Are Tennis Elbow Straps Effective?

Lateral epicondylitis, or tennis elbow, is one of my least favorite injuries.  It can be disabling, nagging, and sometimes even relentless!  A commonly recommended treatment involves the use of a tennis elbow strap.  There has been some support in the literature regarding these orthotics, however results in the literature have varied.

A nice new study published in a recent issue of JOSPT assessed the efficacy of these devices in a group of 52 subjects with lateral epicondylitis.  The study examined the amount of pain-free grip strength and maximum grip strength is subjects with a variety of tennis elbow straps, including a placebo strap.

 

How Do Tennis Elbow Straps Work?

image The theory behind counter-force bracing is similar to the mechanics of a guitar.  When a finger is placed on a string along the neck of the guitar, it reduces tension on the string distal to the fret where your fingers are located.  A counter-force tennis elbow strap can be thought of as your fingers on the neck of the guitar (your forearm) and the extensor muscles, especially the extensor carpi radialis brevis, would be the guitar string, thus reducing tension of the muscles as they attach to the lateral epicondyle.  The authors of the study review this concept well.

 

Counter-force Bracing is Effective

Results indicate that strapping was effective in allowing subjects to produce significantly more pain-free force.  Subjects were able to produce 16% more strength without pain using a strap.  There was no difference between two of the devices they used (a strap vs. a sleeve with a built in strap), indicating the strap itself is likely the significant factor.  The image below on the left is just the strap and the image on the right is the sleeve with a built in strap:

image image

One of my original concerns with the study involved the rest time between repetitions of grip strength.  As anyone that routinely assesses grip strength knows, the amount of force produced can drop significantly if the rest time between repetitions is not adequate.  However, the study design used a mean of 4 repetitions for each device and allowed 5 minutes of rest between testing sessions.  This was adequate for me and I was happy to see this methodology.

 

Clinical Implications

  • I like this study because bracing is simple, cheap, and effective.  People can go to any CVS or Target and get a nice tennis elbow strap these days.
  • Counter-force tennis elbow straps are effective at allowing patients with lateral epicondylitis to produce more grip strength with less pain.
  • The strap should be placed around 2.5 cm distal to the lateral epicondyle.
  • While it is unclear if the size of the strap is important, the study used straps that were between 5-8cm in width.  Considering there is some conflicting results in the literature, I would recommend you try to replicate the width of the strap.  There are some straps on the market that are very skinny.
  • Straps can be an effective way to allow people with lateral epicondyltis to return to athletics or weight lifting when painful gripping can severely limit activities.

 

Fahimeh Sadat Jafarian, Ebrahim Sadeghi Demneh, Sarah F. Tyson (2009). The Immediate Effect of Orthotic Management on Grip Strength of Patients With Lateral Epicondylosis J Orthop Sports Phys

Opt In Image
Learn More From Mike!
Subscribe to my newsletter now and get these 3 FREE bonuses:
  • My new 1 hour+ webinar "5 Things You Need to Understand to Master Functional Rehab and Performance"
  • My popular 36-page eBook "Solving the Patellofemoral Mystery"
  • My Accelerated Rehab Protocol following ACL Reconstruction

Comment on Facebook

comments

36 Responses to “Are Tennis Elbow Straps Effective?”

  1. Trevor Winnegge DPT July 16, 2009 at 6:57 pm

    Good post Mike,
    First time I heard the guitar analogy for counter force bracing. I too do not look forward to treating tennis elbow. I have also found the use of counter force epicondylitis bracing to be very effective!!! We currently use the PneuGel™ Tennis Elbow Support from DeRoyal. Pt has the ability to pump air bubble themselves to varying levels of air/tension. Air bubble can be placed in freezer as well. This is a good study to help get these braces authorized by insurance companies!!!!

  2. Interesting Trevor, I like it. If you dont follow me on Facebook, I also had a friend suggestion the PTDial from diamondathletic.com. Similar concept. Thanks

  3. Pain-free grip strength is such a short term measurement of progress. To me, a brace is more like a band-aid. I'd be more interested in what happened during this study.

    Just reading the news release immediately has me thinking of Achilles tendinosus and neurovascular issues. There might be something to be said about the potential physiological changes that occur with lateral epicondylitis.

    ~Selena

  4. Selena, I agree. Short term, however, immediate. Why not use a band aid if it increases function? But I agree, we are not treating the real issue with a strap. I tried the link you posted but it didnt seem to work for me, please try again! Thanks

  5. Mike,
    Hmmm… try this link:

    Interesting, Jan. With what you shared… does the tape really alter the location of the extensors or if further research were done on the taping technique, would the findings be similar to patellar taping results? In other words, is some sort of neuromodulatory response occurring centrally?

    ~Selena

  6. The tenniselbow is one of my favourites with non-athletes, because:

    1. Painprovocation is predictable and consistent
    2. Painrelief can be achieved instantly
    3. An exercisetreatment exists
    4. It works better than corticoidinjections
    5. It's RCT and clinically proven

    It's the wristextensor glide by Mulligan:

    http://www.youtube.com/watch?v=fNbmB51nVWI

    The exercise treatment is the extensorglide manually (with the other hand) 10 repetitions, 6 times a day.

    If you do not treat, the problem can linger for more than a year. With this treatment, it usually resolves around 4 weeks, with week by week improvements.

    Grtz, Jan

  7. Christie Downing, PT, DPT, cert MDT July 18, 2009 at 12:39 pm

    I'm inclined to agree with Selena. I, too, see this as a temporary solution. Histopatholgically, these tendons need controlled, intermittend STRESS to REMODEL the tendon. In otherwords, we need to be LOADING it to remodel it. However, the stipulation is that the loading cannot result in overloading/mechancial failure which will result in continued tissue dysfunction.

    Where I see the straps' benefit is:
    1. Where normal daily tasks and active motion are too strong to remodel a tissue that is highly dysfunctional and/or at an inflammatory exaccerbation status.
    2. When the patient has to "get on with it for performance of job related or activity related performance"

    Long term, I wonder what the results really are? As a therapist, I might be inclined to use it temporarily to get someone "through" a competition or important task, but I would quickly discard it after that. If we can extrapolate studies done by Hardy and Alfredson in hand extensor tendon injuries and achilles tendon injuries, respectively, we know that loading the tissues is the key to remodeling, not unloading them. The RIGHT amount of load AND frequency will be the keys.

  8. Selena- I saw that too, was going to post on that study soon.

    Jan – Thanks for sharing, sounds like a good technique to try. I must admit that I would agree with Selena, realistically I would be surprised if the actual musculature "moved." Rather, the tape actually seems to function much like a tennis elbow strap!

    Christie – I would agree with your clinical use of the straps completely. Adjunct to treatment, not a cure!

  9. Mike and Selena,

    There a numerous theories why the wrist extensor technique should work, but none of them are proven. It is considered a non-specific derangement by Mulligan. The fact is that one RCT (Bisset 2005) tells us, it works.

    The other question whether the tape really moves muscles, the answer is a definite yes. Ron Alexander, inventor of functional fascial taping, showed live ultrasound imaging. He taped the quadriceps and moved it 0,57 cm with tape. I replicated it myself a couple of times during a ultrasound workshop by Julie Hides on the m.TA. Ron Alexander spoke on the world fascia congress 2007 in Boston and will speak at congress in 2009 in Amsterdam, showing ultrasound proof. Look at the abstract:

    This is the fascia congres:

    http://www.fasciacongress.org/2009/speakers.php

    Maybe this helps.

    Jan

  10. Jan, I thought Bisset did work on corticosteroid injections, wait and see, and manipulation with exercise. I couldn't find anything on taping. Could you be a bit more specific?

    So, if you place the tape like you are suggesting, how long does that altered positioning last? Tape always gives/gets looser over time.

    ~Selena

  11. I agree with Selena. Does the tape alter muscle position? Maybe. Does this last long enough to be any useful functionally? hmmm, not sure about that…

  12. Selena, you're right. In the Bisset trial they did not use taping. They used the wristextensor glide exercise as I described earlier. I use the tape as a inbetween exercise intervention.

    Mike and Selena, as for the tape moving muscles, I can only recommend using ultrasound to verify it. The tape recommended by Mulligan has quite some pressure, so your suggestion that it works like a brace seems more than reasonable. The thing is, when I use a fascia technique, I get results as well, but not as good. With a fascia tape, I mean an elastic tape (kinesio-like) with no stretching at all. The effectiveness of the tape is depended on the direction (although not based on Kinesio theory to origo and insertia). I use minising pain as the direction guideline. The thing is that it seems to work with no pressure at all.That would mean it works different then a brace.

    My thoughts on how it works.

    Although I've hear many theories during workshops, I stick to an easy to understand mechanical view of the matter.

    There is pain, so there are lesions (fair assumption). The direction of the tape will affect the wound. In the right direction, the wound closes, pain is relieved and healing is facilitated. A different direction will tear open the wound and create pain and inhibits healing. This is basically the same as the McKenzie derangement concept.

    So the RCT part is the wristextensor glide exercise. The tape to my knowledge not evidence-based, but in my opinion has the same mechanics as stitching an open wound to facilitate healing.

    Taping will affect muscle properties. Contraction is affected (EMG respons is totally different) and location is moved (ultrasound shows it). What that is, I don't know.

    All said, I know it turned the least favorite intervention in one of my most favorite (from a result point of view). That's how this post started, right? Thank you for you're questions, I helps me sort out reasons, why I do stuff the way I do it.

  13. Jan,

    Thanks for the thoughts.

    Have you ever gone hunting and skinned whatever you killed? (or think of the cadaver classes you've had) There's definitely a layer of adipose tissue between the skin and the fascial layer of the muscles. Everything inside is kind of slick and slippery. AND… if you've ever tried to get the backstrap out of the deer, you know the backstrap is tightly encased. I don't think tape could adequately, really alter the position of muscles because the starting point of the tape isn't really locked down into the muscle.

    In the human forearm area, the extensor wad is kind of mobile as a group, so I would believe you might see the extensor wad move… the research Bisset has listed for that conference on taping the low back – I don't think one can move the extensor muscles of the spine as easily or as readily. The problem is the tape isn't anchored into anything that is immobile, so the tape probably can't maintain a repositioning of any muscle.

    I also doubt taping does anything to a "wound." There really isn't any wound with tendinosus, which I am assuming is the issue with chronic epicondylitis.

    You mentioned "no pressure at all." With no pressure at all, you can't be doing anything at the fascial depth.

    "There is pain, so there are lesions (fair assumption)." This isn't fully accurate either. The soldiers returning from Iraq with amputations have pain, but have no extremity, therefore they have no peripheral lesion.

    Quite interesting… Sorry to disagree with why you think it works, but from my perspective your thoughts seem somewhat flawed. I wonder what else could be playing a role in positive results.
    ~Selena

  14. Great comments. Jan, the important thing is that you feel that the tape and glide is effective in your hands. Since I am sure you use it as only a portion of your treatment plan I see no harm done and only good things can happen. Thanks for sharing, your enthusiasm has interested me.

  15. Selena,

    Thanks for your response and don't be sorry for disagreeing with me, because the goal is to have the best treatments for our patient, right?

    I'm aware of the limitations due to the make up of human tissue, but I can't ignore what I have seen on the ultrasound and others with me. It is possible that we've seen is wrong, but I did try this on three separate occasions with different people who we're experienced in ultrasound muscle interpretation.

    I'm also aware of phantom pain, but that does not mean that it's the other way around. We have this discussion a long time with non-specific low back as well. The observed disc damage does not correlate with the pain, so low backpain is not a physical problem. But with the new research (CT with pain provocation and MRI with bariumsulphate), the damage on the discs does correlate highly with pain. We had to wait for new imaging techniques to verify. Therefor I find it a fair assumption that pain comes from lesions, although we have not seen it yet.

    Mike, the wrist extensor glide is my main treatment. The focus in this discussion kinda moved away from the wrist extension glide exercise, because I showed a video of a accompanying tapingtechnique. That does not mean that the results from the Bisset trial aren't real. And let's face it, none of our clients are interested in theory, they are interested in results. That does not mean I don't care for theory, but that I value EBP(!) results over theory.

    I am enthusiastic about Mulligan techniques in general, and I think every PT should be aware of them. I do make a distinction between what has been proven in RCT's and what seems to be promising. It helps me arrange the order of treatments to try.

    Thanks for the feedback.

  16. Great post and comments!

    I have to agree with the above that the straps are only a band aid, but can serve to help in the interm while the muscle is treated.

    Personally, I have found eccentric loading to be one of the quickest ways to speed remodelling/healing of tendonosis in lifters.

    Along with using a strap for daily activities (that are unpredictable), I find that eccentric training provides an opportunity to load the muscle in a controlled environment.

  17. Mark, I agree 100%, would also add that transverse friction massage has been one of those little additions to treatments that seems to work real well.

  18. Tennis Elbow or Lateral Epicondylitis is a condition that causes extreme burning pain over the bone at the side of the elbow. It is majorly observed in tennis players and in men than women. Some prevention which one can take is, halting any form of activity that leads to pain and inflammation, applying ice or cold water pack on the problem area, trying to raise the elbow at regular intervals, physiotherapy also helps.

  19. Hi.

    I am not a doctor or therapist, but I do have tennis elbow, and I have a very, very basic question. The gel pack. Is it to be placed on the inside of the forearm, or on the outside, just below where the pain is? I ask because I've seen instructions for both…

    Thanks.

    David

    • Hi David! What do you mean on the inside? Placing the gelpack directly on the painful area and within the perimeter it surrounds works well. :)

  20. How does this thing work if you are uncomfortable to it? I guess exercise is a necessity on this kind of play.

  21. When you play tennis this tennis elbow can happen, If you have a Tennis elbow and still you want to play tennis you have to Select Arm friendly racket like ProKennex Ionic Ki 5.

    Get some details of racket:
    http://tennisworld-tennis.blogspot.com/2010/05/prokennex-ionic-ki-5-tennis-racket.html

  22. Cecil@tennis elbow cure April 25, 2011 at 3:53 am

    Injured tendons should have a regular flow of blood that carries the essential nutrients for speedy recovery. Tennis elbow braces or straps compresses the arm to relieve pain and at the same time massages it as you move. This releases the trapped fluids and toxins that causes inflammation.

  23. I am a woodworker, many months ago while using palm sanders, I started getting really massive pain running through my arms. Then my house got flooded and I was only able to recently get back to the shop and start working on my lathe. WOW! I am diagnosing myself with Hand and Arm Vibration syndrome and given my past elbow injuries(hyper extending from pitching baseball, falling directly on my elbows while learning to ice skate)lead me to the conclusion that I suffer from “golfer elbow”. Only when I work on the lathe do I wake in the mornings and my thumb forefinger and middle finger are so stiff that I can’t make a fist, so I have to spend 10-15 minutes in the morning getting feeling and the stiffness out of my hands.

    On my elbow there are two prominent protruding bones on either side of my elbow, when I tap on these with my finger they bring discomfort that would be more severe than normal.

    Would an elbow brace like you folks seem to be advocating be ideal for me?
    Feel free to email me. I am not a “go to the doctor” type of person. My life is not in danger or anything of the sort.

    It would just be nice to be able to do woodworking, painfree as much as possible.

  24. I didn’t understand the guitar analogy at first, because, as a guitarist, I know that when you deflect the string down to the fret, you INCREASE tension on the string.

    I think the way the analogy works is that when you deflect the string to the fret, you isolate the part of the string between the nut and the fret (between the elbow and the strap) from the vibration (work) going on between the fret and the bridge (strap and elbow.

  25. Mike, great analogy! It’s the first time I’ve heard it!

  26. What’s up, all is going sound here and ofcourse every one
    is sharing information, that’s in fact excellent, keep up writing.

Trackbacks/Pingbacks

  1. Ergonomic mouse tray – what works best for someone with tendonitis (tennis elbow)? - September 25, 2011

    [...] FingersMouse Tray For Limited Desk Space : Safe Computing TipsYour Questions About Mouse TraysAre Tennis Elbow Straps Effective? var _gaq = _gaq || []; _gaq.push(['_setAccount', 'UA-17226134-1']); _gaq.push(['_trackPageview']); [...]

  2. Where can I buy an elbow brace/splint to straighten a contractured elbow? | Splint Brace - September 30, 2011

    [...] #split {}#single {}#splitalign {margin-left: auto; margin-right: auto;}#singlealign {margin-left: auto; margin-right: auto;}.linkboxtext {line-height: 1.4em;}.linkboxcontainer {padding: 7px 7px 7px 7px;background-color:#FFFFFF;border-color:#FFFFFF;border-width:0px; border-style:solid;}.linkboxdisplay {padding: 7px 7px 7px 7px;}.linkboxdisplay td {text-align: center;}.linkboxdisplay a:link {text-decoration: none;}.linkboxdisplay a:hover {text-decoration: underline;} function opensingledropdown() { document.getElementById('singletablelinks').style.display = ''; document.getElementById('singlemouse').style.display = 'none'; } function closesingledropdown() { document.getElementById('singletablelinks').style.display = 'none'; document.getElementById('singlemouse').style.display = ''; } Elbow BraceTaking Care of Tennis Elbow BracesTennis Elbow Brace New TechnologyElbow Pain and SwellingAre Tennis Elbow Straps Effective? [...]

  3. Bye Bye Arm Pain « Dave Wolak – Official Website of Elite Professional Angler Dave Wolak - December 11, 2011

    [...] Here is a good link I found that also has some other related links in the response section at the bottom. I like the guitar string correlation: http://www.mikereinold.com/2009/07/are-tennis-elbow-straps-effective.html [...]

  4. Do Tennis Elbow Bands Work? | Somastruct - December 17, 2012

    [...] A 2009 study published in the Journal of Orthopaedic and Sports Physical Therapy showed that using a brace resulted in an immediate increase in pain-free grip strength [1]. Similarly, researchers from the [...]

  5. Tennis Elbow without the Racket / Bio Skin Blog - June 4, 2013

    [...] it reduces tension on the string distal to the fret where your fingers are located. The article “Are Tennis Elbow Straps Effective?” provides a further explanation on how tennis elbow straps [...]

  6. Tennis Elbow without the Racquet / Bio Skin Blog - June 5, 2013

    [...] it reduces tension on the string distal to the fret where your fingers are located. The article “Are Tennis Elbow Straps Effective?” provides a further explanation on how tennis elbow straps [...]