During the early rehabilitation strategies of conquering TE using counterforce braces is highly recommended as it drastically improves threshold of pain pressure 33 (Figure 2). The possible explanation behind its efficacy is that these brace place ‘tension on a more distal segment of the tendon/muscle’ thereby giving time to heal ‘to the injured proximal insertion of the common wrist extensors’. Many times when it is not possible for the patient to avoid the aggravating activity (to let the healing process set in) in such cases these straps are especially beneficial. Like for example, tennis players or individuals doing manual labor jobs have no option to hold the activity; here counterforce brace can be a very supporting alternative 34.

It is advised to the patients that they should use the strap while at work or sports activities but not during their resistant time. The best position to place the strap is ‘two finger widths below the painful area’ and they are told to that tension should be adjusted according to their comfort while the muscles were still relaxed, and that it should never be too tighten 33, 34.

Soft tissue techniques can cause lowering of local pain, and aggravate the flow of blood in the concerned area bringing about tissue healing and also lead to enhance tissue extensibility. the treating therapist is given the option of performing a variety of soft tissue techniques. A kind of soft tissue method is Deep Friction Massage (DFM). It is provided in small circular movements along the common wrist extensor tendon. DFM tends to reduce scar tissue35 by promoting healing process of an already degenerating tendon during its remodeling phase. Also, this kind of soft tissue massage when done throughout common wrist extensor muscle helps to relax and augments tissue extensibility. Again, myofascial techniques that target the common wrist extensors help in pain reduction and recuperate extensibility of soft tissues. 36 Despite of all these evidence available in support of use of soft tissue techniques as treatment of tendinopathies is limited 37.

According to ‘Achilles and Patellar Tendinopathies 12 Eccentric exercises are the gold standard to recupurate from tendon overuse injuries and in prevention of further re-injuries 42. They also have an upper hand (when contrasted with concentric exercises) in cases where patients/athletes are planning to resume their normal functioning/ athletic activities 43. In Achilles tendinopathy tendons responded to eccentric exercises after three months of training 44. But there are other studies too according to which tendons do not respond differently depending on concentric and eccentric exercises 45. But we need to mention that under the exercise regime its type, frequency of doing it, speed and duration of contraction are still dubious 45.

TE is a deteriorating process where thickness of common extensor tendon 46, increases. It is also featured by improper wrist functioning predominantly while try to grip something (probably due to varied neuromuscular strategies) 47 Pain while gripping an object is thus the most common feature of it. Thus load reduction should be included in effective management strategy accompanied by ways to build tissue resilience. An effective and simple way to alter load is suggesting the ‘patient to work under their pain threshold’ and allowing them to do those ‘exercises that load the tendon below the level of exaggerated pain’ 48.

Vishwas et al 49 performed an comparative study highlighting the instant outcomes of isometric exercises that were undertaken different intensities (crossing over the maximum and minimum pain threshold limits) on perception of pain in people suffering from chronic TE. Their results revealed that when exercises of upper pain limit were done it considerably reduced the resting pain intensity immediately as the exercise session ended, in comparison to the other group. They also concluded that those patients who feared this greater fear of movement (while exercising above upper pain limit) experienced higher intensity of pain. 49

Exercising should be maintained at a regular process moving steadily to increase tendon tolerance to loads. Exercises can be carried out in following ways given in Table 1.

A special type of band, known as thera band, is used to perform ‘wrist extensor eccentric strengthening exercise’. This is performed by moving the affected side of the forearm ‘in the state of internal version and the forearm is placed on the edge of the bed but hand is placed outside the bed. This is a more subtle type of exercise where affected side hand is slowly extended with the help of hand that is not under TE pain (while doing eccentric control exercise). This helps to carry out the eccentric control exercise within the no-pain range. This whole exercise is to be performed 15 times which is counted as one set. This type of five sets have to be performed; between each set a one minute break should be taken 50.

They comprise of usage of slings for doing push-up plus exercise using slings 14. The sling that is to be used is at a height of 10 cm from the floor. The position in which it is started is a crawling position and the doer holds the handle of the sling. A right angle (90°) is maintained between the shoulder and knee joint. The alignment of head, spine, and pelvis should be a straight line. A steady eye contact should be ensured with the floor. Placement of hands and knees should be in accordance with shoulder width. Complete extension of the elbows and plantar flexion of ankle joints is to be maintained. While doing the push-up plus exercise, it is made sure that ‘unciform bones of the middle fingers got aligned with the acromions’, while the scapulae getting maximally protracted enabling head and the trunk joints to form straight line. This posture has to be maintained for 5 seconds. This entire process when performed five times constituted one set. Five such sets have to be performed with a 1 minute break in between each set. This is recommended 3 times in a week for 3 consecutive weeks.50

This exercise program has two components. Primarily, it is a stretching exercise of the Extensor Carpi Radialis Brevis standing at a fixed position. This static stretching is done while the patient remains seated position but elbow is extended, forearm is in ‘pronation, and wrist flexion with ulnar deviation’. Stretch force is applied depending on the tolerable capacity of the patient. Patient has to stay in this stretch position for about 30–45 seconds. A total of 6 such sets are to be done but there is protocol for it which is followed in a specified manner. It has to be done 3-3 times (total 6) before and after eccentric exercise portion 50, 51. Each time of stretching should be accompanied by a 30 seconds interval of rest.

In this exercise, the patient remains sitting while his or her elbow should be fully extended, ‘forearm pronation, and maximum wrist extension’ is there. At this position, the patient has to lower the wrist slowly ‘into flexion for a count of 30’. He/she uses the contra lateral hand to enable him/her to return the wrist to maximum extension. Then the patients have to continue the exercise even in case of mild discomfort. But they need to stop if the pain got unbearable. Those patients who were able to do eccentric exercise without minor discomfort/pain, for them the load is can be increased ‘using free weights based on the patients 10 RM (Repetition Maximum)’. This process is to be repeated ten times and three such sets are to be performed. There is a resistant of 60 seconds between each set. An education manual is also made available to the patients which guided them about ‘ergonomics and activity modification technique’ so that they get informed about how to not aggravate their symptoms 52.

It comprises of deep transverse friction massage for a duration of 10 min. and instantly after that a single application of Mill’s manipulation is done. The hand placement is shown in Figure 3. The patient should be seated in a comfortable position and the elbow is fully supinated and in 90° of flexion. The next step is mapping the area of tenderness done on the basis of palpation of ‘anterolateral aspect of the lateral epicondyle of humerus’. Then with the help of a thumb deep transverse friction is rendered. This pressure is applied on tenoosseous junction in a posterior direction. It is continued for at least ten minutes to achieve the numbing effect so that the tendon get receptive for Mill’s manipulation 52.

In Mills manipulation, patients are made to sit with ease and it is made sure that ‘affected extremity in 90° of abduction’ and enough internal rotation brings the olecranon faced up situation is achieved. After this the therapist tries to stabilize ‘patient’s wrist in full flexion and pronation with one hand’, simultaneously placing the other hand over the olecranon 4, 51, 52. Refer to Figure 3 for Mill’s Manipulation.

The therapist is supposed to assume full wrist flexion and pronation position, and thus ‘apply a high-velocity, low-amplitude thrust at the end range of elbow extension’. However a comparative study on tennis elbow showed that that group which underwent a one month supervised exercise program reported significantly better functioning and pain-reduction status as compared to Cyriax physiotherapy treatment 53, 54.

Laser has been a choice of management in tennis elbow over time and found to have varying degree of success in minimizing pain, disability and promoting range of motion and functionality based on varying therapeutic factors. Its advised to administer low level laser therapy with dose ranging from 904nm and 632nm wavelength and the effect is better felt when combined with exercise.53 It is also noted that LASER can be a second line option in pain relief and alternative for surgical intervention in chronic cases of pain. 54.

PEMF reduces the pain intensity and lot of studies have reported higher degree of positive effect specific to tennis elbow. Along with the list of advanced therapies like PEMF, Shockwave therapy have been an added second range of choice with additional cost. 55, 56

The tennis elbow and ultrasound as a method of its management is a conventional approach and well documented as well is a subject of controversy. The varying concerns is more related to the procedural methods, choice of dosage and supportive exercise regimen. 57, 58