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What do you do for patients with chronic tennis elbow? Most evidence-based chiropractors have a multimodal recipe that includes manipulation, manual therapy, anti-inflammatory modalities, and stretching.  Today’s blog will describe 5 proven ingredients to help improve your clinical recipe for this stubborn diagnosis.

Watch Dr. Steele will cover the five must do’s for Tennis Elbow.

The first and most critical step in managing chronic tendon problems is to decide if this is a real “itis” (acute), or an “opathy” (chronic). Refer to THIS past blog on making the differentiation between the two. Let’s review the research behind the latest recommendations for lateral epicondylopathy.

Eccentric Exercises

Eccentric strengthening is thought to stimulate collagen metabolism and synthesis in the rehabilitation of tendinopathies. Wrist eccentric control exercises can be useful for relief from pain due to lateral epicondyopathy and for the improvement of functions impaired by tennis elbow. (1)

Additionally, “A systematic review was undertaken to identify randomized and controlled clinical trials incorporating eccentric exercise as a treatment for patients diagnosed with lateral epicondylitis. Eight of the twelve studies were randomized trials investigating a total of 334 subjects. The majority of consistent findings support the inclusion of eccentric exercise as part of a multimodal therapy program for improved outcomes in patients with lateral epicondylitis.” (2)

Wrist & Elbow Orthoses

The use of a counter-force strap applied firmly approximately 10 cm distal to the elbow joint has been shown to decrease pain and improve grip strength. Counter-force braces should not be used in cases of concurrent radial tunnel syndrome, as the additional pressure will likely exacerbate compressive neuropathy symptoms. Use of wrist-extensor splints has also demonstrated positive results. (3) Be careful with the long-term use of orthoses as they may lead to increased activity in upper trapezius, lower trapezius, serratus anterior, and anterior deltoid as these muscles must compensate for that lack of mobility in the wrist. (4)

Extracorporeal Shockwave Therapy (ESWT)

In the past decade, shockwave therapy had emerged as a leading choice for many orthopedic disorders including lateral epicondylopathy. (5-8) ESWT was found to yield significant clinical improvement. (5-8). ESWT units are expensive, however, may add substantial benefit to patients suffering from chronic symptoms. (3)


Tennis elbow patients are looking for symptomatic relief NOW. Elastic therapeutic tape may help. In one study, taping produced significant effects on pain relief and pain-free grip strength for patients with lateral epicondylitis, and seemed to have additional effects on controlling pain that was elicited by resisted wrist extension. (9)

Shoulder Rehab

Don’t forget about the shoulder when treating tennis elbow! Wrist eccentric control exercises and shoulder stabilization exercises can be useful for lateral epicondylopathy and for the improvement of functions impaired by tennis elbow.  Shoulder stabilization exercises in a closed chain (hand stabilized on a wall or floor) are valuable therapeutic exercises for the upper extremities (10)

Here are two popular shoulder stabilization exercises you can use tomorrow:

A survey of ten chiropractic treatment protocols for tennis elbow would most likely reveal ten different strategies. As illustrated by two recent papers, this discrepancy is no different from other healthcare professions. Bateman et al. found physical therapists used varying recipes for managing tennis elbow:

“there was no consistency in the choice of modality used, the type of exercise or the dose of exercise prescribed. The use of passive modalities and corticosteroid injections was found to remain commonplace, despite a lack of supporting research evidence. There is a clear need for evidence-based guidelines for physiotherapists treating patients with tennis elbow.” (11)

Not only is there a lack of consensus among physical therapists in the treatment of lateral epicondylitis; there is considerable individual variation among orthopedic surgeons.

“Six hundred twelve upper extremity surgeons completed a survey. The six most frequently prescribed nonoperative treatments for lateral epicondylitis were home exercise program/stretching (81%), nonsteroidal anti-inflammatory drugs (75%), steroid injection (71%), counterforce bracing (68%), formal physical therapy (65%), and wrist brace (47%). Less commonly performed nonoperative treatment measures included platelet-rich plasma injection (16%), Tenex procedure (6%), and iontophoresis (2%).” (12)

Applying best practice evaluation and treatment is not commonplace. It takes years for new treatment strategies to transfer from research to clinical practice. Clinicians often rely on outdated information to guide their decision-making process. Delays in knowledge transfer result in a wide variation in treatment approaches. Evidence-based chiropractors have made it their mission to apply the right treatment to the right patient at the right time. Knowing how to apply the best procedures and evaluations per condition is dependent on the knowledge of peer groups, colleagues, seminars, personal research, and continuing education. Our friends at FAKTR provide excellent training for many of the latest tendinopathy strategies.

Changing your treatment recipe impacts your time, patient responsibilities, and staff utilization. However, small modifications to clinical care can add substantial benefit to patient recovery rates and satisfaction. ChiroUp.com has already incorporated these up-to-date “best practice” recommendations into your clinical protocol and patient education. We will continue to work hard to provide you with the most useful information for patient-centric care.

Not yet a subscriber? Start automating the delivery of up-to-date best practices for tennis elbow and 95 other conditions by clicking HERE.




    1. Lee JH , Kim TH , Lim KB, Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow. J Phys Ther Sci. 2018 Apr;30(4):590-594. doi: 10.1589/jpts.30.590. Epub 2018 Apr 20.
    2. Cullinane FL , Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014 Jan;28(1):3-19. doi: 10.1177/0269215513491974. Epub 2013 Jul 23.
    3. Aydın A , Atiç R. Comparison of extracorporeal shock-wave therapy and wrist extensor splint application in the treatment of lateral epicondylitis: a prospective randomized controlled study. J Pain Res. 2018 Aug 2;11:1459-1467. doi: 10.2147/JPR.S166679. eCollection 2018.
    4. Yoo IG1, Jung MY, Jeon HS, Lee J. Effects of wrist-extension orthosis on shoulder and scapular muscle activities during simulated assembly tasks. Ind Health.2010;48(1):108-14.
    5. Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L, Smidt N: Systematic review of the efficacy and safety of shock wave therapy for lateral elbow pain. J Rheum. 2006, 33 (7): 1351-63.PubMedGoogle Scholar
    6. Rompe JD, Theis C, Maffulli N: Shockwave treatment for tennis elbow. Orthopade. 2005, 34 (6): 567-70. 10.1007/s00132-005-0805-x.PubMedView ArticleGoogle Scholar
    7. Rompe JD, Maffulli N: Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and qualitative analysis. Br Med Bulletin. 2007, 83: 355-78. 10.1093/bmb/ldm019.View ArticleGoogle Scholar
    8. Stasinopoulos D, Johnson MI: Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis). Br J Sports Med. 2005, 39 (3): 132-6. 10.1136/bjsm.2004.015545.
    9. Cho YT , Hsu WY , Lin LF , Lin YN . Kinesio taping reduces elbow pain during resisted wrist extension in patients with chronic lateral epicondylitis: a randomized, double-blinded, cross-over study. BMC Musculoskelet Disord. 2018 Jun 19;19(1):193. doi: 10.1186/s12891-018-2118-3.
    10. Lee JH , Kim TH , Lim KB, Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow. J Phys Ther Sci. 2018 Apr;30(4):590-594. doi: 10.1589/jpts.30.590. Epub 2018 Apr 20.
    11. Bateman M , Whitby E , Kacha S , Salt E. Current physiotherapy practice in the management of tennis elbow: A service evaluation. Musculoskeletal Care. 2018 Jun;16(2):322-326. doi: 10.1002/msc.1236. Epub 2018 Feb 22.
    12. Niedermeier SR , Crouser N , Speeckaert A , Goyal KS. A Survey of Fellowship-Trained Upper Extremity Surgeons on Treatment of Lateral Epicondylitis. Hand (N Y). 2018 Apr 1:1558944718770212. doi: 10.1177/1558944718770212.

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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