Tennis elbow is pain on the outside of the elbow, where the muscles that lift the wrist attach to bone. Most people who get it have never held a racket: it comes from gripping, typing, and lifting. The exercise with the best evidence treats it as a tendon that has lost its tolerance for load, and slowly gives that tolerance back.
A load problem, not an inflamed tendon
The old name, tendinitis, suggests swelling. When researchers examined the tendon they found a lack of acute inflammatory markers, which is why clinicians now say tendinopathy, and why anti-inflammatory tablets often do less than exercise. A 2021 review in the Journal of Clinical Medicine describes the pain as coming from impaired tendon healing. Rest alone rarely sorts it. Controlled loading does.
Why slow lowering helps
An eccentric contraction is a muscle producing force while it lengthens. For the wrist extensors that is the lowering phase: your hand drops toward the floor while the muscles on top of the forearm act as a brake. Lowering slowly keeps the tendon under tension for several seconds per rep, and that sustained load appears to be what the tissue responds to. The 2021 review pooled six trials with 429 participants and found that adding eccentric exercise to usual care reduced pain and improved strength more than usual care alone, though the authors call the evidence limited.
The Tyler twist with a rubber bar
The best known version comes from Tyler and colleagues in the Journal of Shoulder and Elbow Surgery in 2010. Twenty-one patients with chronic tennis elbow completed it. All had standard physiotherapy; half also twisted a flexible rubber bar eccentrically, three sets of 15 daily, about four seconds per rep, for an average of seven weeks. Pain improved 81 percent in the bar group against 22 percent with standard care, and strength 79 percent against 15. It is one small trial, but it changed practice.
- Hold the bar in the sore hand with the wrist fully extended, knuckles toward you.
- Grip the other end with the good hand and twist the bar, keeping the sore wrist extended.
- Bring both arms out in front with the elbows straight, holding the twist.
- Slowly let the sore wrist bend forward so the bar untwists over about four seconds.
- When three sets of 15 feel easy, move to the next stiffer bar.
The dumbbell version
Sit with the sore forearm flat on a table, palm down, wrist over the edge, holding a dumbbell of five pounds or less, or a soup can. Lift the wrist with the other hand, let go, and lower over three to five seconds using only the sore side. Cleveland Clinic suggests two sets of 12 to 15 at least twice a week for the first two weeks. The trials mostly used three sets of 15 once a day for six weeks to three months.
How much pain is acceptable
Most therapists accept mild pain during the set as long as it settles afterwards and is not worse the next morning. Sharp pain, pain that climbs through the sets, or an elbow that is more irritable each day all mean the load is too high. Cleveland Clinic calls pushing through pain a common mistake. Your therapist should set your limit.
Stretches alongside
- Wrist extensor stretch: arm straight, palm down, use the other hand to bend the wrist so the fingers point at the floor. Hold 15 to 30 seconds, one to three times a day.
For more on tempo, rest, and how long tendon programmes take to pay off, see our guide to dosing eccentric exercise for tendon pain
Doing this exercise in a guided session
Lowering speed is the whole point here, and the first thing to slip once you are tired. A camera-guided session in KineTrue shows your therapist whether each lowering took the full count, with your pain score beside it, so they can decide when to add load or ease off.
Check with a clinician first if the elbow is swollen, hot, or locks, if you have numbness or tingling into the hand, or if the pain started with a fall. Stop and get assessed if pain keeps climbing instead of settling, or if there is no improvement after six to eight weeks.