Physical Therapy for Tennis Elbow

4 Reasons Your Physical Therapy For Tennis Elbow Isn’t Working

Let’s not sugar-coat this, physical therapy for tennis elbow can be annoying. What’s more annoying is that the name of this injury is misleading. You don’t have to be Roger Federer to be at risk of developing it. Tennis elbow can affect anyone who uses their hands repeatedly for work. If you’ve had it before, you’ll know about the pain on the outside of your affected elbow. It’s deep, sometimes sharp and is accompanied by a painful weakness in your wrist’s ability to extend (the movement you’d imagine needing to rev up a motorcycle handle). 

But I’ll refrain from details about the treatment plan, something that’s been done a million times already. Instead let’s focus on something important that’s not talked about enough. Here are the top 4 reasons why your physical therapy for tennis elbow isn’t working and how to fix it. 


The physiotherapist is excited about the progress you’ve made. Your elbow improves after each session which builds up your confidence. They recommend you continue actively resting it since the elbow’s still healing, but you’re feeling good. Next thing you know, you’re working or playing your sport at 100% intensity. Initially it feels good but you notice it starts to get sore again. Now each time you work or play, it takes less and less time to get sore… Uh oh. 

Let’s be clear – I understand it’s tough to avoid work activities. A lot of hard-earned incomes rely on the use of one’s hands. Tradesmen, desk workers, tool operators, and musicians can all attest to this. But if that’s not the case for you, or if you can modify your work to offload your elbow a bit longer, then it’s advisable to do just that. Physical therapy for tennis elbow requires time, and one of the things that delay recovery is reaggravation. 

Tennis Elbow Physiotherapy Metrics

The Fix: Metrics

When doing physical therapy for tennis elbow, y’all need to decide on some ground rules. We typically create a rating system for allowable pain during rehab. This system uses three metrics:

First is the sheer amount of pain that’s allowable. On a scale of zero to ten (zero being no pain, ten being the most pain imaginable), I generally allow no more than 2/10 pain with any given activity. Anything that exceeds this mark should alarm the client to ease up or refrain from the aggravating activity. 

Second is the subjective nature of the pain. Do certain activities cause pain that feels like a dull ache or burning sensation? Or, is the pain more sharp, intense, or throbbing in nature? You can typically get away with the former type of pain. However, sharp, intense, and/or throbbing pain is a sign that you might be pushing it. These are pains that indicate a higher chance of harm occurring (pain with damage being caused) versus hurt (pain without causing damage). We always want to stay in the range of pain that is more “hurt” than “harm”.

Third is how long the pain lasts afterwards once the activity has stopped. If the pain lasts no more than 5 minutes, that’s typically a good sign. Avoid activities (if possible) that cause pain lasting into the 30-minute and above range. This is a sign you aggravated symptoms enough to cause more inflammation in the elbow. Increased inflammation during tissue healing can delay the recovery process. If you’re able to stick to the above ground rules, you’ll help speed the recovery of your elbow.

Reason #2 - Stopping tennis elbow physiotherapy once pain is gone

The healing process continues even in the absence of pain. That’s one thing that’s hard to digest for people. If you work on rehabbing your elbow to the point of no pain, the journey shouldn’t end there. Pain is simply a signal. The absence of it is actually a poor indicator that things have fully healed. Instead, it should be used as an opportunity to build on your tennis elbow physiotherapy protocol. 

As your elbow continues healing, a lot of things are happening. Tissue is repairing and aligning back to normal. The amount and the quality of elbow movement are slowly increasing. Tolerance to forces and loads on the elbow continue needing to improve. The tricky part is that all of the above mentioned phases can all happen in the absence of pain. 

Physio for Tennis Elbow Protocol

The Fix: Finish The Protocol

Once pain is resolved, pat yourself on the back. It’s a big step in the right direction. Now it’s time to focus on restoring full function in the elbow. At the same time, it’s imperative to prevent an injury like this from happening again. The fact that you injured it in the first place puts you at a higher risk of injuring again. 

The physical therapy for tennis elbow will become a bit more aggressive now. You’ll need to start getting rid of any lingering restrictions in motion with more intense stretches. Strengthening should be scaled up to involve movements you need at work. Eventually you should feel like your elbow is stronger than when you first came into the clinic (or if you did physiotherapy at home). Movements you’ll need to make sure are strengthened include wrist flexion, wrist extension, grip strength, and combined movements.

Reason #3 - Not using your tennis elbow brace or using it too often

We sometimes prescribe and fit our clients with braces to supplement their tennis elbow physiotherapy. These braces are useful in offloading stress from the painful muscles. The problem is when the brace either isn’t used enough, or is used far too often. Another issue is proper placement of the brace. 

The Fix:

It’s pretty straightforward. The brace needs to be fitted and placed on the elbow the right way. The bulkiest end needs to sit on the outside of your elbow (see diagram above). The fit should be snug and comfortable. This can be verified by quickly checking if you can slide your index finger underneath the brace without too much difficulty. You definitely shouldn’t feel like your circulation is being restricted. 

Wear it only as needed. This means any time you’re doing activities that bother your elbow, you should use the brace. Otherwise, the brace should be off. If you’re sleeping, relaxing, or not really using your hands, there’s no need for it. This is because you don’t want to get accustomed to artificial support. Overdoing it with the brace also runs the risk of leading to muscle weakness around the elbow. That’s a big no no. 

Reason #4 - Not modifying the environment that initially caused pain

Ergonomics Setup to Prevent Elbow Pain

One of the most common causes of tennis elbow apart from arm weakness is the work or living environment. Desk workers typically have this problem. Computer desks that put undue stress on your arms make pain almost inevitable with prolonged keyboard use. You’d be surprised how many things can be adjusted on a desk to decrease stress on your body. These include screen height, arm and leg position, keyboard height and position, light sources and angles, desk/chair models, and more. 

The Fix:

You must fix the environment. Level the top of your computer screen with your eyes. Using a laptop? Elevate it on a book and get a separate keyboard. Using one screen? Make sure it’s dead center and not off to the side. If you’re using two screens, divide your time evenly between them. Any glare on your computer screen? Try changing the angle of your workstation to prevent the glare. 

Your wrists should be straight when typing. Shoulders should be relaxed, not hiked. Elbows, hips, knees, and ankles should all be bent at 90 degrees. Feet should be resting comfortably beneath you on the floor. You should also avoid poking your head forward. Choose chairs that offer ample low back support and armrests for your forearms. 

Yes, tennis elbow physiotherapy is no joke.

Physical Therapy for Tennis Elbow Summary

Fixing common mistakes made while you’re doing physical therapy for tennis elbow can make a huge difference. It can speed recovery times, prevent further injuries, and make you stronger than you were before. Here’s the best part: you can also empower others to do the same! More likely than not, you’ll work with someone who has a similar role and hence, similar work environment to you. Once you’ve unlocked the code on physio for tennis elbow, use it to teach others. After all, one of my favourite goals for clients is making them effective ambassadors of their own health!