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THE ANKLE SPRAIN SELF-TREATMENT SERIES: How to diagnose your ankle sprain (this article) How to know if you've broken your ankle How to treat your ankle sprain Ankle sprains are very common and most people reading this blog would have twisted their ankles at some stage in their lives. The patients we see in our online clinic describe a wide range of causes - some as innocuous as stepping off a curb - while others are sustained through high-impact collisions on the sports pitch. Recovery times can vary from 4 weeks for a mild ankle sprain to more than 12 weeks if you have done a proper job of it. Being able to walk in a near normal way within 48 hours is usually a sign that you will make a good recovery. The recovery time of an ankle sprain is heavily dependent on what structures you've injured and the quality of your rehab programme . In this article: What happens when I sprain my ankle? How do I know if I have torn a ligament of the ankle? How do I know if I have torn a muscle in my ankle? Should I go to A&E for a sprained ankle? What happens when I sprain my ankle? The ankle joint consist of three bones (tibia, fibula, talus) which are held together by a strong capsule and ligaments. The joint surfaces are covered with articular cartilage. The tendons of the muscles that control the different movements of the foot also cross the ankle joint on all sides. Which structures are injured when you roll your ankle, depend on what direction you twist the foot into. In most cases you will stretch the ligaments and muscles on one side of the ankle while you compress the joint surfaces on the opposite side. You can even cause the bone to bruise or fracture if the movement is forceful enough. The joints and ligaments of the rest of the foot can also be injured during an ankle sprain. Ankle Sprain: How do I know if I have torn a ligament of the ankle? You can be pretty sure that you've at least partially torn an ankle ligament if there's some local swelling and bruising in the area of the ligament and it is painful to press on it (see picture below). There are 3 grades of ligament tears: Grade 1: You have only torn a few of the fibres of the ligament. It is painful to stretch the ligament but there's no noticeable laxity (i.e. the ligament still stops the joint from moving too far). There is usually only a mild area of swelling. Grade 2: You have torn a significant number of fibres, but not all of them.  There is usually a lot of swelling. It is painful to stretch the ligament and the joint is moving slightly further than what it should. Grade 3: You have fully torn the ligament. There is usually significant swelling in the area. It may not be painful to stretch the ligament (since there is nothing left to stretch) and the joint moves a lot further than what it should when you compare it to the uninjured side. Grade 3 tears will require an extended period of protection (in a brace or boot) and may even require surgery, while you can usually walk with a pretty normal gait after sustaining a Grade 1 ankle ligament tear. Picture 1: Lateral ligaments of the ankle Picture 2: Medial ligaments of the ankle Ankle Sprains: How do I know if I have torn a muscle in my ankle? You have likely torn a muscle or tendon if it is painful to press on it and if it hurts to actively contract that muscle against resistance. For instance, use your hand to try and turn your foot inwards while you actively resist the movement with your foot. The net effect should be that the foot stays in the same position. If it hurts when you do this or if you are unable to keep your foot in the same position, you may have torn your peroneal muscles. The movement you use during testing will depend on which muscle you want to test. Picture 3: Some of the muscles of the foot and ankle Should I go to A&E for a sprained ankle? You should go to A&E if you suspect that you may have broken a bone in your foot or ankle.  I know, you're not a doctor, but you can use the Ottawa Rules to help you decide. You can find a detailed explanation of how to use the Ottawa Rules to diagnose an ankle fracture in this blog post . Steph also explains it very well in the video below. You should also go to A&E if your ankle swells up very quickly, within 30 minutes of injuring it, or you are unable to walk on it for four steps (walking with a limp counts). Swelling that occur this quickly is usually indicative of an injury to the cartilage or bone inside the ankle joint and it is good to have it investigated further.  These types of ankle sprains are typically the ones that take 12 or more weeks to recover from. If, however, you can walk on the foot and it gradually swells over a few hours, I would rather consult a physiotherapist. Knowing exactly what structures you've injured and how to strengthen them will speed up your recovery. This is something that our team of sports physios can easily help you with via an online consultation . Research has shown that a physical examination carried out 4 or 5 days after an ankle injury produces more accurate results than if it is done on the day of injury. You can read more about how to treat ankle sprains in this blog post or if you find that you're stuck in a cycle of recurring ankle sprains, then this article may be of use. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Kerkhoffs, G. M., van den Bekerom, M., Elders, L. A. M., van Beek, P. A., Hullegie, W. A. M., Bloemers, G. M. F. M., et al. (2012). Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. British Journal of Sports Medicine, 46(12), 854-860. Tayeb, R. (2013). DIAGNOSTIC VALUE OF OTTAWA ANKLE RULES: SIMPLE GUIDELINES WITH HIGH SENSITIVITY. British Journal of Sports Medicine, 47(10), e3.

Hip bursitis or trochanteric bursitis is a tricky condition. It’s sometimes called “the great mimicker” because its symptoms are easily mistaken for other conditions like back pain or gluteal muscle injuries. But I’ve also found that quite a few patients I’ve seen have been misdiagnosed as having trochanteric bursitis when in fact the pain was caused by something else. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In the video below, I give a very detailed explanation of what causes the bursae over your lateral hip to become inflamed and sore and how you can help it to recover. In this article I’ve highlighted some interesting facts that even clinicians sometimes don’t take into consideration. 1. You have about 9 different bursae in the area of your lateral hip (the outside of the hip) and any of them can be the cause of your pain. A bursa is a sac filled with fluid and you find them in most areas where your muscles and tendons cross over or attach into bones. They are meant to help reduce friction between the bones and overlying soft tissue. There are several layers of muscle that attach into the top of your thigh bone from several directions, so it makes sense that you’ll have more than 1 bursa there. Bursae have lots of nerve endings and when they become irritated or inflamed can cause a lot of pain. Adapted from Williams, B. S. and S. P. Cohen (2009). "Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment." Anesthesia & Analgesia 108(5): 1662-1670. A popular treatment for bursitis is a corticosteroid injection. If your injection did not work, it may be that the clinician missed the spot. I always try to refer my patients to someone that I know will do an ultrasound guided injection. This means that the person doing the injection uses ultrasound to look at where she/he places the needle and can aim it much more accurately . 2. It’s difficult to diagnose You would think that diagnosing trochanteric bursitis should be easy. Surely it’s a case of just pressing on the outside of the hip where the bursae are and seeing if it hurts? Erm no - the research has shown that there are several other injuries that also cause pain with pressure over that area. Even the two most sensitive tests (pain when standing on one leg for 30 sec; pain with resisted hip external rotation) can also produce pain when you have gluteus medius tendinopathy. Some of the injuries that can feel very similar to hip bursitis include referred pain from the lower back, gluteal tendinopathy and gluteal tendon tears. An experienced clinician will be able to distinguish between these conditions by taking a thorough history and listening to how you describe your symptoms, what makes it worse or better and by getting you to perform some specific tests. 3. Trochanteric bursitis likes company Not only can lateral hip bursitis be misdiagnosed but it can also be present in addition to another condition. In one study researchers found that 91.6% of the patients that they examined had other associated conditions. One of the most common “combinations” that I see in clinic is patients with ongoing lower back pain who also present with bursitis. Another example is glute med tendinopathy. If you want all the symptoms to improve you shouldn’t just treat one and leave the other. I go into this in a lot more detail in the video. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Rothschild B. Elusive trochanteric bursitis relief. Clinical Rheumatology 2019:1-1. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesthesia & Analgesia 2009;108(5):1662-70.

Hip bursitis (medical name: trochanteric bursitis) is often confused with other conditions that also cause outer hip pain , and sometimes it occurs together with one of these conditions. In this article, I explain hip bursitis symptoms and causes as well as how to treat it, including massage and which exercises to avoid. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: What is a bursa and where does hip bursitis hurt? What is hip bursitis? How to diagnose hip bursitis Treatment for hip bursitis How we can help We also made a video about this: What is a bursa and where does hip bursitis hurt? A bursa is a little fluid-filled sac, and you have them wherever a muscle or tendon is close to a bone. They sit between the muscle or tendon and the bone and in some cases between muscles, and their function is to prevent friction between these various body parts. It’s almost like those inflated marine fenders hanging over the side of a boat to protect it from contact with the dock or jetty. Adapted from Williams, B. S. and S. P. Cohen (2009). "Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment." Anesthesia & Analgesia 108(5): 1662-1670. There are plenty of bursae in the hip, because there are so many muscles in that area: the gluteus maximus, medius, and minimus, the piriformis muscle deep inside the hip, as well as quite a few smaller muscles. And these muscles are all attached to the hip bone or the top of the thigh bone with tendons. Note that there are a total of nine hip bursae in the picture, and quite often it’s more than one bursa that’s causing the pain. This is why injections to relieve hip bursitis pain sometimes don’t work; they often inject the wrong bursa. (More about that later on.) Interestingly, not everyone has exactly nine bursae – some people have fewer, and others have more. The circled area in the picture above is where you typically experience hip bursitis pain. What is hip bursitis? Bursae have many nerve endings. So, when they become injured or irritated, it causes a lot of pain. There are two main ways in which a hip bursa can get injured or an existing bursitis can be aggravated. A sudden impact This usually happens when you fall on your side, like when you fall off a bicycle or trip and fall. In this case, the pain usually sets in within a few hours to a day after the impact. Excessive friction or compression This is the more common cause of hip bursitis. Yes, a bursa is there to reduce friction, but it can only sustain a certain amount of force. If, for some reason, the compression and friction are a lot more than it can handle, it will get painful and sometimes inflamed. Note “sometimes” in the previous sentence. The research has shown that bursitis doesn't always go hand-in-hand with inflammation in the bursa. That is why anti-inflammatories don't always help. Things that can cause excessive compression or friction: Biomechanics Think of the way catwalk models walk, with an excessive sideways tilting of the hips. There’s actually a name for it – the Trendelenburg Sign, and walking or running like this stretches the muscles, tendons, and IT band tightly over the outside of the hip bone, which increases pressure on the bursae. Standing, walking, or running with excessive hip tilting can cause hip bursitis. Merely standing for a long time with your hips in this sideways tilted position could also cause problems. When you’re doing the dishes, waiting in line for something, or standing at the bus stop, it’s better to distribute your weight evenly between your legs. Another biomechanical cause of hip bursitis is when the knee turns inwards excessively when you run or walk. Again, this pulls the muscles and tendons tightly over the hip bone. People usually stand, walk, or run like this because it’s become a habit, they have weak glute muscles, or when they’re very tired. Sudden overuse This usually happens when you do certain strenuous activities without having built up to it gradually. Bursae are like many other parts of the body – if you slowly increase the amount of pressure they have to handle, they will adapt to it, but if you overdo it and/or they don’t get enough time to recover between activities, it becomes a problem. Examples include running a very hilly race without having trained for it properly or suddenly doing a lot of hill walking. The effect on the bursae becomes worse when this makes you really tired and you lose your running or walking form. Tightness Excessive tightness in the muscles that cross over the hip bursae will increase the pressure there and irritate them. Tight muscles can also pull the IT band too tightly over the outside of the hip. There are also certain conditions in the lower back that can cause tightness over the hip – more about that later. Snapping hip And lastly, there's a condition called “snapping hip”, where your IT band goes “click-click-click-click” over the outside of your hip. This is quite common in people who are hypermobile or very supple, like dancers. If your IT band keeps on flicking over the hip bone, it can irritate a bursa. How to diagnose hip bursitis Bursitis and conditions with similar symptoms Bursitis pain is easily confused with other conditions and vice versa. This is because there are several things that can cause pain in the area where the bursae are. Bursitis pain is usually over the outside of the hip, but it can refer pain down the side of the leg. It can also, if it's very irritated, cause your lower back to tighten up and make that hurt. Then again, if you have lower back pain, this can refer pain into the side of the hip and/or down the side of the leg. The tendons that attach your gluteal muscles to the hip bone are in exactly the same spot as some of your hip bursae. If you have gluteal tendinopathy it can cause pain in that same area, and you won’t know which is causing it by just pressing on it. The same goes for a torn gluteal tendon. There’s sometimes a clue in how the pain developed. For instance, when you tear a tendon you usually experience a sudden sharp pain, while bursitis tends to have a more gradual onset. If there’s a history of back pain, then you'd suspect back pain rather than pure bursitis. We also want to look at how the symptoms behave over the 24 hours after exercise. For instance, if you are okay to do lots of weight-bearing activities and it doesn't really make it worse, I would not really suspect bursitis. The same if you can stand for extended periods of time without pain, because bursitis doesn’t really like this. But if you find that stretching the hip hurts, e.g. you can’t sit with your legs crossed, I would think that there could be a bit of bursitis there, although this can also irritate gluteal tendinopathy. Treatment for hip bursitis Hip bursitis often needs to be treated together with something else. For example, someone with back pain might have hip bursitis that is caused by the back pain. And research has shown that 35% of people with glute med tendinopathy also have hip bursitis. This combination of conditions is called greater trochanteric pain syndrome, and Alison has made a series of videos about this . As with most conditions, there's no one-size-fits-all treatment. A conservative treatment approach that takes into account the sub-headings below can work really well. A small percentage of people don't react to this approach, and then hip bursitis surgery is an option, but none of my patients have needed surgery – the most invasive thing some have had to go for is a cortisone injection. Identify the cause(s) It is always important to try and identify the cause for your hip bursitis (biomechanics, overuse, etc.). If you only focus on treating the symptoms and don't address the underlying cause, you may get rid of the pain in the short term, but it will just come back later. Work on bad habits Linked to this, we need to look at bad habits, like putting most of your weight on one leg when you stand. I get all my patients with hip bursitis or any other pain on the outside of the hip to make sure that they're always standing on both feet equally, because otherwise you just annoy that sensitive tissue all the time. The same goes for crossing your legs when you’re sitting. This will also stretch the muscles and tendons over the outside of the hip, which will just keep the pain cycle going if you have a sensitive bursa or even a sensitive gluteal tendon. Exercises for hip bursitis – and which hip bursitis exercises to avoid Strengthening exercises are not my first choice for this condition. The bursae have to be properly calmed down first before strength exercises are introduced, otherwise you tend to make it worse. However, if biomechanics or something like a lack of glute strength contributed to the hip bursitis, those muscles will have to be strengthened at a later stage . It is best to avoid exercises like clams or side-leg lifts during the early stages of rehab. These exercises can often irritate the irritated bursae more because they can pinch the bursae when your leg moves out and compress the bursae by stretching the muscles and tendons over the outside of the hip when your leg moves back in. Exercises like glute bridges or leg presses will still strengthen the gluteal muscles, but because the legs move in a straight line, you avoid the positions that are most likely to irritate the bursae. Also, something like isometric wall sits would be better to start with than the repetitive motion of doing squats, where you are more likely to rub your bursa. Stretches for hip bursitis are best avoided I tend not to give my patients stretches to do, because stretching increases the compression, and nine times out of ten you will just make it worse. If stretching does not make the pain over the outside of your hip worse, it was likely not a proper bursitis and it may have just been sensitive from other things. Here's a video with more details: But what to do if you think that tightness could be a cause of the bursitis? Massage for hip bursitis Massage, whether you do it yourself or a physio or massage therapist does it, works really well, because if you can get the muscles to relax, you'll take the pressure off the bursa. However, it's not about pressing onto the bony bits where the really sensitive spots are. You want to start in the less sensitive areas and work on the trigger points. You don't want to elicit a strong pain, especially not in the first session, because if you go too heavy on it in the first session, you won't know how it's going to react, and it may cause it to flare up. A tennis ball is very handy if you want to do it yourself. Target the soft, squishy, muscley bits in your bum, not the bony bits on the hip itself. It’s better to do it against a wall than on the floor – that way you have more control. Relax the leg that is closest to the wall, press yourself into the wall with the other leg, and move the area around over the tennis ball. Here’s a video demo: How vigorously should you do this? I tell my patients that it has to feel no worse than “comfortably uncomfortable”. Sometimes, if you've had pain for a long time, it can feel quite satisfying to replicate that pain and feel how it burns. Don’t do it! Rather go gently and see how it reacts in the next 24 hours. If the pain isn’t worse than before the massage, you can go a little bit harder the next time, and vice versa if the pain is worse. Dry needling I find that, especially in the very painful early stage when you can't apply a lot of pressure, not even with massage, acupuncture can provide really good pain relief and relaxation of the muscles. I have even come across one study that found that dry needling produced similar results to cortisone injections. However, I would want that study to be replicated before I believe this 100%, because I've definitely seen in practice that, for some people, dry needling just doesn't work, and they do need to go on to injections. Hip bursitis injections We're talking hip bursitis cortisone (steroid) shots here. You can do a cortisone injection in two ways. The doctor or physio can either go on the landmarks of the body, pressing to find the painful spot and inject it “blind”. Or they can do the injection under ultrasound guidance (where they use an ultrasound scanner to locate the injured bursa) to ensure that they get it exactly in the correct spot. These scans work the same as when scanning a foetus, and you can use them to see several types of soft tissue, including bursae. I always try to refer my patients to somebody who will be doing the injection under ultrasound guidance. Anti-inflammatories Again, hip bursitis is one of those weird conditions where sometimes there's inflammation, sometimes there's not. So, for some people anti-inflammatories work really well, while for others they don’t really work. Always check with your GP before you take these, because there's certain medications that they interact with. Also, anti-inflammatories have a way of upsetting stomachs. So, it’s always better if you can get away without using them. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Barratt, P. A., et al. (2017). "Conservative treatments for greater trochanteric pain syndrome: a systematic review." British Journal of Sports Medicine 51(2): 97-104. Rothschild B. Elusive trochanteric bursitis relief. Clinical Rheumatology 2019:1-1. Williams BS, Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesthesia & Analgesia 2009;108(5):1662-70.

The best triceps tendonitis treatment is to give your tendon a break without totally resting it (relative rest) and then to strengthen it with exercises that don’t make your injury worse. This article explains the principles behind this approach. It also covers the anatomy involved and the causes of triceps tendonitis – understanding these will help you to understand the rehab process better. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: Anatomy of the triceps tendon Causes of triceps tendonitis Triceps tendonitis symptoms What happens when you get triceps tendonitis? Triceps tendonitis treatment How we can help We’ve also made a video about this: Anatomy of the triceps tendon The triceps muscle has three heads that run down the back of your upper arm and fuse together into one tendon, the triceps tendon. You use your triceps mainly to straighten your arm, for example when doing push-ups or throwing a ball. It also supports the shoulder muscles with movements like adduction (bringing your arm closer to your body) and with general shoulder stability. The triceps tendon attaches the lower end of your triceps muscle to several parts of your elbow. It mainly attaches to the top of the ulna (one of the two bones in your forearm) and to the capsule of your elbow joint (a sinewy sac that you find around most joints). Tendons are made up of many collagen fibres arranged parallel to each other, and these fibres are arranged in bundles, also parallel to each other. This configuration makes a tendon quite strong, in the same way that a cable or rope is stronger than the sum of the strength of its individual strands. Causes of triceps tendonitis Most commonly, you get triceps tendonitis when you overwork the tendon; this is known as an overload injury. An overload injury can happen in several ways. It’s usually movements involving weight, for example gym exercises such as skull crushes or triceps dips, and, less often, fast movements such as throwing a ball or javelin repetitively. Triceps tendonitis can be due to acute overload, where you overdid it in a single exercise session, or it can be chronic overload, when you don’t give your tendon enough time to recover and repair between sessions over a period of time. Other causes In some cases triceps tendonitis can develop after: Taking fluoroquinolone antibiotics - Ciprofloxacin is a commonly prescribed one that has detrimental effects on tendons and other tissues. Getting hit on the tendon. Triceps tendonitis symptoms The pain when you have triceps tendonitis is mainly located at the back of your elbow and in the lower portion of your triceps. The triceps muscle may also feel stiff and sore, and you can get some referral into the forearm. You typically first notice the pain several hours after a hard training session or the next morning. Your elbow may feel stiff, and keeping it bent for long periods of time may make it hurt more. Any activity where you have to extend your elbow against resistance will usually increase your pain. Sometimes, you may not feel pain while doing the exercise or activity, but then it hurts more several hours later. Tendons are known for having a delayed pain response to exercise. Triceps tendon tear vs. tendonitis You’ll usually know when you’ve torn your tendon, because you’ll feel a sudden, sharp pain when you injure it. If this happened, go see a doctor as soon as possible. What happens when you get triceps tendonitis? Triceps tendonitis usually only affects one bundle of fibres or a few of them at most. That injured part loses its parallel configuration, which causes it to lose some strength, whereas the rest of the tendon is still fine. Contrary to a widely held belief , there’s very little, if any, inflammation in a tendon that is injured in this way. So the term “triceps tendinopathy” is actually more correct than “triceps tendonitis” (which implies inflammation), but we use the latter here because that is how most people refer to it. The injured tendon is painful because, in its weakened state, it can’t cope with the loads that it used to be able to cope with when you straighten your arm. Another common source of pain is when the tendon is stretched and/or compressed against the bones in your elbow as you bend your arm. Injured tendons don’t like being stretched or compressed – it’s a bit like pressing on a new bruise. Triceps tendonitis treatment Let’s start with one commonly prescribed treatment that you shouldn’t do. Triceps tendonitis stretches When your tendon is injured, it can often make your tricep muscles feel tight and sore, and it is natural to want to stretch them. It can also feel quite satisfying while you’re stretching it. But in my experience, this often just ends up irritating the tendon further because it causes it to compress against the bone and can prevent the pain from settling down. If you have been doing triceps stretches for an injured tendon and it hasn’t been getting any better, see what happens if you leave them out for two weeks: Are you starting to see any improvement? Some alternatives to doing triceps stretches are massaging the muscle and stretching your arm across your body with a straight elbow - this stretches part of the top of the triceps but avoids compressing the tendon over the elbow. This position stretches part of the top of the triceps but avoids compressing the tendon at the elbow. Take care not to stretch your triceps tendon too much unintentionally. For example, try to change your sleeping position if you usually sleep with a deeply bent elbow, and check whether you have a habit of resting your chin in your hand while your elbow is resting on a table or desk. Reduce the load on your injured triceps tendon One of the first questions many of my triceps tendonitis patients ask me is, “Can I still work out with triceps tendonitis?” The short answer is yes, but there is a BUT. This is an overload injury, so you can’t continue with business-as-usual; it will just keep on overloading your tendon, and the pain cycle will persist. For your tendon to recover, you have to reduce the load you put through it to a level that it is currently able to tolerate. This is called relative rest; as opposed to complete rest, it does not require you to drop all activities. Identify those activities that really aggravate your injury and either cut them out (for now) or reduce them (for now) to the point where your tendon pain doesn’t get any worse. For some athletes, it may be that they need to avoid all exercise that involves the triceps action, so no push-ups, bench presses, overhead presses, etc. But for others it will just be that they need to reduce the load that they put through their tendon and perhaps increase the recovery time between exercises and also between training sessions. It may be that you have to bring the weight right down and really start with baby weights to find a level that doesn't actually aggravate it, or do your push-ups on your knees and not in the usual full plank position. Also, especially at the beginning, go for exercises that do not cause your elbow to bend past 90 degrees, to avoid compressing the tendon against the elbow bone. So, just working it from 90 degrees to straight rather than from a fully bent position. Tendons are sneaky things, and they sometimes only complain the next day if you’ve worked them too hard. So, the trick is to figure out what is the most you can do with it without increasing your pain during the session or in the 24 hours afterwards. Exercises for triceps tendonitis However, to make your tendon as strong as before, your exercises should increase in weight and difficulty as you recover. Tendons need strength exercises that gradually increase in difficulty to: stimulate the production of new, healthy collagen fibres, align the newly formed collagen fibres into that strong, parallel structure, and then make them as robust as before you got injured. You can play with three things to manage this, two of which you’ll be familiar with if you’ve been doing weight training for some time: You can increase the weight, and you can increase the sets and reps. For injury rehab, it’s better to increase only one of these two factors at a time. And thirdly, you can (and should) increase the range of motion of your arm so that you can eventually straighten it against resistance from a fully bent position. The process of increasing the difficulty of your strength exercises should happen very gradually. Use pain as your guide. An exercise is at the right level: if you don’t feel pain at more than a niggle level (about 3 out of 10) while you're doing it, if there’s no flare-up or increase in pain in the hours afterwards, and if it’s not more painful the next day. If you get a delayed pain response that lasts for more than just an hour or two and it's more uncomfortable the next day, what you did the previous day wasn't right for it, and you need to dial things down a bit. Massage for triceps tendonitis Massage can make your injury feel less stiff and reduce the pain for a few hours, but it will contribute nothing to the healing process because it won’t make your tendon any stronger. Make sure that whoever is doing the massage doesn’t grind your tendon against your elbow bones, because that will just irritate the tendon further and cause more pain. Let them concentrate on the triceps muscle belly rather than the tendon. Massage can provide temporary pain relief and reduce muscle tension. Shockwave The very little research that has been done on this doesn’t indicate that it’s very useful. However, if you’ve tried rehabbing your tendon with strength exercises as described above for at least 12 weeks and it has not worked, it's something you could consider. PRP injections Again, there's not a lot of research out there about it yet, so I can't really say whether it works or not. But if you've tried rehab properly and it hasn't really worked, it's always worth trying this. Here’s our article about PRP injections for sports injuries . How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References: Donaldson, O., et al. (2014). "Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies." Shoulder & Elbow 6(1): 47-56. Jafarnia, K., et al. (2001). "Triceps tendinitis." Operative Techniques in Sports Medicine 9(4): 217-221. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the "tendinitis" myth. BMJ. 2002 Mar 16;324(7338):626-7. Lappen, S., et al. (2020). "Distal triceps tendinopathies." Obere Extremität: 1-5. Taylor, S. A. and J. A. Hannafin (2012). "Evaluation and management of elbow tendinopathy." Sports Health 4(5): 384-393. Shybut, T. B. and E. R. Puckett (2017). "Triceps ruptures after fluoroquinolone antibiotics: a report of 2 cases." Sports Health 9(5): 474-476.

Distal biceps tendonitis (also called lower biceps tendonitis) is an injury that typically affects people who do weight training in the gym, but it can also affect those doing certain other sports. In this article, I explain the causes of this lower biceps pain and the treatment for distal biceps tendonitis. There are also some guidelines on how to tell a distal biceps tendon tear from a tendonitis. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: What is distal biceps tendonitis? Sussing out the symptoms: Is it a distal biceps tendon rupture or a tendonitis? Distal biceps tendonitis treatment How we can help We've also made a video about this: What is distal biceps tendonitis? Your biceps muscle is anchored to your skeleton with three tendons: two at the top ( here’s a video about injuries to those ) and one at the bottom. The lower biceps tendon, which is also called the distal tendon, runs across your elbow and attaches to the bones in your forearm. Distal biceps tendon anatomy. Picture credit: Wikimedia The biceps muscle has two functions: It flexes the arm, i.e. it bends your forearm upwards, towards your shoulder, e.g. when you do a bicep curl. It also supinates your hand, which means it turns it outwards, e.g. when you turn a doorknob clockwise with your right hand or counterclockwise with the left. A tendonitis develops when you overwork or overload the tendon. So, any exercise or work that involves flexion of the forearm or supination of the hand that you overdo can cause an injury of the distal biceps tendon. It can be a sudden overload, for example when you do one gym session that’s a lot harder than what you usually do, and the next day or hours later it starts aching. Or it can be a cumulative overload, where you've done quite a lot of hard training over several weeks, and the tendon has not had enough time between sessions to repair the micro-damage from the training, so instead the damage accumulates over time. Sussing out the symptoms: Is it a distal biceps tendon rupture or a tendonitis? A tendonitis might become gradually more painful during a game or training session. But sometimes, the pain only starts hours later, or you even wake up the next morning and you go, ‘What's wrong with my tendon? It's really painful!’ However, if you’ve experienced a sudden, sharp pain during a training session or game, there’s good reason to suspect that you may have a distal biceps tendon tear rather than a tendonitis. If this is the case, you need to see a doctor who can do an ultrasound scan or an MRI scan to see the extent of the damage. The hook test - picture from Bain et al. 2010 You could also do the hook test if you want to get an initial indication of whether you’ve ruptured your tendon. If you tense your biceps muscle, you should be able to feel the distal tendon, and you should be able to hook your finger underneath it. If you can do that, it means that the tendon is not totally torn off. It can still be a partial distal tendon tear if you felt a sudden sharp pain, but there's still some tendon left. If you can't feel your tendon and you can’t hook your finger under it, you really need to see a doctor because you may have actually ruptured your tendon totally. Another indication of a distal biceps tendon rupture is called the Popeye sign, where your muscle is bunched up on your upper arm even though you’re not tensing it. This could mean that you’ve ruptured either the distal biceps tendon or one or both of the top ones and now the muscle has contracted. Distal biceps tendonitis treatment If it is a tendonitis and not a tear, how can you get it better? When you have a tendonitis, the structure of the tendon changes; it becomes a little bit more pliable, it loses some of its strength, and it can't handle all the stress from the sports you want to be doing. If you carry on with your training or sport as if it’s business as usual, the pain will just escalate and, when eventually have no option but to take it easy and start treating it, your recovery time will be longer. Relative rest as part of distal biceps tendonitis treatment This doesn’t mean that you have to take a total break from being active. Careful strength training is the best way to get your tendon back to its full capacity, but first you have to decrease the load on it – the amount of work that you’re asking it to do. This article explains the concept of relative rest within the bigger scheme of recovering from sports injuries in some detail. How much you have to rest it and what you can do will depend on your case and how bad it is. Most of the time, if the tendon is acutely flared up, it's good to go easy on exercises that involve flexing the elbow or supinating it. So, if we think of gym exercises, it'll be things like pull-ups and biceps curls that should be reduced. Exercises where you push stuff away from you are usually okay. The golden rule here is: If it causes you any pain during this first period of recovery, just don't do it, or reduce your weight to a level where it doesn’t hurt. Let’s say you usually use 30 kg with biceps curls; it may mean that with your injured distal bicep tendon, you've got to come right down to about 10 kg and see if it can handle that. So, you have to establish a baseline of what activities the tendon can still do that don't flare it up. And then you have to use that and slowly build up from there until you get back to the weights that you used to be able to do. All this is a bit trickier if your activity isn’t weights. Some people can get distal biceps tendonitis through tennis, for example, and I know of a young girl who got it from swimming. In this case, you have to figure out where the weakness in the kinetic chain is. What is it about your technique that puts too much strain on that tendon? How can you change your technique to prevent this from happening again and to give your injured tendon some respite while you recover? Strength exercises for distal biceps tendonitis treatment Even if weight training isn’t your thing, you’ll have to do strength exercises to get the tendon back to at least its original strength, if not stronger than before. As we’ve seen above, there are two motions that you have to strengthen the tendon for. There’s flexing the elbow so that the forearm moves towards the shoulder, but there’s also turning the hand outwards. Start really easy I find with biceps tendonitis – especially the distal tendon – you have to start at a really easy level. Start much lighter than what you think you should. Especially if you're a big bloke or a really strong girl who's been doing lots of heavy lifting, you might think, ‘10 kilos, that's nothing!’ Your distal biceps tendon may not feel the same way. Monitor the 24-hour response Often, a tendon won’t tell you that it's hurting while you’re doing the activity; it will only be hours later or even the next day. So, you've got to monitor it over the 24 hours after a strength training session, and if you find that it’s fine, you can go a little bit heavier the next time. If you find that it's there-or-thereabouts, that it's not quite happy with it but it's sort of okay and it calms down within that same day, I would stick with that session until it's comfortable, and only then should you increase the weight. Recovery time Make sure you give your tendon enough recovery time between sessions. Some of our patients do well with twice a week, so that there’s a nice, big recovery gap between sessions. Others can handle three times a week. Daily activities Be aware of how your daily, non-sporting activities can influence the healing process. Everyday things like carrying shopping bags or lifting your child up can irritate that tendon. If you have a job where there's a lot of lifting involved, you're going to have to make a plan to give your tendon a bit of a rest, so have a talk with your manager. If you can skip one week of house cleaning or get someone else to carry things for you for a couple of weeks, go for it, so that you can better concentrate on your rehab for your distal biceps tendon to strengthen it back up. As it gets stronger, you can integrate those daily activities into your life again. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Donaldson, O., et al. (2014). "Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies." Shoulder & Elbow 6(1): 47-56. Luokkala, Toni, et al. "Distal biceps hook test–Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction." Shoulder & Elbow 12.4 (2020): 294-298. Bain, Gregory I., and Adam W. Durrant. "Sports-related injuries of the biceps and triceps." Clinics in Sports Medicine 29.4 (2010): 555-576.

Biceps tendonitis pain is one of the more common types of shoulder pain. This article explains what causes biceps tendonitis, what biceps tendonitis feels like, and how to rehab it, including exercises to do and activities and exercises to avoid. It also discusses recovery times for biceps tendonitis. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. In this article: Anatomy and function of the biceps muscle and tendons What causes biceps tendonitis? What does biceps tendonitis feel like? Treatment for biceps tendonitis Alternative treatments Biceps tendonitis recovery time How we can help We’ve also made a video about this: This article is about proximal biceps tendonitis, at the upper or shoulder end of the biceps muscle. We also have an article on distal biceps tendonitis , at the lower or elbow end of the muscle. Anatomy and function of the biceps muscle and tendons The bicep muscles are your “guns” that run from the font of your shoulder down to the crook of your elbow. Picture adapted from wikimedia The shoulder end of the muscle has two heads – the long head and the short head. The long head is attached directly to your shoulder joint via a tendon, and the short head is similarly attached to the coracoid process, which is a bit of bone sticking out from the top of your shoulder blade. Biceps tendonitis most commonly affects the long head's tendon but it can affect either or both of these tendons. The biceps muscle has three main functions 1. It bends the elbow When you stand with the palm of your hand facing forwards or up (forearm in supination) and bend your elbow (do a bicep curl), it’s the biceps doing most of the work; it doesn’t do much work when you do this movement with your palm facing inwards or down. The biceps muscle does most of the work when you bend your elbow with your palm facing up. The biceps muscle does not work as hard when you bend your elbow with your palm facing in or down. 2. It helps to flex the shoulder Its second function is to help your other shoulder muscles to lift your arm upwards (shoulder flexion), like when you’re lifting something above your head. 3. It turns the forearm out (supination) The third function is to help rotate the forearm outwards (supination) What causes biceps tendonitis? There are three types of causes of biceps tendonitis: overload, overstretch (especially if it’s combined with added weight), and poor biomechanics. Overload The most common cause of proximal biceps tendonitis is that the tendon has been worked too hard to an extent that it isn’t used to or not allowing enough recovery time between workouts. So, we’re talking about something like a pull-up challenge, massively ramping up the weight on your bicep curls, or a marathon session in front of a one-armed bandit. Even a sudden increase in household activities that requires you to either lift your arms above your head or carry heavy things can cause trouble, e.g. redecorating the house. Any sudden increase in activity that uses the biceps muscle can cause biceps tendonitis. Overstretching or excessive compression A second cause is overstretching, where the tendon is stretched too tight over the bones. This can cause excessive compression between the shoulder bone and tendon which then causes it to get injured. An example is when you go too far with certain yoga positions. And during the lockdowns of the COVID-19 pandemic, I had quite a few patients who got biceps tendonitis from doing triceps dips with their arms behind them – typically off the edge of a chair or coffee table. In that position, your upper bicep tendons are really stretched and compressed over the bone and can get irritated if you don’t have good strength and control in your shoulder girdle. Tricep dips stretch the biceps tendon while also loading it and can cause biceps tendonitis if you lack the strength to control the movement properly. Poor biomechanics Lastly – and this is especially the case with swimmers and people who do racket sports – biceps tendonitis can be caused when the muscles that stabilise the shoulder blade aren’t strong enough to do their job properly towards the end of a long session. When these muscles are tired, the shoulder blade tilts further forward than it should, and this leads to more compression and friction than the biceps tendons are used to. This is also the reason why you should avoid rounding your shoulder girdle while lifting weights. What does biceps tendonitis feel like? Tendons are sneaky things. Often, they won’t complain at the time when you’re overworking them, only to pipe up hours later or even the next day. So, it could be difficult to trace the cause of the pain. When the pain caused by proximal biceps tendonitis does arrive, it is over the front of the shoulder, and it is painful when you press directly on the biceps tendon in that area. If the tendon is very irritated, you may even feel the pain down your arm, in the biceps muscle itself. The muscle can also feel tight, and if your nerves are affected (they run close to the tendon), you can get a tingling feeling. There are other conditions that may cause similar symptoms. A tingling feeling might be due to nerve issues in the neck, and your pectoral and rotator cuff muscles are attached to your skeleton in the same area. In fact, upper biceps tendonitis is often misdiagnosed as a rotator cuff injury. An indication that it might indeed be your biceps tendon causing the trouble is if it hurts when, with the palm of your hand facing up, you curl up your forearm or lift your arm up towards the ceiling against resistance. However, other muscles also contract during these movements, so it’s not a 100% accurate test. Seeing a physio would be useful, because they will ask you some specific questions and make you do some movements to piece the puzzle together. Treatment for biceps tendonitis The treatment for biceps tendonitis comprises two aspects: Treatments that help the pain to calm down. These include using ice, relative rest, avoiding certain exercises and activities, and performing gentle exercises. See the sections below for more details on each of these. Exercises that restore the strength and endurance in your injured tendon. Here is the clip from our main video about the treatment of upper biceps tendonitis. At some of the exercises discussed below, we have provided a time stamp of where in the video you can see a demo. Treatments that reduce pain The early stage of rehab refers to when the tendon is still really painful, and any type of exercise or activity easily makes it worse. The right treatment here is to give it a bit of breathing space and to get the pain levels down to where you can start doing some strengthening exercises. Ice Ice is really useful for calming the irritation down. We have an article with more information on using ice for sports injuries . Relative rest Relative rest means that you don’t have to rest your tendon completely. Instead, you adapt your daily activities and training so that you cut out all the things that aggravate your pain but continue with the activities that don’t affect it. When done correctly, relative rest can help to preserve your strength and speed up your recovery. Remember to check the 24-hour pain response. Tendons will often feel absolutely fine during an activity only to flare up and hurt a lot more several hours later or even the next day. The guideline for relative rest to be effective is: You can do any activity as long as it doesn't cause an increase in pain during and within the 24 hours after completing the activity. Stretches for biceps tendonitis Avoid stretching your shoulder backwards - this includes doing pec and bicep stretches as well as movements that take the biceps into a stretch position. Avoid stretching your biceps tendon during the early stage of rehab. One of the symptoms of biceps tendonitis is a stiff feeling in the biceps muscles, so many people are naturally inclined to want to stretch. However, the stiffness is due to the irritation caused by the injured tendon and will only permanently go away once your tendon starts to recover. Injured tendons don’t like being stretched. When you stretch the biceps muscle, you also stretch the tendon and, whilst that can feel really good and satisfying in the moment, it often causes it to hurt more later, or it’s the reason why the pain does not want to settle down. A better solution to help relieve that tight feeling is to massage the muscle. Just be careful not to massage too hard over the biceps tendon itself, because that can further irritate it and also cause it to hurt a lot more several hours later. And if someone tells you that your tendonitis is due to a tight biceps muscle that needs to be stretched, don’t listen to them. Biceps tendonitis is not caused by overly tight muscles. Everyday activities to avoid When you lift your arm towards the ceiling, the space in the front of your shoulder joint reduces as the bones move closer together, and they press on your biceps tendon. This is normal, and for a healthy tendon this isn’t a problem; but when the tendon is injured and sensitive, this can really irritate it. This is why, during the early stages of recovery, it is best to avoid positions that lift your arm above 90 degrees shoulder flexion or where you have to keep it at that level for a prolonged period of time. You’ll be surprised how often we move our arms into that position. Be careful with seemingly innocuous activities that can cause compression or friction on the tendon. Obvious movements to avoid are things like washing windows and hanging the washing out to dry. But there are several less obvious activities that can cause trouble. For example, when you’re driving, it would be better to grip the steering wheel towards the bottom than at the top. If you sleep on your front with your arm up next to your head, try and change that position so your arm is next to your body. Sleeping with your arms up causes a low level of compression on your shoulder tendons and can increase your pain. If your job involves sitting at a desk and working on a computer, make sure that your chair is high enough and you sit close to the keyboard, so that your shoulders are not as flexed and your biceps muscles and tendons don’t have to work too hard to keep your arms stretched out. Keeping things moving – exercises that can reduce pain You have to rest your tendon, but not moving enough can also make an injured tendon ache more. (This is why relative rest is better than total rest.) Pendulum exercise A nice, gentle way to get some movement going is to lean slightly forwards while supporting yourself with the uninjured arm on a desk or table and to let your injured arm swing gently back and forth and from side-to-side – nothing more vigorous than the pendulum of a grandfather clock. The pendulum exercise can help reduce your pain when you have biceps tendonitis. See video for demo: 00:12:32 Place your uninjured side's hand on a table and bend over so your injured arm is hanging down relaxed. Gently swing your arm forwards and backwards, or side to side. You may find that it hurts if you swing to vigorously or into a specific direction, so keep the movements gentle and choose the direction that feels most comfortable. Avoid doing circles, because that can often irritate the tendon - stick to straight lines. Do this for 30 seconds. Come upright and rest for 30 seconds. Do 3 sets. Do this 2 to 3 times a day. Shoulder blade positioning A movement that will create some more space for your tendon is opening up the space in the front of your shoulder by gently rolling your shoulder blades back from time to time. This reduces the pressure over the tendon and can make it feel a lot more comfortable. Gently rolling your shoulder back can reduce the pressure on your injured biceps tendon. See video for demo: 00:13:48 Grow tall – by lengthening your spine up towards the ceiling, you will find that your shoulders naturally move into a more open position. Your natural inclination might be to pull your shoulder blades down and back as much as you can, but this isn’t that useful for the biceps tendon because it can often make the bones press down on it more. The better way is to pull your shoulders up slightly and then roll them back gently. It's a very small movement. Hold the position for 10 seconds. Rest for 10 seconds. Do 6 repetitions. Do this 2 to 3 times a day, and correct your position every time you become aware that your shoulders have hunched forward. Biceps tendonitis exercises that strengthen the tendon Once the pain has calmed down, you can gradually start to build the tendon’s strength back up. The key word here is “gradually”. If you were doing weights, forget about what you used to be able to do, and try out every exercise with super light weights first. It’s easier to increase the weight when you feel it's too easy and doesn't flare it up than to start out too heavy, irritate your tendon, and then having to go back to square one and wait for it to calm down again. Also, in the first few weeks, don't do strength training that involves lifting your upper arms higher than 90 degrees, because we still want to avoid compression of the tendon at this stage. Bicep curls Check the position of your elbow. If your elbow is going to be at your side or further behind your trunk, it will stretch the tendon more than when you have it out in front of you (supported). So, seated bicep curls with your upper arm resting on or over something in front of you are better. Start with a very light weight and only do a few repetitions to test what your tendon can tolerate. Supporting your arm so your shoulder is flexed between 10 and 45 degrees can be useful. Seated rows These are useful for strengthening the muscles around your shoulder blades, which will lessen the compression and friction on your biceps tendon. Only pull your elbows back as far as your torso; pulling them back further during the early stages may irritate the tendon. Initially, avoid pulling your elbows back too far when doing the seated row exercise. Overhead press It is usually best to do these only to shoulder height or even a bit lower (about 80 degrees shoulder flexion) initially to avoid compressing the tendon while it is still irritable. You may also find that it is more comfortable to have your elbows slightly forward rather than straight out to the side. Initially, it may be better to start the overhead press movement with your elbows slightly forward - find the position that feels most comfortable. Once the tendon has calmed down significantly and my patients are able to lift weights without discomfort to 90 degrees shoulder flexion, it is usually time to start going higher. For the first few sessions, I then start my patients with just the weight of their arm. Only when their shoulders are happy to do three sets of 15 through full range do we start adding some weights. I don't recommend exercise bands for these; the resistance of the band increases as your arm goes higher, but your shoulder is normally not as strong in the fully extended position. So, as you get to the weaker range, the band is now tighter. It's a much better option to use light weights , so that the load stays constant throughout the movement. Here's a selection of weights in different price and weight ranges: If you don't have weights, remember that one litre of water equals 1 kg or 2.2 lbs. So, you can use bottles or other containers filled with water. If you want to increase the weight eventually and you don’t have bottles that are big enough, put a number of smaller bottles in a bag. The endgame As you carefully progress your exercises to become more difficult without flaring your biceps tendon up again, you should eventually aim to replicate the movements of your arm that your sport will require you to do, whether it’s doing weights, swimming, or tennis. Exercises to avoid (during the early stages) Turning your arm in and out An exercise that often aggravates the biceps tendon when it is injured is where you have your elbow tucked into your side, forearm parallel to the floor, and you move your forearm in and out against resistance (lateral rotation). The exercise is typically prescribed for rotator cuff injury rehab, and I think clinicians sometimes just assume it should be good for the biceps tendon as well. The reason it can often cause trouble when you have biceps tendonitis is that the rotation movement causes increased rubbing or friction on your injured biceps tendon, and that can make it hurt more. A better way to train your shoulder rotators is to start with isometric holds, but even these may aggravate the biceps tendon if it is still very sensitive. Rotating your shoulder against resistance often irritates the biceps tendon. Doing isometric holds may be a better option. See video for demo: 00:16:04 Stand with your elbow tucked in your side and bent to 90 degrees, forearm pointing forwards. Hold an exercise band in your hand so it is pulling straight out to the side. Now gently step away (very small step) from the band so it pulls on your hand, but resist the movement so that your arm continues to point straight forward. It should be a very light pull, just requiring a gentle activation of your muscles. If you're too aggressive, it will likely make your pain worse. Hold the contraction for 10 seconds. Rest for 10 seconds. Do up to 10 repetitions. Train it into both directions to work the internal and external rotators. Push-ups Avoid these until you have progressed quite a bit with the other strength training exercises, because they create a huge compression force on the bicep tendon. Push-ups often irritate the biceps tendon when you have biceps tendonitis. Start with low-load positions and then gradually progress from there. For example, start off by doing push-ups against a wall, then gradually progress to doing them with your hands on the edge of a table, then on the floor but on your knees, and then finally in the classic hands-and-feet position. Test different hand placements to find the most comfortable one for your shoulder. Alternative treatments Medication I’m not a doctor who can prescribe medicine, so check with your GP before you follow any of the following advice. Anti-inflammatories are not usually prescribed for tendon injuries, because inflammation is not a big component of this type of injury. However, if your pain just doesn’t want to go away, it could be that you also have an inflamed bursa in your shoulder. A bursa is a fluid-filled sac that is meant to reduce the friction between various body parts, e.g. between tendons and bones. But if a bursa experiences excessive compression or friction, it can become inflamed and painful. In that case, it could be useful to speak to your doctor to ask whether it's okay to take a short course of anti-inflammatories to see whether it makes a difference. Only consider using a corticosteroid injection as the very last resort. It works well to calm down pain, but it will do nothing to heal your tendon. In fact, steroids are harmful to tendons, and may have detrimental effects on long-term healing. Shockwave Shockwave can be useful, but it has to be introduced at the right time. If your biceps tendon is still very irritated and painful, shockwave is not the way to go. Biceps tendonitis recovery time If you follow the advice in the pain management section of this article, resting the tendon from all activities (exercise and daily life) that make the pain worse, your pain should calm down within a few weeks. However, the rehab period that follows this can be quite long. Tendon injuries generally take longer to heal than muscle injuries. If you have flared it up very badly or ignored it for a long time and continued to train with it, expect anything from four to six months of doing rehab exercises before it’s back to its former strength. Biceps tendonitis recovery time also depends on what you want to be doing. If you just want to get on with life, you could be looking at three months. However, if you’re seriously into stretchy or strength things like yoga or weightlifting, it could take up to six months or even more. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References: Cools, A. M., et al. (2014). "Rehabilitation exercises for athletes with biceps disorders and SLAP lesions: a continuum of exercises with increasing loads on the biceps." The American Journal of Sports Medicine 42(6): 1315-1322. Brukner P, Clarsen B, Cook J, Cools A, Crossley K, Hutchinson M, McCrory P, Bahr R, Khan K. eds. Brukner & Khan’s Clinical Sports Medicine: Injuries, Volume 1, 5e . McGraw Hill; 2017.

The answer to this question leans heavily towards no, but there may be some exceptions. Let me explain why cortisone shots should not be a first line treatment for tennis elbow and what to do if you do decide to have one. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: Why are steroid injections used for tennis elbow? Short term gain vs. long term harm What if I combine a steroid injection with physiotherapy? When could steroid injections be useful? Is a cortisone injection for tennis elbow painful? What should I do after I have a steroid shot? How we can help We discuss all the research-backed treatment options for tennis elbow in this video: Why are steroid injections used for tennis elbow? They are really good at relieving pain. Clinicians therefore often use them because they know they will likely have a happy patient … in the short term. Short term gain vs. long term harm The research  shows that steroid injections provide better pain relief than other treatments for the first six weeks. The problem is, when researchers  looked at the same patients 3, 6, and 12 months later, the ones who’ve had steroid injections are actually not doing as well as the ones who’ve not had steroid injections. So, steroid injections decrease your initial tennis elbow pain quicker, but after six weeks it then seems to slow your recovery down. Image from Smidt et al. (2002) showing short- and long term effect of steroid injections for tennis elbow. Other treatments like load management, physiotherapy exercises, shockwave, and injections such as PRP may not reduce your pain as quickly, but they seem to allow your injury to heal better in the long run. There is also evidence to suggest that people who have had more than one corticosteroid injection for their tennis elbow are more likely to have surgery later on. And steroid injections may also increase your chances of tearing your wrist extensor tendons; this is a small risk and it can be reduced by following a sensible rehab plan after your injection. What if I combine a steroid injection with physiotherapy? This has been tried, and it seems that the negative long term effect of the steroid injection still persists  despite following it up with physiotherapy. When could steroid injections be useful? If the benefits of short term pain relief outweighs the negative effect of slower healing. For instance, if someone has to complete an important test or exam that can significantly impact their life. Also if the pain is totally unbearable and not reacting to any other treatments, one could argue that a steroid injection may be an option. It is also something I would try before heading for surgery. Icing your elbow can help calm pain after the steroid injection. Is a cortisone injection for tennis elbow painful? Doctors often add a small amount of local anaesthetic to the injection, which means that you may experience immediate pain relief. However, it is not uncommon for a steroid injection to cause a significant pain flare-up the next day. The person injecting you will usually warn you about this and provide advice on what to do if it aggravates your pain. Icing the area for 10 minutes at a time can often help to relieve the pain. What should I do after I have a steroid shot? Do NOT jump into strenuous activity as soon as your pain subsides! The injection only took your pain away, it hasn’t strengthened your tendon. If you’ve had your elbow pain for quite a while, your muscles and tendons would have lost quite a bit of strength. So, it will be very easy to overload them and cause your pain to flare back up or worse, cause a tear. Instead, slowly ease back into activity and rehab exercises and slowly and progressively strengthen your arm to the level you need for your sport or daily tasks. We’ll discuss how to do this in a future article. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call  for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw  is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn  and ResearchGate . References Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. Coombes BK, Bisset L, Vicenzino B. Management of lateral elbow tendinopathy: one size does not fit all. Journal of Orthopaedic & Sports Physical Therapy 2015;45(11):938-49. Kemp, J. A., et al. (2021). "Platelet-rich plasma versus corticosteroid injection for the treatment of lateral epicondylitis: a systematic review of systematic reviews." International Journal of Sports Physical Therapy 16(3): 597. Orchard JW, Saw R, Masci L. The use of ultrasound-guided injections for tendinopathies. Current Radiology Reports 2018;6(10):38.

So, you’ve read the advice, watched the YouTube videos and been doing all the exercises, but your tennis elbow STILL isn’t getting better. Before you sink into total despair, let me explain a few common reasons why this might be the case and what you can do about it. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: Quick recap on what tennis elbow is So why isn’t my elbow pain getting better? And finally... How we can help I've also explained all of this in more detail in this video: Quick recap on what tennis elbow is Tennis elbow is that nagging ache on the outside of your elbow that tends to be more bothersome when trying to grip, lift or carry things. Most of the time, it has absolutely nothing to do with playing tennis , which makes the name ‘tennis elbow’ seem slightly daft. Tennis elbow’ is also known as ‘Lateral elbow tendinopathy’ and this is the term we’ll stick with for now, as this is the up-to-date term for it in the most recent scientific literature – it basically means ‘a problem with the tendons on the outside of the elbow’ . For some reason, medical people love to turn simple descriptions half into Latin, but ‘lateral elbow tendinopathy’ does fit the bill better than ‘tennis elbow’. What do tendons do? Tendons are there to attach muscles to bone. Many of the muscles in the back of the hand, wrist and forearm all attach via a common tendon to the outside of the elbow on the ‘lateral epicondyle’ – the source of pain in lateral elbow tendinopathy. When you grip, lift or carry things, these muscles are put to work and load the tendon attachment. Why do tendons get irritated? Like most of the tendon problems that start without any obvious trauma or accident, lateral elbow tendinopathy is usually caused by a mismatch between the load being placed on the tendon versus the load it can consistently cope with. In real terms, the sudden increase in load might have been from chopping a stack of logs, completing a DIY job, starting a new regime at the gym, or completing a particularly nasty CrossFit WOD. A sudden increase in any activity that requires gripping, pushing or pulling can lead to lateral elbow tendinopathy. Sometimes it can be from resuming normal activities but following a period of relative deconditioning – like if you had been out of action for a period of time, and sometimes it can be a more gradual build-up such as a change in job or workstation set up over a period of several months. Here's a more comprehensive article on the causes of tennis elbow . How do tendons recover? The earlier you deal with an irritated tendon the quicker it can recover. Generally speaking, the management of lateral elbow tendinopathy tends to follow the same stages as any other tendon problem: OFFLOAD  – temporarily modify activities so the tendon doesn’t get irritated and has a chance to settle down; REHAB  – address underlying individual biomechanical issues, work out what loads are tolerated without causing an increase in pain and start working on them (this is the bit a physio can be of most help after a thorough assessment); STRENGTHEN  – gradually add resistance to the exercises, strategically progressing the type and amount of loading, working towards your individual goal; RECONDITION / GRADUAL RETURN TO LOAD  – gradual return to the activity that may have caused the overload in the first place, but in much better condition so it doesn’t happen again! So why isn’t my elbow pain getting better? OK, so let’s say you know all that already. And it’s STILL HURTING. Here are the most common reasons, in my experience, why lateral elbow tendinopathy can fail to progress: 1. Inadequate offload Most of the YouTube videos and existing advice for lateral elbow tendinopathy tends to include ‘eccentric’ exercises for the wrist, slowly lowering the hand using a weight or a hammer – if you do these while the tendon is still irritated, this just overloads the tendon even more. It’s not the fault of the video makers or the leaflet writers, because some of the research on elbow pain suggests these are the exercises to do. BUT, that’s because elbows seem to be rather an unfashionable thing to research, so there really isn’t much good quality research out there. If there was, they would soon see the hammer exercises at the early stages are a bad idea and that giving it time to settle down first is more effective. When it comes to rehab exercises, timing is important. If you do the wrong exercises at the wrong stage of injury, you usually just make it worse. 2. Over treating Friction massage, heat balms, freeze rubs, anything that perpetually pokes at a painful tendon is likely to keep it irritated. If you were already angry, wouldn't it make you more irritated if someone kept poking at you? Leave it alone for a bit to let it settle down. Yes, massage may help reduce pain in ongoing cases, but constantly poking or rubbing the painful part can actually cause it to become more irritated. 3. Forgetting other factors It’s easy to think ‘elbow, elbow, elbow’ and concentrate only on the bit that hurts. But to get the elbow better, attention also needs to be paid to shoulder stability, core stability, ergonomics at work / in the gym, general fitness, diet, sleep, anxiety / stress, nerve irritation / sensitisation, or other medical conditions. All of these can contribute to elbow pain and might need addressing in order to get things better. 4. It might just need more time Unfortunately, a great deal of patience is often required for lateral elbow tendinopathy to get better. And we’re talking 3 to 6 months, if not more, most of the time. Why does it take so long? Most likely because it is REALLY HARD to offload an elbow tendon that you use every day for simple things, like pouring a kettle, opening doors and having a drink. Tendons are also mainly made up of collagen, and producing and strengthening collagen fibres takes much longer than producing muscle fibres for instance. So, if your symptoms are slooowly getting better and you find you can do more before it hurts (even though the pain is not gone yet), then it might just need more time. Tennis elbow recovery takes a long time because it's difficult to rest your arms properly and repairing tendons take much longer than other tissues in the body. And finally… When things aren’t getting better, it is important to get a qualified healthcare professional to assess you, whether it is your GP, a physiotherapist or a sports medicine physician. Just in case it isn’t what you thought it was. It is always worth trying simple treatment and rehab first, before seeking further interventions such as injections, shockwave therapy and surgery. Most of the time the basics, when done correctly, can not only solve the issue but address some of the underlying causes that went with it. Injections with corticosteroid have more recently been shown to provide short-term benefit, but symptoms tend to be worse in the intermediate term and the long term effects are not yet known. Research has also shown that Platelet Rich Plasma (PRP) injections have been ineffective in the treatment of persistent lateral elbow tendinopathy. Another recent clinical trial compared the outcomes for surgery for chronic lateral elbow tendinopathy with ‘sham surgery’ and found that both groups improved and were no different to each other at follow up – suggesting it wasn’t what was done in surgery that helped, it was what they did afterwards during rehabilitation that mattered. Food for thought. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call  for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can follow Steph on LinkedIn . References: Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Kroslak M, Murrell GAC (2018) Surgical treatment of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2018; 46 :1106–13 Millar NL, Murrell GAC, Kirwan P (2020) Time to put down the scalpel? The role of surgery in tendinopathy British Journal of Sports Medicine ; 54: 441-442 Olaussen M, Holmedal O, Lindbaek M , et al (2013) Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review BMJ Open Scott A, Squier K, Alfredson H , et al (2020) ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology British Journal of Sports Medicine ; 54: 260-262 Scott A, Docking S, Vicenzino B , et al (2013) Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012 British Journal of Sports Medicine ; 47: 536-544 de Vos R, Windt J, Weir A (2014) Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review British Journal of Sports Medicine ; 48: 952-956

Tennis elbow (also called lateral epicondylitis or lateral elbow tendinopathy) is an overuse injury and the most common cause of pain on the outside (lateral) elbow. We explain tennis elbow’s causes and how to know whether you have tennis elbow, including three simple tests you can do yourself. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. In this article: What causes tennis elbow? Why tennis elbow isn’t the best name for this injury The stages of tennis elbow (and why this matters) Pain is no indicator of the severity of your tennis elbow How to know whether you have tennis elbow How we can help We've also made a video about this: What causes tennis elbow?   Tennis elbow develops in the tendons that attach the muscles in your outer forearm to your outer elbow. These muscles work together to extend your wrist (bend it backwards). The most commonly affected muscles are the extensor carpi radialis brevis and extensor digitorum. The natural cycle of tissue breakdown and repair Tendons are made up mostly of collagen fibres, packed tightly in parallel. It is this parallel structure that makes them so strong. Structure of a healthy tendon under a microscope. When we exercise or do activities that use our muscles and tendons, they naturally sustain micro-injuries. These injuries are normal and signals to the brain that it needs to make these areas stronger.   👍 If you allow enough recovery time between bouts of work or exercise, the body repairs these small injuries so that the tissues grow stronger and stronger over time. This is why someone who has been doing a physical job or specific exercise for a long time can do so much more than someone who is just starting out. Where things go wrong 👎 If you don’t allow enough recovery time between hard bouts of work or exercise, or you ramp up the intensity or volume too quickly, the body doesn’t have enough time to repair all these micro-injuries. When they accumulate, they can cause overuse injuries like tennis elbow.   Typical activities that cause tennis elbow Any activity or action that overworks the wrist extensor muscles will also cause excessive force on the tendons and their attachments into the outer elbow and can cause tennis elbow.   Typical activities that can cause tennis elbow include: Typing Using a computer mouse DYI, e.g. using a screwdriver, painting, and bricklaying (especially if you’re not used to it) Gardening Knitting Carrying shopping bags for long distances Gripping, pushing, and pulling heavy weights Sports like tennis, squash, or gymnastics.   None of these activities have to be a problem – it is only when you do them excessively or you suddenly ramp up how much you do that the injury might develop. Why tennis elbow isn’t the best name for this injury   “Tennis elbow” is not the best name for this injury, since it’s rarely caused by playing tennis. (When it is caused by playing tennis, it’s mostly the backhand that’s the culprit.)   The medical term is lateral elbow tendinopathy. However, I’ll continue to use the terms tennis elbow and lateral elbow tendinopathy interchangeably, as the former is what most people know and understand.   Why not lateral epicondylitis or tendinitis? Medical terms that end in “itis” imply that inflammation plays a major part in the injury process, and this is simply not the case for overuse tendon injuries such a tennis elbow, as you’ll see in the next section. Lateral or outer elbow pain is often caused by activities like typing and DIY, so "tennis elbow" isn't really the best name for this injury. The stages of tennis elbow (and why this matters)   You tennis elbow will be in a specific stage of healing or injury depending on how long you’ve had it for. This matters, because the best treatments in the various stages differ quite a bit.   The three stages of tennis elbow (and other overuse tendon injuries) are:   1. Reactive tendinopathy This is typically the stage your tendon is in when you first injure it, e.g. your tendon pain and stiffness only started a few days ago.   What scans show:  When you scan the tendon, it typically shows an accumulation of fluid between the collagen fibres, but without any major structural changes or injuries to the collagen fibres. There may be a few inflammatory cells, but researchers seem to agree that inflammation is not the main cause of the injury. Microscope view of a reactive tendinopathy injury, showing fluid accumulating between the collagen fibres. Impact on recovery:  The good news is, if you apply the correct treatment during the reactive stage, the tendon can fully recover without suffering permanent structural changes.   The best ways to deal with tennis elbow during this stage are rest, load management, and treatments that will help it settle. The worst thing you can do during this stage is strength training exercises (more on this in our treatment article). The stage of your lateral elbow tendinopathy will determine what combination of treatments works best. 2. Tendon dysrepair If you don’t allow the tendon to rest and calm down and you continue to irritate it while it’s in the reactive stage (either through too much physical activity or perhaps by applying the wrong treatments), it might enter the dysrepair stage. Instead of healing, the injury gets a bit worse.   What scans show:  During the dysrepair stage, in addition to tendon swelling, you start seeing the collagen fibres moving away from each other and starting to lose their nice, strong parallel structure. It’s worth noting that this tends to affect only a small portion of the tendon – the rest of the tendon is usually still strong and healthy. There are usually also small blood vessels growing into the tendon, which are normally absent, and there are no signs of inflammation.   In the dysrepair and degenerative stages of tennis elbow, the collagen fibres lose their parallel structure. Impact on recovery:  Recovery tends to take a bit longer than in the reactive stage. There is evidence that the tendon structure can mostly revert to normal with the correct mix of load management and careful loading (learn more about this in our treatment article).   3. Degenerative tendinopathy Your tendon might have entered this stage if the tennis elbow injury has dragged on for several months.   What scans show:  The injured area of the tendon (remember, this is usually only a small part ) now show signs that the collagen fibres have been damaged and have totally lost their parallel structure. You also see many blood vessels growing into the area. There is no inflammation. Impact on recovery:  You can still restore full pain-free function in your tendon, but the injured area will likely not be normal again. Recovery now depends on getting the rest of the tendon (the uninjured part) to grow stronger and to take over the work of the injured part.   The best treatments  for tennis elbow during this period should focus on reducing pain and increasing the tendon’s strength with a training plan that gradually becomes more challenging. Pain is no indicator of the severity of your tennis elbow   The pain people experience when they have lateral elbow tendinopathy can vary dramatically. Some people may feel only a bit of discomfort or only have pain with activities that really load the tendon, e.g. carrying a heavy bag or gripping something strongly, while others may have lots of pain even when the tendon is not working.   It’s important to understand that pain is not linked to how severe your tennis elbow is . There's evidence that your tendon might show only a minor injury on scans, but your pain can be very intense, and vice versa.   Research has shown that the level of pain can be amplified when you’ve had your injury for longer than three months, are under a lot of stress (work or otherwise), don’t sleep well, and believe that the injury won’t get better. So, in addition to treating the tennis elbow itself, these are all factors worth addressing if your pain persists or is very intense. Just because your elbow hurts a lot does not mean that it is badly injured. How to know whether you have tennis elbow   Tennis elbow symptoms The best way to diagnose tennis elbow is to combine information from: What the symptoms feel like:  The main symptoms of tennis elbow are pain and stiffness. 💡If you’re getting tingling, funny sensations or numbness, it might mean that you’ve injured a nerve; this can be in addition to or instead of having tennis elbow. Location of the symptoms: The pain is mainly in the tendons of the wrist extensors or where they attach to the outer elbow. In ongoing cases, you may get some stiffness and pain going into your forearm or upper arm. 💡If you’re getting neck, shoulder, or wrist pain, it might be worth getting it checked by a physiotherapist, as you may have a different injury. The main tennis elbow symptoms are pain and stiffness over the outer (lateral) elbow. How the symptoms started: Tennis elbow symptoms usually start gradually during an activity, several hours after the activity, or you may even wake up with the pain and stiffness the day after an activity. 💡If your symptoms started when you felt a sudden, sharp pain while doing something, it might be a tear rather than tennis elbow. How the symptoms react to activities:  You usually experience pain with activities that require extending the wrist or gripping, pulling, pushing, or turning things. Some people may only feel mild discomfort, while others may get intense pain when they do something as simple as lifting a cup of tea. 💡If your pain is mainly aggravated when you move your elbow (without involving the hand) you might have an injury inside your elbow joint rather than tennis elbow. Tests for tennis elbow You can further hone the diagnosis with three simple tests:   Important:  You might not experience pain in all of these tests. If your symptoms fit the above descriptions and you have at least one positive test, you might have tennis elbow.   Cozen’s test The aim of this test is to strongly contract the wrist extensor muscles to see if it causes pain. The test focuses on the extensor carpi radialis brevis muscle, but all the other wrist extensor muscles also have to work. Sit with the arm to be tested straightened at the elbow. Turn your wrist so that your palm faces down and make a fist. Now, move your fist slightly inward (abduction) and up. Place your other hand on top of your fist. Now try to tilt your fist on the injured side upwards (extending your wrist) while pushing down on it with the other hand, creating a strong isometric contraction of the wrist extensor muscles – don’t allow it to move. If this causes pain over the outer elbow where the tendons run or attach, you might have tennis elbow.   Mill’s test The aim of this test is to stretch the wrist extensor muscles and their tendons to see whether it causes pain. Sit with your arm extended at the elbow. Turn your wrist so the palm is facing down and your hand is horizontal. Now use your other hand to push your hand downwards as far as it will do. If this causes pain over the outer elbow where the wrist extensor tendons run or attach, you might have tennis elbow. I often adapt this test – if it doesn’t cause pain at first – by getting the patient to make a fist with their hand before they push it downwards. This increases the stretch on the extensor digitorum and can sometimes cause pain if that is the tendon that is affected most.   Maudsley’s test This test targets the extensor digitorum muscle further by getting it to contract against resistance. Sit with your injured arm straight out in front of you and your palm facing down. Extend your fingers so that they form a straight line with your arm. Use your other hand to press down on your middle finger but resist the downward pressure by pushing back up with your finger; in other words, don’t allow your finger to be pressed down. If this causes pain over your outer elbow, you may have tennis elbow.   What about scans for tennis elbow? The best scans for diagnosing tennis elbow are ultrasound scans and MRI scans.   However, you usually don’t need a scan to diagnose tennis elbow. The few scenarios in which scans are useful are if your injury isn’t healing as expected or your doctor or physiotherapist suspect that you may actually have a different type of injury, e.g. a tendon tear or ligament injury.   Okay, so if you or your physio have figured out that you do have tennis elbow and in what stage of the injury it is, what do you do next? Here is our article on the best treatments for tennis elbow. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Cook, J. L. and C. R. Purdam (2009). "Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy." British Journal of Sports Medicine 43(6): 409-416. Cook, J. L., et al. (2016). "Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?" British Journal of Sports Medicine 50(19): 1187-1191. Coombes, B. K., et al. (2015). "Management of lateral elbow tendinopathy: one size does not fit all." Journal of Orthopaedic & Sports Physical Therapy 45(11): 938-949. Butler, D. and Mosely, L. (2013). Explain Pain. Noigroup Publications: Adelaide, South Australia.   Hanlon SL, Pohlig RT, Silbernagel KG. Beyond the Diagnosis: Using Patient Characteristics and Domains of Tendon Health to Identify Latent Subgroups of Achilles Tendinopathy. J Orthop Sports Phys Ther. 2021 Sep;51(9):440-448 Lai, W. C., et al. (2018). "Chronic lateral epicondylitis: challenges and solutions." Open Access J Sports Med: 243-251. Menon, N. A. (2024). "A Review of Lateral Epicondylitis Injection: Drugs Used, Injection Techniques and Guidance Method." Indian Journal of Physical Medicine & Rehabilitation 34(1): 21-26. Karanasios, S., et al. (2021). "Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials." Br J Sports Med 55(9): 477-485.

Peroneal tendonitis (or tendinopathy) is an overuse injury that causes pain over the outside (lateral) of your ankle or foot. You have three peroneal muscles, but peroneus brevis tendonitis is the most common, followed by peroneus longus tendonitis. In this article: Anatomy of the peroneal muscles How do you know that you have a peroneal tendinopathy? Common causes of peroneal tendinopathy in runners Top tips for treating peroneal tendinopathy We've also made a video about peroneal tendonitis: Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you. Anatomy of the peroneal muscles Both the Peroneus Brevis and Peroneus Longus muscles are located on the outside of your lower leg. The Peroneus Longus muscle starts from just below the head of the fibula. Its tendon runs behind the lateral malleolus of the ankle to the outside of your foot and wraps under your foot to attach the base of your big toe. The Peroneus Brevis muscle starts just above the middle of your fibula and runs down the side of your leg. Its tendon also wraps around the outside of your ankle and it attaches to the outside of your foot at the base of the 5th metatarsal bone (the knobbly bit you can feel on the outside border of your foot). Both these muscles help to point your foot down and to turn your foot out. They play a very important role in stabilising your ankle. How do you know you have a peroneal tendonitis? There are several different structures that can cause pain in the same area as the peroneal tendons so it’s always good to consult a physiotherapist to confirm the diagnosis. You may have a peroneal tendinopathy if: You have pain on the outside of the ankle or heel in the area where the peroneal tendons run. This pain is usually made worse by activities like running and walking and eases with rest. If it is tender or sore when you press on the peroneal tendons. Make sure you test the other side as well, because even healthy tendons can feel a bit tender when you press on them. It has to be more tender than your other foot to be significant. Turning your foot in fully (inversion) while it is pointing down (plantar flexion) may cause pain in the tendons. Remember, the pain you feel with this has to correlate with where the tendons are. This test can also cause pain in the ligaments or the tibial nerve (and its branches) if they are strained - where you feel the pain as well as the type of pain you feel is important when making the diagnosis. Trying to turn your foot out (eversion) against resistance may cause you pain in the tendons. I find in practice that this is not always easy to reproduce. Sometimes you have to contract the tendons in a lengthened position (inversion + plantar flexion) or do an eccentric contraction to elicit pain in them. Common causes of peroneal tendonitis in runners Lateral ankle sprains are one of the most common causes for this injury. When you sprain your ankle by turning it in, the tendons undergo a severe stretch injury. If you then neglect the injury and don’t rehabilitate it properly it can lead to peroneal tendonitis/tendinopathy. Chronic ankle instability. This usually develops as a result of an ankle sprain that’s not been treated properly which causes you to have poor control over your ankle. A sign that you may have an unstable ankle is when you find yourself spraining your ankle for no apparent reason – often when just walking. Not only do the peroneals strain every time you twist your ankle, but they tend to also get over-worked because the other muscles aren’t doing their part. This can easily be fixed through a good rehab programme that strengthens all the muscles around the ankle. Soft or very flexible shoes act as an “unstable” base when you walk or run. For some runners this can cause the peroneal tendons to overwork and strain as they will have to work a lot harder to try and stabilise your ankle than if you were wearing a less flexible shoe. Doing a lot of running on a cambered surface that forces your foot to turn in excessively (inversion) can also cause an overuse injury / tendinopathy in the peroneal tendons. Top 5 tips for treating peroneal tendonitis/tendinopathy Make sure that you wear supportive shoes. Strengthen all the muscles in the lower leg that support the ankle – especially the Soleus. Be careful when strengthening the peroneal muscles themselves – if the exercises are too hard you can make it feel worse. Make sure you retrain your position sense/proprioception so that your brain knows exactly where you ankle is. That way it can control it better when you run and walk. If you’re getting sharp pains/electric shock sensations/pins and needles go and see a physio because you may also have irritated the nerve that runs in that area. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. Best wishes Maryke About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References Brukner, Peter & Khan, Karim, (author.) (2016). Brukner & Khan's clinical sports medicine : injuries (5th edition). McGraw-Hill Education (Australia), North Ryde, N.S.W Hallinan JTPD, Wang W, Pathria MN, et al. The peroneus longus muscle and tendon: a review of its anatomy and pathology. Skeletal radiology 2019:1-16.

It’s important to understand that pronation of your foot or ankle is a normal part of how we walk. It’s only when it’s excessive or not well controlled that it may cause injuries. In this article I explain what exercises I usually prescribe to help correct overpronation. In this article: What is an ideal foot posture? Practising the components Putting it all together Video demonstration of exercises to correct overpronation What is an ideal foot posture? Our feet all look different and there is truly no ideal shape. I was trying to think about how to describe what I look for in people’s feet but have come to the conclusion that it’s easier to explain it in a video (see below). In short, we’re looking for an arch under the middle of the foot. This arch can be high for some people and very low for others. The important thing is that your arch should allow your foot (the subtalar joint specifically) to sit in a neutral position so that the foot does not form a big angle with the tibia by rolling in excessively (pronation). If your foot does sit in a more pronated position it will cause the ligaments and tendons on the inside of the foot to strain and the ankle joint on the outside to compress causing Sinus Tarsi Syndrome . I often find this to be the case if patients struggle with ongoing pain over the outside of their feet after an ankle sprain . It may also cause injuries in your knee and hip. Sometimes your foot may have a good posture while you’re standing but then roll in excessively when you’re walking or running. Strengthening the muscles inside your foot as well the ones that control pronation can help to support your arch, restore your foot’s posture and help you to control pronation better when you walk and run. Practising the components When teaching foot correction exercises, I usually break it down to the component parts first and do: Exercises that strengthen the intrinsic muscles inside the foot. These are meant to support your foot’s arch as your walk. Exercises that strengthen the muscles that control pronation like the Tibialis Anterior and the Tibialis Posterior muscles. Putting it all together Once you’ve got the hang of the basic exercises you have to put it all together. I usually get my patients to first practise correcting their feet in sitting. Once they can do it easily in sitting I get them to do it in standing and finally in more challenging positions like standing on one leg and while doing more dynamic movements. Have a look at the video below for some ideas. Video demonstration of exercises to correct over-pronation In this video, I walk you through some of the most basic exercises that you can do to help strengthen your feet and correct over-pronation. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate .

Tarsal Tunnel Syndrome is one of many conditions that can cause pain or funny sensations on the inner part of your ankle as well as under your foot. In this article, I'll explain what it feels like, how you can test for it, and what treatments may be useful. In this article: What it is What can cause it? What it feels like How do you test for it? Treatment for Tarsal Tunnel Syndrome Here's the video I did about this: What it is Your Tarsal Tunnel is located on the inside of your ankle. The tunnel is formed between the bones on the inner part of the ankle and a thick fibrous band (the flexor retinaculum) that runs from the medial malleolus to your heel bone. The Tarsal Tunnel contains the posterior tibial tendon, the flexor digitorum longus tendon, the posterior tibial artery and veins, the posterior tibial nerve and the flexor hallucis tendon. The posterior tibial nerve runs behind and below the medial malleolus and divides into two smaller nerves, the medial and lateral plantar nerves. Tarsal Tunnel Syndrome develops when the pressure inside the tunnel increases, compressing the posterior tibial nerve or any of its smaller branches. What can cause it? Tarsal Tunnel Syndrome can be caused by anything that decreases the space and therefore increases the pressure inside the tarsal tunnel. Some of the most common causes include: Changes in the foot anatomy e.g. when the foot arch flattens. Excessive pronation of the foot Thickening of retinaculum or the tendons that run inside the tunnel e.g. thickening of the tibialis posterior tendon when you have Tib Post Tendinopathy Cysts or growths inside the tunnel What it feels like We all have slight differences in where the tibial nerve runs and also at what level it splits into the medial and lateral plantar nerves. As a result you may find that where you feel your pain or symptoms is in a different area than other people with this condition. You can experience pain, throbbing, numbness, tingling or funny sensations on the inside of the ankle or underneath your foot, but it can also shoot up into your calf. The pain from Tarsal Tunnel Syndrome can easily be misdiagnosed as plantar fasciitis , because it can cause a similar pain under the heel. Nerve root irritation involving the L4, L5 or S1 nerve roots can also refer pain into that area. You can even have a “double crush” injury where the nerve can be stuck higher up the leg or in the lower back, causing it to pull extra tight around the ankle when you walk. This is why it is useful to consult a clinician who can listen to all your symptoms and test everything from your lower back down to your ankle. How do you test for it? Important! None of these tests are 100% accurate. This means that the test may sometimes produce pain even when you don’t have Tarsal Tunnel Syndrome and other times all the test may be pain free despite your nerve being compressed. The tests have to be combined with a full examination of the rest of your leg and lower back. Tinel’s test: You tap over the nerve in the area that you think it may be compressed. If it produces funny sensations or pins and needles, the test is positive and you may have Tarsal Tunnel Syndrome. Combined Dorsiflexion & Eversion test: You bend the foot up into dorsiflexion and at the same time turn it out into eversion. This position puts extra strain on the posterior tibial nerve. Combined Plantar flexion & Inversion: You point the toes down and at the same time turn the foot in into inversion. This position compresses the tarsal tunnel. Treatment for Tarsal Tunnel Syndrome Treatment for Tarsal Tunnel Syndrome has to be specifically designed for you. It has to address the reason why YOUR nerve is being compressed. Is it your foot’s position or thickened tendons or maybe an activity that you’re doing on a regular basis that is causing your problem? Conservative treatment consisting of soft tissue massage, dry needling and stretches can work well for some. Just be careful – calf stretches can sometimes make the pain feel worse. Orthotics or supportive insoles can also be useful to help reduce over-pronation. Strengthening the muscles that support the foot and leg may help for others. In cases that does not respond to conservative treatment, corticosteroid injections and immobilising the foot for a period in a boot may work. Surgery, where they release the nerve, is also an option and can give good results. However, that too doesn’t work for everyone. Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References: McSweeney, S. C. and M. Cichero (2015). "Tarsal tunnel syndrome—a narrative literature review." The Foot 25(4): 244-250. Tu, P. (2018). "Heel pain: diagnosis and management." American family physician 97. Raikin, S. M. and J. M. Minnich (2003). "Failed tarsal tunnel syndrome surgery." Foot and ankle clinics 8(1): 159-174. Yang, Y., et al. (2017). "Fine dissection of the tarsal tunnel in 60 cases." Scientific reports 7: 46351.