The 4 Phases to Fix Tennis Elbow Pain for Good
Why Your Elbow Hurts During Pull-Ups, Deadlifts, Climbing, and Even Lifting a Coffee Mug
You reach for your morning coffee and your elbow lights up. You grab the pull-up bar and feel that sharp ache on the outside of your forearm before you even leave the ground. You deadlift, you row, you climb - and every time you do so, you pay for it later.
If that sounds familiar, you are dealing with what most people call “tennis elbow.” Despite the name, the majority of people we see with this issue haven’t ever picked up a racket in their lives!
So what’s going on?
Tennis elbow, or “lateral epicondylalgia” in nerdy talk 🤓, is one of the most common overuse injuries in active adults. It shows up in lifters, CrossFit athletes, climbers, Hyrox competitors, and weekend warriors. It is frustrating, it lingers longer than people expect, and if you try to push through it without a plan, it almost always gets worse.
Here is what is actually happening in your elbow, why it holds on for so long, and a clear, phased framework for getting out of pain and back to you again.
WHATS HAPPENING IN YOUR ELBOW
The lateral epicondyle is the bony bump on the outside of your elbow. The muscles of your wrist that lift the back of your hand up twist out (extensors and supinators) attach right there. When those tendons are overloaded over time without enough recovery, the tissue starts to break down at the cellular level.
This is not a typical inflammatory injury. Research shows us that tennis elbow is primarily a “tendinopathy,” which is a degenerative process where the tendon loses its normal structure. This matters because chasing inflammation with ice, rest, and anti-inflammatories alone won’t fix the main issue.
The tendon needs to be loaded, progressively and wisely, to reorganize and get strong again.
This is the single most important thing I want you to take away: rest doesn’t fix tendons…but loading does!
THE 4 PHASE REHAB FRAMEWORK
This is the framework I use with every elbow case at Training Nation. It respects where the tissue is at, builds tolerance progressively, and earns the right to return to full activity.
Phase 1 - Isometric Loading: Calm the Tissue Down
Goal: decrease pain and begin loading the tendon without creating more irritation.
Holds, or “isometric exercises” are where the muscle contracts but the joint doesn’t move, is where we start. Research has consistently shown that isometric contractions provide meaningful pain relief for tendinopathies. 3-5 sets of 30-45 seconds are a great place to start
What this looks like: Hold a wrist extension position against light resistance (a towel, a band, or a light weight) for 30 to 45 seconds. Four sets. Pain should stay at a 3 out of 10 or below during the exercise. Do this daily.
The goal isn’t to build strength yet. The goal is to start telling to the nervous system that load is safe and to begin starting tissue repair without aggravating the tendon again.
Phase 2 - Isotonic Loading: Build Strength Through Range
Goal: Restore strength and load-bearing capacity through full movement.
Once pain during isometrics is consistently low (usually 1 to 2 weeks in for milder cases, longer for chronic ones), we progress to slow, controlled isotonic (movement) exercises. The lowering phase (eccentrics) are especially important here.
What this looks like:
Wrist extensions with a light dumbbell or band, 3 sets of 12-15 reps, slow and controlled (3 seconds up, 3 seconds down)
Grip work with a soft ball or putty
Twisting (pronation and supination) exercises to restore forearm rotation capacity
Pain guidelines stay the same: 3 out of 10 or below during, and it should settle back to baseline within 24 hours after.
Phase 3 - Speed and Tissue Tolerance: Load at Real-World Demands
Goal: Train the tendon to handle fast, high-force movements.
Tendons do not just need to be strong. They need to be fast. When you deadlift, row, or catch a hold on a climbing wall, your forearm tendons are absorbing and producing force quickly. If your rehab never includes speed, you will return to sport and get hurt again.
This phase introduces:
Faster reps with moderate resistance
Plyometric grip training (ball tosses, controlled ball slams)
Wrist and forearm work with elastic energy (releasing tension quickly, recoil drills)
Functional movement patterns: rows, pull-downs, hinges, and farmer carries all with increasing load
The key here is progressive loading. You are teaching the tendon what it will actually face when you return to the gym or sport. This phase should feel like training, not just rehab.
Phase 4 - Return to Full Activity and Sport
Goal: Full return to sport, gym, or activity with confidence and no restrictions.
Phase 4 is where benchmarks matter. Before we clear someone for full activity, we want to see:
Equal or near-equal grip strength on both sides
No pain with loading at sport-level intensity
The ability to complete sport-specific movements - whether that is a clean and jerk, a dead hang, or a hundred pull-ups - without compensation
Returning to sport is a process, not a light switch. We have to bring volume and intensity back gradually typically over 4-14 weeks and monitor how the elbow responds. The biggest mistake I see is people feeling 80% better and going straight back to full training. That last 20% of tissue tolerance takes time, unfortunately.
HOW TO MAKE RECOVERY FASTER
Building on the four phases, there are several other modalities that top sports and performance physical therapists use to move the needle faster.
Blood Flow Restriction Training (BFR)
BFR involves applying a blood pressure cuff to the upper arm and training at very low loads (20 to 30 percent of max) while partially restricting blood return to the heart (venous blood flow). The result is a metabolic and hormonal response that mimics heavy loading…but without the tissue stress! How wild is that!? Is my nerdiness showing again?
It lets us get the stimulus for strength adaptation while keeping the load on the healing tendon minimal. For early-phase rehab, especially in people who flare up easily, this has been really helpful.
Manual Therapy and Soft Tissue Work
Forget about me being a nerd, my hippy is about to come out. I’ve found (and so has more research) that there is a HUGE improvement with people doing manual therapies. Deep tissue work, instrument assisted soft tissue mobilization (IASTM), and cupping can be used to create controlled microtrauma in the irritated tissue which helps the healing response and restore tissue quality. Plus it just feels REALLY GOOD (after it’s done 😏)
Elbow and wrist joint mobilizations can also restore movement that has been lost due to guarding or disuse. If there is any restriction in cervical spine mobility or nerve tension along the radial nerve, that has to be addressed too. A neck or upper back restriction can keep elbow pain lingering far longer than it should.
Dry Needling
Dry needling to trigger points in the forearm extensors and even the rotator cuff can reduce muscle tone and pain that can keep the pain cycle going. It doesn’t replace loading, but really helps for breaking the pain-guarding-weakness loop early in rehab.
Proximal Strength: The Often-Missed Piece
Pain is rarely where the problem starts. Weak rotator cuff muscles, poor shoulder blade control, and limited upper back rotation all shift load down the chain and create more stress onto the elbow. If we ignore the shoulder and upper back while rehabbing the elbow, we are treating a symptom instead of a system.
Including shoulder external rotation strength, scapular retraction and depression work, and mid-back mobility into your tennis elbow program is important!
Load Management and Education
Understanding the dose-response relationship for loading can be tricky. Tendon health lives on a spectrum: too little load leads to atrophy, too much leads to breakdown. The sweet spot is progressive overload with the right amount of recovery too.
That means tracking how activities outside the gym affect your symptoms, managing total grip and pulling volume during the week, and understanding that a good day don’t mean you should max out your training. Pacing is a skill. Teaching it is part of good physical therapy.
HOW LONG THIS WILL TAKE
Tennis elbow is known to be slow to fully resolve, unfortunately. Mild cases managed correctly can see significant improvement in 6 to 8 weeks. Chronic cases can take 3 to 6 months for complete resolution. It’s not a failure of rehab, it’s simply the biology of tendons. What matters is that you are making consistent, measurable progress.
That being said - we’re always clear with our clients that we want to be proved wrong, and we want them to get better faster!
FREQUENTLY ASKED QUESTIONS ABOUT TENNIS ELBOW
Can I still train if I have tennis elbow? Absolutely! The goal is to modify load, not stop it. We want to find which movements aggravate the tendon and adjust your training around them while the rehab program is in full swing.
Should I use a strap or brace? An elbow strap brace can reduce pain during activity in the short term by shifting the stress point on the tendon. It is a helpful tool, but not the solution.
Is cortisone a good idea? Cortisone injections can provide short-term pain relief but have been shown in research to lead to worse long-term outcomes compared to physical therapy. I recommend exhausting a well-structured loading program first.
What is the difference between tennis elbow and golfer's elbow? Tennis elbow (lateral epicondylalgia) affects the outside of the elbow. Golfer's elbow (medial epicondylalgia) affects the inside. Both are tendinopathies. Both respond well to progressive loading. The exercises and tissue involved differ, but all priciples talked about here stay the same.
Does stretching help? Gentle wrist flexor and extensor stretching can be useful for symptom management and tissue mobility, especially in the early phases. But stretching alone typically doesn’t fix the whole problem. Reminder - loading is the treatment!
THERES HOPE!
Tennis elbow isn’t a mystery and it is not a life sentence, either. It is a loading problem, but there’s a solution!
If you have been dealing with elbow pain during pull-ups, deadlifts, climbing, rows, or even just reaching for something off a shelf, there is a clear path forward. You do not have to keep guessing, keep avoiding things you love, or accept that your elbow will be like this forever.
At Training Nation Performance Therapy, we specialize in helping active people in Dayton, Ohio get out of pain and back to doing the things they love…without unnecessary rest, injections, or surgery. If you want to talk through what is going on with your elbow, we offer free discovery calls. No pressure, just a real conversation about what is happening and what we can do about it.
Keep moving!
Dr. Luke
