral epicondylitis, initiated once acute symptoms settle, as they form the foundation of conservative treatment with 80% of patients recovering within 3-6 months. 1, 2

Primary Exercise Intervention: Eccentric Strengthening

Begin with eccentric wrist extensor exercises as soon as acute pain allows, as this approach has the strongest evidence for improving pain-free grip strength and reducing disability. 2, 3, 4

Specific Eccentric Exercise Protocol

• The Tyler Twist technique is the most effective eccentric exercise approach, demonstrating superior outcomes compared to other manual therapy techniques in reducing pain (from 5.8 to 2.0 on pain scales) and improving grip strength (mean 24.13 kg post-treatment). 5

• Daily home eccentric exercise regimens are effective when performed for 6 weeks, significantly increasing functional pain-free grip strength and reducing the proportion of cases suffering from lateral epicondylitis. 4

• Eccentric exercises should be incorporated as part of a multimodal therapy program rather than in isolation, as all high-quality studies showing benefit used eccentric exercise combined with other interventions. 3

Complementary Exercise Components

Stretching Exercises

• Progressive stretching exercises for wrist extensors should accompany eccentric training to optimize outcomes and promote tendon healing. 2

Strengthening Beyond Eccentrics

• Once eccentric exercises are tolerated, progress to combined concentric and eccentric strengthening to increase overall tendon strength and functional capacity. 2

Treatment Sequencing Algorithm

Follow this specific progression:

1. Acute phase (first 1-2 weeks): Relative rest, activity modification, cryotherapy for 10-minute periods, and NSAIDs for short-term pain relief only. 1, 2

2. Subacute phase (once acute symptoms settle): Initiate eccentric strengthening exercises (Tyler Twist technique preferred) combined with progressive stretching. 1, 2, 5

3. Progressive phase: Add manual joint mobilization combined with exercise therapy, as this combination is more effective than exercise alone. 2

4. Maintenance phase: Continue exercises for 3-6 months as most patients require this duration for full recovery. 1, 2

Critical Implementation Points

Activity modification to reduce repetitive wrist extension is mandatory alongside any exercise program, as exercises alone without load management will not succeed. 1, 2

Counterforce bracing (tennis elbow brace) may be used during daily activities to improve function while performing the exercise program, though evidence for bracing is limited. 2

Deep transverse friction massage can be added to reduce pain during the exercise rehabilitation period. 2

Common Pitfalls to Avoid

• Do not prescribe exercises in isolation—the evidence consistently shows multimodal approaches including eccentric exercise are superior to eccentric exercise alone. 3

• Do not rely on corticosteroid injections as a primary treatment—while more effective than NSAIDs acutely, they provide only short-term relief and do not change long-term outcomes or affect the exercise rehabilitation timeline. 2

• Avoid passive treatments without exercise—modalities like ultrasound, phonophoresis, and electrical stimulation have inconsistent effectiveness and should not replace active exercise therapy. 6