The Proper Application of a Tennis Elbow Strap

Tennis Elbow Straps, or Counterforce Straps, can be very helpful in reducing the pain of lateral epicondylitis (tennis elbow) or medial epicondylitis (golfer’s elbow).
However, very rarely are people instructed in the proper technique to apply these straps.

The purpose of the counterforce strap is to reduce the tension on the tendinous origin of the muscles that start at the outside of the elbow for tennis elbow or the inside of the elbow for golfer’s elbow. These are the muscles that bend and straighten the wrist and the fingers. The strap helps distribute the tension that the tendon normally receives over a wider area. This allows the tendon to rest and become less inflamed.

To apply the strap for tennis elbow:

  • Rest your hand and forearm flat on the table, palm down.
  • Gently close the fingers.
  • Pull the wrist and fingers back off the table.
  • Do you see the muscle bulge out a bit in the forearm close to the elbow? (You may need to place your other palm over the muscles so you can feel the muscle contract.)
  • This muscle bulge is where the strap should be placed (normally about 2 finger widths from the elbow crease).
  • If the strap has a cushion or pillow, that cushion should be placed right over the muscle bulge.
  • Tighten the strap with just enough tension to feel the strap while the muscle is contracted.
  • When the muscle is not contracted, you should not feel any tension from the strap.

To apply the strap for golfer’s elbow:

  • Rest your hand and forearm flat on the table, palm up.
  • Gently close the fingers.
  • Pull the wrist forward off the table
  • Do you see the muscle bulge out a bit in the forearm close to the elbow? (You may need to place your other palm over the muscles so you can feel the muscle contract.)
  • This muscle bulge is where the strap should be placed (normally about 2 finger widths from the elbow crease).
  • If the strap has a cushion or pillow, that cushion should be placed right over the muscle bulge.
  • Tighten the strap with just enough tension to feel the strap while the muscle is contracted.
  • When the muscle is not contracted, you should not feel any tension from the strap.

Dos & Don’ts:

  • Do wear the strap only during activity.
  • Don’t wear the strap at night while sleeping.
  • Wearing the strap all the time places undue stress on tissues that are not used to the stress and can create new problems.
  • Do not wear the strap if you have numbness or tingling.
  • Do not wear the strap if you have nerve compressions such as carpal tunnel, cubital tunnel, or radial tunnel syndrome.  The tension can make these conditions worse.
  • If the strap seems to increase your pain level, do not wear it.
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The Elbow & Repetitive Strain Injuries

Unlike the shoulder, the elbow joint has a tremendous amount of bony stability. The lower end of the long bone of the upper arm (the humerus) meets the two long forearm bones (the radius and the ulna) at the elbow. The majority of the muscles that bend the wrist and the fingers attach to the inner portion of the elbow. The majority of the muscles that straighten the wrist and the fingers attach to the outer portion of the elbow.

The neutral position of the elbow, with the arm relaxed at the side of the body, is with the thumb facing forward and the palm facing toward the body. With the elbow bent, this neutral position is the “handshake” position.
Factors that Contribute to Elbow Pain

  • Repetitive wrist movement, especially with the forearm fully rotated palm-up or palm-down, repetitive rotation of the forearm, and repetitive elbow bending and straightening can all contribute to inflammation of the tendons as they insert into the elbow.
  • Bony and ligamentous grooves and tunnels near the elbow through which the three main nerves that provide power and sensation to the hand pass. The shearing motion or compression of the tendon and nerves as they pass through these tight areas can contribute to repetitive strain injuries.
  • The degree of the elbow carrying angle (the angle of deviation of the forearm bones in relationship to the upper arm bone when the arm is held at the side with the palm facing forward).
  • Maneuvering the arms around a larger upper body when placing the hands on the keyboard is also a factor.

Cubital Tunnel Syndrome

When you hit your “funny bone” you are actually hitting the ulnar nerve as it passes through a bony groove at the inside of the elbow. The nerve is particularly vulnerable as it passes through this superficial groove. Bending the elbow stretches the nerve through this groove tautly. Holding the elbow bent for prolonged periods, such as when holding a phone to the ear or sleeping with the elbows bent, can cause this nerve to become irritated. If you experience aching along the small finger (ulnar) aspect of the forearm and hand, or if you have tingling or numbness in the ring and small finger, it is especially important to avoid positioning the elbow in a bent position, either with activity or at night. Avoid repetitive elbow bending and straightening. Contact a medical professional for treatment.
Tennis Elbow (Lateral Epicondylitis)

Tennis elbow initially begins as an inflammation where the muscles attach to the outside edge of the elbow. Activities that contribute to this inflammation include repetitively pulling back (extending) the wrist and the fingers; repetitively rotating the forearm palm-up and palm-down, especially when holding an object in the hand; and lifting objects with the forearm rotated in the palm-down (pronated) position. Carrying a suitcase, briefcase or laptop backpack are activities that can cause tennis elbow.
Golfer’s Elbow (Medial Epicondylitis)

Golfer’s elbow is similar to tennis elbow, except that it begins as an inflammation where the muscles attach to the inside edge of the elbow. Activities that contribute to this inflammation include repetitively bending the wrist and closing the fingers; performing fine motor activities with the wrist bent, and repetitively rotating the forearm.

The farther away from the body that you perform activity, the more tension that is placed on the tendons where they insert into the elbow.

RSI and Prevention

Positioning

      • Avoid sleeping with the elbow bent more than 90 degrees to reduce the amount of stress on the nerve.
      • Don’t sleep with the hands placed behind the head.
      • Avoid sleeping on your stomach.
      • Use soft pillows under the arms.
      • Wear a sleeve with a pad that protects the elbow or wrap an ace bandage around a small, soft pad.

Computer Use

    • Position the keyboard so that the elbows are open more than 90 degrees.
    • Pad any sharply angled surfaces that the arms rest upon. Or place a folded towel under the arms as a cushion.
    • Don’t lean on the elbows.
    • Avoid repetitive elbow bending and straightening, excessive wrist movement or repetitive forearm rotation.
    • Use a split keyboard, especially if you find that you need to deviate the wrists out of the
      neutral position (middle finger in line with the forearm bones) when placing the fingers on the keyboard. This is particularly important if you have a large elbow carrying angle or a larger upper body.
    • Move the mouse from the shoulder, not the wrist.
    • Take frequent micro-breaks.
    • Stretch often.

Radial Tunnel Syndrome

As a certified hand therapist, I often treat people suffering from the symptoms of carpal tunnel syndrome (CTS). A less commonly known injury, but one that we are seeing more frequently in the clinic, is Radial Tunnel Syndrome (RTS). If you are experiencing an aching or burning sensation in the back of the forearm or over the back of the wrist or hand, you may have symptoms of RTS rather than CTS.

Anatomy

The radial nerve is one of three main peripheral nerves that provide sensation and power to the arm and hand (the other two are the median nerve and the ulnar nerve). The radial nerve leaves the spinal cord at the neck and travels down the arm and into the back side of the forearm. In the forearm it passes through the supinator muscle, the muscle that turns the palm up (such as when using a screwdriver).

The radial nerve is responsible for providing sensation to the back side of the forearm and the back of the hand. It is also responsible for providing power to the muscles that pull the wrist back and straighten the fingers at the large knuckle joint.

Causes of Radial Tunnel Syndrome

As the nerve travels down the arm, repetitive or forceful movements can cause friction at several sites along the nerve pathway as it passes through muscles and ligament bridges. Repetitive or forceful movements can also cause swelling in the tissues that surround the nerve. This compresses the nerve, pinching it and causing sensations of aching, burning, numbness and tingling.

Symptoms of Radial Tunnel Syndrome

Symptoms of RTS include an aching or burning pain over the back side of the forearm and/or into the back of the wrist. There may be tenderness over the back of the elbow and forearm close to the elbow. Pain may become worse with activities that require a lot of wrist movement (such as manipulating the mouse), finger movement (such as clicking the mouse), and palm up movements (such as using a screwdriver). With pressure against the tender area close to the elbow, you may experience a tingling or radiating pain. The arm may feel tired and heavy.  An aching pain may radiate down the arm into the hand or up into the shoulder.  The back of the hand, the index finger knuckle, and the muscular space between the index finger and the thumb may feel swollen.

Things to Help Prevent and Control Pain from RTS

If you are experiencing symptoms of RTS, here are a few things you might try to help you reverse the symptoms.

  • Rest as best as you can from the activities that are causing the problem.
  • A vertical mouse that places the forearm in a neutral position (the “handshake” position) may be helpful.
  • Do not swivel the mouse with wrist movement.
    • Keep the wrist neutral (straight and level, not bent forward or back or angled to either side) when typing and using the mouse.
    • Control the mouse by using the larger shoulder and elbow muscles to move it.
  • Keep the fingers relaxed on the keyboard and mouse.
    • Don’t forcefully straighten or lift the fingers while typing or clicking.
    • Use the least amount of pressure necessary to activate the keyboard and control the mouse.
  • Use a wrist brace to limit wrist movement and to help keep the muscles of the forearm relaxed.
  • Take frequent micro-breaks.
  • Use cold packs and hot packs.
    • A cold pack placed over the forearm muscles several times a day can help control swelling from overuse.
    • Hot packs can help improve flexibility.
    • Both can temporarily relieve pain.
  • Gently stretch the forearm muscles.
  • Avoid the following:
    • Heavy lift, grip or activities that twist the forearm.
    • Using a screwdriver   (Use electric tools whenever possible.)
    • Picking up luggage.
    • Weight-lifting.
  • Be careful of using tennis elbow straps that can place additional pressure on the radial nerve.
  • Seek medical attention if symptoms do not rapidly improve.

RTS is often confused with tennis elbow. Tennis elbow is an inflammation of the tendons as they attach on to the lateral epicondyle (the bony bump on the outside edge of the elbow). The tenderness associated with RTS is often a few inches farther down the forearm, more on the muscle than on the bone. A tendinitis pain is often sharper with activity and, unless it is a severe case, lessens with rest. Nerve pain, such as with RTS, can be more of an aching, burning pain that may become more severe after activity or at night. When seeking medical attention, be specific with your description of symptoms so that you can help your doctor diagnose the problem accurately.