Tennis Elbow Physio Brisbane | Elbow Pain Rehab

Elbow Pain Rehabilitation

Elbow pain is surprisingly common affecting around 1-3% of the Australian population every year. The most common presentation of elbow pain is tennis elbow and golfers elbow is probably a distant second. Most presentations that I see as a physiotherapist tend to fit more within the overuse category. Of course, there are still acute injuries like fractures, tendon avulsion injuries, muscle strains or ruptures, but these appear to be far less common than overuse-style injuries at the elbow.

Unsurprisingly, elbow pain can cause a lot of functional deficits in everyday life. From simple things like opening a door, picking up some plates, opening a jar, and even typing on a computer or driving. Fractures often give us mobility deficits after coming out of casting if needed, tennis elbow stops us from gripping, and our hands do so much that we need our elbow to be working well to make it all happen.

Optimising the strength of the shoulder, elbow, wrist, hand and fingers is all necessary to ensure optimal recovery from an episode of elbow pain whether it be an overuse injury or an acute injury.

Physiotherapist treating the muscles of a client's forearm

Anatomy of the elbow

The elbow joint is a synovial joint that connects the humerus (upper arm bone) to the radius and ulna (forearm bones). It is a hinge joint, which means that it allows for movement in one plane, which is flexion and extension.

The elbow joint is formed by the following bones:

Humerus: The humerus is the bone in the upper arm.
Radius: The radius is the bone on the thumb side of the forearm.
Ulna: The ulna is the bone on the pinky finger side of the forearm.
The articulating surfaces of the elbow joint are covered with hyaline cartilage, which helps to reduce friction and wear and tear on the joints. The joint capsule is a thin layer of tissue that surrounds the joint and helps to keep it in place. The elbow joint is also innervated by nerves from the radial nerve and the ulnar nerve.

Diagram of elbow arthritis showing bone spurs, cartilage loss and a narrowed joint space

The muscles supporting the elbow joint are divided into two groups:

Flexors: These muscles bend the elbow. They include the biceps brachii, the brachialis, and the brachioradialis muscles.
Extensors: These muscles straighten the elbow. They include the triceps brachii muscle.

The biceps brachii muscle is the most superficial muscle in the front of the upper arm. It has two heads, the long head and the short head. The long head originates from the supraglenoid tubercle of the scapula, and the short head originates from the coracoid process of the scapula. The two heads of the biceps brachii muscle join to form a single tendon that inserts into the radial tuberosity of the radius.

The brachialis muscle is located deep to the biceps brachii muscle. It originates from the anterior surface of the humerus and inserts into the coronoid process of the ulna.

The brachioradialis muscle is located on the lateral side of the forearm. It originates from the lateral supracondylar ridge of the humerus and inserts into the styloid process of the radius.

The triceps brachii muscle is the largest muscle in the back of the upper arm. It has three heads, the long head, the lateral head, and the medial head. The long head originates from the infraglenoid tubercle of the scapula, the lateral head originates from the lateral epicondyle of the humerus, and the medial head originates from the posterior surface of the humerus. The three heads of the triceps brachii muscle join to form a single tendon that inserts into the olecranon process of the ulna.

The muscles of the elbow joint are innervated by the radial nerve and the ulnar nerve.

The muscles of the elbow joint are important for flexing and extending the elbow. They are also important for rotating the forearm.

Diagram of the muscles of the upper arm and forearm

The elbow joint is stabilized by a number of ligaments, including:

Radial collateral ligament (RCL): This ligament runs from the humerus to the radius. It prevents the elbow from hyperextending (bending too far back).

Lateral view of elbow joint ligaments
Ulnar collateral ligament (UCL): This ligament runs from the humerus to the ulna. It prevents the elbow from valgus (bending towards the pinky finger side).

Lateral view of elbow joint ligaments
Anterior capsule: This ligament runs along the front of the elbow joint. It helps to stabilize the joint.

Anterior view of elbow joint ligaments
Posterior capsule: This ligament runs along the back of the elbow joint. It helps to stabilize the joint.

Posterior view of elbow joint ligaments
Medial collateral ligament: This ligament is located on the inside of the elbow joint and helps to prevent valgus instability.
Lateral collateral ligament: This ligament is located on the outside of the elbow joint and helps to prevent varus instability.
The ulnar collateral ligament (UCL) is the most important ligament in the elbow joint. It is responsible for preventing valgus instability, which is when the elbow bends towards the pinky finger side. The UCL is also the most commonly injured ligament in the elbow joint.

The radial collateral ligament (RCL) is also important for stabilizing the elbow joint. It prevents the elbow from hyperextending (bending too far back).

The anterior and posterior capsules are the weakest ligaments in the elbow joint. They help to stabilize the joint, but they are not as strong as the UCL or RCL.

The medial and lateral collateral ligaments are located on the inside and outside of the elbow joint, respectively. They help to prevent varus and valgus instability, which is when the elbow bends towards the thumb side or pinky finger side, respectively.

The ligaments of the elbow joint are important for stabilizing the joint and preventing injuries. If the ligaments are injured, it can cause pain, swelling, and instability in the elbow joint. In some cases, surgery may be necessary to repair the injured ligaments.

Diagram of the ligaments on the outside and inside of the elbow

Elbow Pain Subjective Assessment

Elbow pain can present with a range of different presentations, ranging from acute injuries such as a fall onto the arm, to gradual onset presentations such as tennis elbow. Differential diagnosis between these presentations and other causes, such as nerve pain, means a thorough subjective assessment is crucial.

What Happened?

The first step in a subjective assessment is always understanding what has happened and how the pain began. Whether it be a gradual onset type of injury or if there was a mechanism of injury, any detail that you can recall in the lead up to the symptom onset is important in helping me diagnose and develop a treatment pathway for your recovery. Some common mechanisms for elbow pain could include falling onto an outstretched hand, a significant increase in computer usage, a DIY home project on the weekend using power tools or a hammer. There can be an array of potential causative factors for elbow pain, determining yours helps get the pathway straight from the start.

What did you feel?

The type of symptoms that you feel are a very important discussion point for elbow pain. There can be an array of potential tissues that can cause symptoms at the elbow. The lucky part is that often they all create very different sensations. Nerve pain differs vastly from joint pain, and an acute muscle strain is often different from pain originating from tendon. Determining how the pain behaves and the sensations that you feel can help me differentially diagnose your presentation.

Any Strange Sensations?

Some elbow issues can create some strange sensations, some clients report sensations of electric shocks, sharp shooting sensations down their forearm, and pins and needles, tingling, or sensations of numbness. These could show neural system involvement. Whether it is coming from higher up the pathway at the neck, or further down within the upper arm or at the elbow. Determining the point at which this restriction is occurring will happen during our objective assessment, but these sensations are important to disclose.

Your History

The biggest predictor for pain at the elbow is having had a previous history of elbow pain. A history of injuries is one question I always ask. Another key component of your history is your sporting and work history. Both, in particular, work history, might lead me further down one pathway, such as tennis elbow, for example. A client who has had a manual labour job such as a mechanic, windscreen installer, painter, these types of manual labour jobs often require consistently high levels of force production through the common extensor tendon group.

Elbow Pain Objective Assessment

A physiotherapist's objective assessment of elbow pain needs to be concise, targeted, and expertly implemented. The range of potential diagnoses of elbow pain means I need to do an expert job to determine if the cause of your symptoms is muscular, tendon based, neural, or joint based.

Isometric Muscle Tests

Isometric assessments are designed to specifically isolate a muscle and tendon complex, and I must perform these with no joint movement. By isolating a muscle contraction without movement, I can determine that if you develop symptoms during this test, the cause of your symptoms is likely to be muscular or tendon based. The most common muscles that I assess via isometric assessments include the wrist extensors, wrist flexors, biceps, and triceps. In specific circumstances, we may need to perform an isometric assessment of the forearm supinators and pronators, but this is an uncommon area to injure.

Neural System

Neurodynamic assessments are specifically designed to assess specific nerve pathways through the limbs. In the upper limb, there are three main pathways to assess: the radial nerve, ulnar nerve, and median nerve. All three pathways often present with a specific set of symptoms within specific regions. The radial nerve feeds to the area of the forearm running down towards the thumb and first finger, the ulna nerve feeds into the little finger side of the forearm and hand, specifically the fourth and fifth fingers, and the median nerve feeds the middle of the forearm and the second and third fingers. Through these particular assessments, I can determine if there is a restriction to neural mobility, as well as determine whether an issue causes the restriction at the cervical spine, shoulder, upper arm, elbow, or forearm.

Palpation

Palpation is a key skill that all physiotherapists must develop. There is often no replacement for experience here. Knowledge of anatomical landmarks such as tendon origin points, nerve pathways, and being able to identify muscle bellies of specific muscles is necessary. Often, palpation will include assessing for muscle tone and tenderness to touch, presence of tenderness to touch on a tendon origin point, when part of a clinical picture can be highly beneficial in determining the diagnosis of tennis elbow or golfers elbow.

Ruling Out Other Diagnoses

As with every other part of the body, the common diagnoses aren’t the ones we always need to be looking for. Knowledge of less common presentations is always necessary, so having my radar on for odd things that don’t fit common clinical pictures is necessary. These odd presentations often require more specialised and specific assessments, or sometimes referral to a GP for imaging such as an x-ray, MRI, or ultrasound.

Steps to Success for Recovering from Elbow Pain

Hands On and Adjunct Treatments

Treating elbow pain can be a little challenging at times. Often I like to work off of the basis of treating one thing on the initial consultation, particularly if we are managing an overuse injury. Whether I choose to treat the cervical spine because I think there is a nerve component to it, or I choose to treat the wrist extensors and maybe some joint mobilisations to treat the elbow directly, more often than not I choose to treat just one to avoid things getting too complex on a follow-up. Like if you get worse, which one made you worse, and if you get better, how do I know where to put the most time of treatment into to get our best effect?

Most commonly when looking at cases of overuse injuries I’m usually performing work on the muscles surrounding the elbow joint and doing mobilisations to optimise the movement and reduce stiffness at the elbow. Soft tissue techniques like massage and dry needling can be highly effective at reducing pain and improving freedom of movement to allow you to maximise the effects of an exercise program. Joint mobilisations are often my go-to for clients who have a movement restriction such as a restriction in turning the palm upwards. I can perform isolated mobilisations or a technique such as mobilisation with movement. This is a technique that performs a joint mobilisation as you move into the range of motion that is restricted and this is then repeated and reassessed to determine whether we had a lasting improvement.

Adjunct treatments like dry needling and taping can work wonders in these cases. In fact, when I had a small case of tennis elbow two years ago, dry needling was a bit of a saviour for me. Dry needling works well at reducing muscle tone in the short term, and it can work within a few minutes and will often be less irritable than what some hands-on techniques can be. Taping is the other adjunct I commonly use. Whether it be taping to improve joint positioning, or taping to unload a muscle in a tennis elbow case, there can often be effective and lasting results from a good taping job.

Physiotherapist assessing a client's forearm and elbow

Elbow Pain Exercises

As with every other body part, exercise is the most important intervention and has shown the best long-term benefit for both symptom reduction and prevention of recurrence. For most elbow pain presentations, we will undertake a program for specific elbow strengthening coupled with strengthening of more proximal body parts, often including the shoulder. Specific strengthening of the elbow will be highly dependent upon the injury you have sustained. In cases of tennis elbow you will undertake a program highly targeted to strengthen the wrist extensors, and golfers elbow clients will do a program targeted to the wrist flexors. It’s important that we don’t forget higher up the chain, particularly for those clients with manual handling jobs. If we can optimise the function of the arm, as well as the forearm, we can optimise your movement strategies, reduce your overall risk of sustaining an injury, and improve function significantly.

Your Questions About Elbow Pain

What causes tennis elbow?

Tennis elbow, or lateral elbow tendinopathy, happens when the tendons that attach to the outside of the elbow are overloaded. These tendons control your wrist and fingers, so repeated gripping, lifting with the palm facing down, typing and using tools all load them. Despite the name, most people with tennis elbow do not play tennis. It is most common between ages 35 and 55 and often follows a change in activity, like a big weekend of gardening, a renovation project or a new job.

What is the difference between tennis elbow and golfer's elbow?

The difference is the side of the elbow. Tennis elbow affects the tendons on the outside of the elbow, which extend your wrist and fingers. Golfer's elbow affects the tendons on the inside of the elbow, which bend your wrist and fingers and turn your palm down. Tennis elbow is much more common. Both are overload problems of the tendon, and both are managed with load management and a progressive strengthening program, with the exercises targeting the affected side.

Do I need a scan for elbow pain?

Usually not. Tennis and golfer's elbow are diagnosed from your history and a clinical assessment, and scans rarely change the treatment plan. Imaging is more useful if your pain started with a fall or a significant injury, if there is swelling in the joint or loss of movement, if nerve symptoms like pins and needles are present, or if you are not improving with rehab. If I think a scan would help, I will write to your GP to organise it.

Will a cortisone injection help tennis elbow?

A cortisone injection can reduce pain in the short term, but research shows that for tennis elbow, people who have an injection tend to do worse after a year than those who have physio or simply wait, with a higher chance of the pain returning. For that reason, it is not usually recommended as a first option. Exercise-based rehab and load management give better long-term results. If you are considering an injection, it is worth discussing the pros and cons with your GP.

What exercises help tennis elbow?

Strengthening the tendon is the key. Early on, holding exercises, like gently lifting your wrist against resistance and holding for 30 to 45 seconds, can ease pain. We then progress to slow lifting and lowering exercises with a dumbbell or band, grip strengthening and exercises for the shoulder and upper back, which help share the load. Progress is gradual over 8 to 12 weeks, because tendons adapt slowly. Some discomfort is fine, but pain should settle quickly and not be worse the next morning.

Making everyday life easier

Life can get a little frustrating when you have an episode of elbow pain, suddenly you realise just how integral your elbow is. Just like when you realise how great it is not to have a stuffy nose when you get a cold it’s amazing how great life can be when it starts to get better. So how can we get some quick wins on the board for elbow pain? Probably the best avenue is taping or bracing in my experience. For cases of tennis elbow – you can buy a tennis elbow brace either at the chemist or through me or basically any other physio and it should have a significant effect. Otherwise, there is a multitude of ways that you can strap a tennis elbow case to improve symptoms and functions, some tapings try to affect joint alignment and position, others will work to just simply deload the wrist extensors, whilst some cases could be driven higher up by the shoulder or cervical spine could respond really well to a shoulder taping. Other presentations can also respond well to taping, often with elbow joint-based presentations responding well to medial or lateral glide taping techniques.

Dry needling is the other technique I find is a really nice quick win for these cases, particularly in cases of tennis elbow or golfers elbow. Nobody is quite too certain what the true effects of dry needling are with a lot of different researchers proposing different hypotheses, but sometimes it just works, and if it works why stop?

Elbow Pain FAQs

Tennis elbow can be slow to settle. Without treatment it often lasts 6 to 12 months or longer. With a targeted strengthening program, most people improve a lot within 6 to 12 weeks.

A tennis elbow brace, a strap worn just below the elbow, reduces pain during gripping and lifting for many people. You can buy one from a chemist or from me. It is a useful short-term tool, but it does not fix the tendon on its own, which is why strengthening is still needed.

In most cases, yes, with some changes. Reducing heavy or repetitive gripping, adjusting your grip or technique, and spreading tasks out through the day all help while we build strength in the forearm muscles.

Each consultation is 45 minutes and costs $110, for both your first appointment and follow-ups. Dry needling, taping and exercise bands are included at no extra cost. If you need a longer course of rehab, my 3, 6 and 12 week rehabilitation programs work out cheaper than paying per session.

Yes. You can claim a rebate from your health fund for every session. PRP Physio is not a preferred provider for any fund, so your rebate may be slightly smaller than at a preferred provider. Your fund can confirm the exact amount using item code 500 for your first consultation and 505 for follow-ups.

Yes, if your elbow pain was caused by your work, such as repetitive gripping, tool use or lifting. Your GP starts the claim and gives you a WorkCover certificate, which acts as your referral. Once your claim is accepted, I bill WorkCover directly, so there are no out-of-pocket costs for you. WorkCover covers your first five sessions, and I speak with your case manager if you need more.

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Elbow Pain & Tennis Elbow Physiotherapy