Tennis Elbow Eccentric Exercise: The Tyler Twist With a Towel

You Don't Play Tennis, So Why Tennis Elbow — Starting Eccentric Exercise With a Towel

Have you ever gripped a mouse all day, then reached for a frying pan handle that evening, and felt something tear-like flare up on the outside of your elbow? Hearing the diagnosis 'tennis elbow' at the doctor's office can be confusing when you haven't held a racket in years. It's hard to see why that name applies to you.

In practice, most cases of lateral epicondylitis (tennis elbow) have nothing to do with tennis. Clicking a mouse, carrying a heavy grocery bag with your wrist bent, repeatedly torquing a screwdriver, or the moment your wrist bends while lifting a child — any of these can build up repeated microtrauma at the bony bump on the outside of your elbow where your wrist extensor muscles originate, and it can happen to anyone.

Search for eccentric exercise online and you'll find nearly the same explanation every time: your other hand lifts the weight, and only the lowering phase — done slowly, over 3-4 seconds — counts as the exercise. The principle is correct, but that explanation alone only reproduces half of the actual stimulus the tendon on the outside of your elbow needs. A simple flexion-extension exercise that only moves the wrist up and down in the extension direction is different from the twisting exercise physical therapist Todd Tyler designed, known as the 'Tyler Twist' — the two stimulate the same eccentric principle from different angles. And this twisting motion can be reproduced almost exactly with nothing more than a bath towel, no expensive equipment required. Related reading: Tennis Elbow Eccentric Loading Training, 12-Week Tendon Regeneration Protocol

From here, we'll walk through the towel-based home version of the Tyler Twist, the standard FlexBar version you can move up to once pain eases, and the eccentric wrist extension exercise you can try first during an acute flare — starting position, breathing, sets, and common mistakes, coached the way a physical therapist would walk you through it in person.

Why Slow Lowering Isn't the Whole Story — How Twisting Loads the Tendon Differently

Eccentric contraction is a form of muscle action where the muscle generates force while lengthening at the same time — the classic example being the moment you resist and control your wrist as it slowly bends from an extended position. This lengthening-under-tension stimulus has become, over the past several decades, a core principle in tendinopathy rehabilitation, driving collagen fiber realignment and restoring tendon stiffness.

A Specific Target: The ECRB

The source of pain in tennis elbow is, in most cases, a single muscle tendon: the extensor carpi radialis brevis (ECRB). This muscle is involved not only in extending the wrist but also in the combined motion of angling the wrist slightly toward the thumb (radial deviation). A movement that purely flexes and extends the wrist up and down only stimulates the ECRB in a simple extension direction — but the movements that actually trigger pain, like turning a doorknob or twisting open a bottle cap, are combined motions where extension and rotation happen together.

The Idea Behind the Tyler Twist

Physical therapist Todd Tyler, drawing on clinical experience treating professional athletes, observed that some patients plateaued when their recovery relied on pure extension-direction eccentric exercise alone. He designed a twisting motion using a rod-shaped elastic bar (FlexBar) that reproduces the exact combined extension-plus-rotation load the ECRB experiences in real life. Because the top hand twists the bar concentrically while the bottom hand (the affected side) unwinds it eccentrically, only the eccentric stimulus reaches the painful area — the other hand absorbs the concentric load entirely.

Why a Towel Can Reproduce This

What makes this twisting motion work isn't the elasticity of the tool itself — it's the structure where the top and bottom hands rotate in opposite directions and only the affected hand resists alone during the eccentric phase. Fold a bath towel lengthwise and grip it, and the towel's own resistance to twisting stands in for a low-resistance elastic bar. The intensity is lower than a FlexBar, but that lower resistance is actually appropriate during the early, more painful stage.

Exercise 1. The Towel Twist — A Tyler Twist With No Equipment

All you need is one bath towel (or a thick sports towel). Lay it out lengthwise, fold it two or three times along its length, and roll it into a grip about 4-5cm (1.5-2 inches) thick.

1. Starting Position

Sit or stand, bend the elbow of your painful arm to 90 degrees, and tuck it lightly against your side. Hold the rolled towel vertically with the painful hand at the bottom and the unaffected hand at the top, about 20-25cm (8-10 inches) apart. Keep your forearm perpendicular to the floor.

2. Movement Sequence

1. Both hands twist the towel inward together (like wringing out laundry), with the top hand (your unaffected, healthy hand) doing most of the work.
2. Hold for about 1 second at the fully twisted point.
3. Release all tension from the top hand and hold it fixed in place, while the bottom hand (the painful one) alone slowly unwinds the towel in the opposite direction over 3-4 seconds. This is the phase where the eccentric stimulus actually reaches the tendon.
4. Once fully unwound, the top hand helps again to return to the starting twisted position for the next rep.

3. Breathing Timing

Exhale in a short burst during the twisting (concentric) moment. During the 3-4 second unwinding phase, don't hold your breath — exhale slowly while counting one, two, three, four in your head. If you find yourself holding your breath while unwinding, that's a sign your whole forearm is bracing instead of just the bottom hand.

4. Sets, Reps, and Weekly Frequency

When starting out, aim to complete just 10 reps in 1 set, pain-free. After watching how you respond for a couple of days, if pain hasn't worsened, build up to 10 reps for 3 sets, 5-6 days a week, with at least one full rest day.

5. Common Mistakes and Corrections

• Mistake: The elbow drifts forward away from the torso during the unwind. Correction: Imagine pinning a thin book between your elbow and your side and keep it there. If the elbow drifts, your shoulder and whole arm take over, and the stimulus meant for the wrist gets diluted.
• Mistake: The whole forearm rotates instead of just the wrist. Correction: Fix your upper arm against your side and check in a mirror that rotation is happening only at the wrist joint.
• Mistake: Unwinding the eccentric phase in under 1 second. Correction: Practicing while counting out loud to four for a few days will build the right sense of pace naturally.

6. Stop If You Notice

Stop immediately if sharp pain suddenly spikes on the outside of your elbow during the twist, or if new tingling spreads toward your thumb and index finger rather than your pinky. If the outside of your elbow is noticeably swollen or stiffer than the day before the next morning, take that day off, and cut your reps in half when you resume.

Exercise 2. Moving Up to a FlexBar — The Standard Tyler Twist

Once you've done the towel twist pain-free for 2 weeks or more, it's time to move to a FlexBar, which lets you fine-tune resistance in stages. FlexBars are color-coded by resistance level (yellow and red are the lightest, progressing to green, blue, and black), giving you more precise control than a towel. Related reading: Tennis Elbow Chronic 12-Week NIR Program

1. Starting Position

Start with the lightest yellow or red bar. Hold it vertically, painful hand at the bottom and unaffected hand at the top, just as with the towel twist. Extend your elbow and bring it slightly forward in front of your body, keeping your upper arm against your side.

2. Movement Sequence

1. The top hand (unaffected) twists the bar roughly 90 degrees.
2. While holding the twist, raise your whole arm to shoulder height with the elbow straight (optional — add this advanced variation only if pain-free).
3. The bottom hand (painful) alone slowly unwinds the bar back to its starting position over 3-4 seconds.
4. Lower the arm and let the top hand help return to the starting position.

3. Breathing Timing

Exhale briefly during the twist and during the arm raise, then exhale slowly and continuously through the 3-4 second unwind. The advanced variation with the arm raise tends to speed up your breathing, so don't rush the pace.

4. Sets, Reps, and Weekly Frequency

The default is twice daily, morning and evening, 3 sets of 15 reps each. Only move up to the next color once you've completed at least 2 pain-free weeks on the current one.

5. Common Mistakes and Corrections

• Mistake: Starting straight away with a green bar or stronger. Correction: Bar color should be decided by pain response, not by strength. Even if yellow feels too easy, stay on it for at least a week before moving up.
• Mistake: Twisting with the shoulder instead of the wrist. Correction: Fix your upper arm against your torso, and use your other hand to lightly press down on the upper arm of the painful side while practicing — this makes it easier to feel rotation happening only at the wrist joint.
• Mistake: Adding the arm-raise variation while pain is still present. Correction: Only add the variation once you've completed the base movement pain-free for at least 2 weeks.

6. Stop If You Notice

Stop and drop back to the previous bar color if new pain appears on the inside of your wrist (the opposite side) while twisting, or if your grip weakens noticeably enough that you drop a cup. If elbow swelling hasn't settled after 3 days or more, see a professional.

Exercise 3. Eccentric Wrist Extension — A Foundation Move for When It Hurts the Most

If the twisting motion still feels like too much because your pain is too severe, it's safer to start with eccentric wrist extension, a pure extension-direction movement with no rotation component. All you need is a water bottle (start with an empty one, work up to 500ml-1L, or about 17-34oz).

1. Starting Position

Rest your forearm on a table or desk with your wrist and hand hanging off the edge. Turn your palm down and grip the bottle.

2. Movement Sequence

1. Use your unaffected hand to support the back of your painful hand and lift your wrist upward (into extension).
2. Release your unaffected hand, and let the painful hand alone slowly lower the wrist downward (into flexion) over 3-4 seconds.
3. Once fully lowered, your unaffected hand supports the back of the hand again to lift it back to the extended position.

3. Breathing Timing

Exhale slowly through the 3-4 second lowering phase, and inhale as your other hand lifts it back up.

4. Sets, Reps, and Weekly Frequency

Start with an empty bottle for 3 sets of 15 reps, and once that's pain-free, progress the water level to 300ml, then 500ml, then 1L. Do this 5 days a week, dropping the weight a level on days when it hurts more.

5. Common Mistakes and Corrections

• Mistake: Lifting with the painful hand alone from the start, with no help from the other hand. Correction: The lifting (concentric) phase must always be handled entirely by the unaffected hand. If the painful hand does the lifting too, you lose the pure eccentric-only stimulus.
• Mistake: The forearm lifts off the table. Correction: Keep your whole forearm pressed flat against the table and confirm that all the movement happens below the wrist joint.

6. Stop If You Notice

If pain on the outside of your elbow crosses 5/10 on a pain scale while lowering the wrist, or if it comes with tingling in your fingertips, drop the weight and go back to an empty bottle. If pain persists, take the day off.

To sum up the order: during an early, more painful phase, start with eccentric wrist extension to adapt to load in the extension direction; once pain settles, add the towel twist to bring in the rotation component; and finally move to a FlexBar to fine-tune resistance upward. You don't need to do all three at once — prioritizing the one or two that match your current pain stage is enough.

Weekly Progression Table: Where to Start and How to Build Up

The table below is a general starting point. Adjust your own pace based on how your pain responds.

If you've reached weeks 5-6 and pain hasn't eased from the week 1-2 level, it's safer to stay at the earlier stage longer rather than forcing the table's schedule — let your body's response set the pace, not the calendar.

When to Avoid These Exercises

These three exercises are safe for most people with tennis elbow, but if any of the following apply to you, see a doctor before self-treating. Nothing here replaces a medical diagnosis or prescription.

• Within 24-48 hours of an acute injury: If pain suddenly appeared after lifting something heavy and there's noticeable swelling or redness, that's an acute inflammatory phase — rest and ice come first, not eccentric loading.
• Tingling in the pinky finger: Because the ulnar nerve runs along the inside of the elbow, tingling in the pinky and ring finger alongside your symptoms calls for a check on possible nerve entrapment before moving on to self-directed exercise.
• Recently had a corticosteroid injection: Tendon tissue can be temporarily weakened for 1-2 weeks after an injection — resume exercise only after the timeline your doctor recommends.
• Sudden severe pain after trauma along with noticeable loss of strength: This can indicate a partial or complete tendon tear, and needs imaging.
• Reduced peripheral sensation from conditions like diabetes: If you can't reliably feel pain signals, you may not notice overload — proceed only under professional guidance.

Fitting This Into Your Day: One Towel Is All You Need

The equipment list is really just one towel, or a water bottle if you already have one. Rather than carving out new time, folding this into a routine you already have makes it far easier to stay consistent.

• Morning, right after washing your face: Roll up the towel you just used to dry your face and finish your first set at the sink or in front of the mirror.
• Lunch break, at your office desk: A handkerchief or a thin scarf works as a lighter substitute. Slip in a short set while seated.
• Evening, before or after washing dishes: A dish towel already in hand lets you go straight into a set with nothing extra to grab.
• Before bed, in bed or on the couch: Eccentric wrist extension works fine seated, so it's an easy one to finish with a water bottle while watching TV.

Why This Approach Is Evidence-Based

Tyler et al. (2010, Journal of Shoulder and Elbow Surgery)

Tyler and colleagues compared 21 patients with chronic lateral epicondylitis, one group receiving standard physical therapy alone and another receiving standard therapy plus FlexBar-based eccentric wrist extension-rotation exercise (the Tyler Twist). At 8 weeks, the group that added the Tyler Twist showed significantly greater improvement in pain scores and grip strength than the standard-therapy-only group. The limitation: a sample size of only 21 patients from a single institution means the results should be generalized to other patient populations with some caution.

Bisset et al. (2006, BMJ)

An Australian research team followed 198 tennis elbow patients across three groups — physiotherapy (eccentric exercise plus joint mobilization), corticosteroid injection, and wait-and-see — for one year. The injection group showed the fastest pain relief at 6 weeks, but also had the highest relapse rate after that point, while at the 1-year mark the physiotherapy group's full-recovery rate was significantly higher than either of the other two groups. This result is frequently cited as evidence that eccentric-exercise-centered physiotherapy, while slower to show short-term effects, delivers more stable long-term recovery. The limitation: the physiotherapy protocol in this trial included manual mobilization alongside the exercise, making it hard to isolate the pure contribution of eccentric exercise alone.

Cullinane et al. (2014, Clinical Rehabilitation)

This systematic review synthesized multiple studies on the effect of eccentric exercise in lateral epicondylitis and concluded that eccentric exercise showed an advantage over other conservative treatments for short-term pain reduction. The authors also flagged, however, that the individual studies included varied widely in exercise intensity, frequency, and outcome measures, which limits the confidence of any pooled conclusion.

Post-Exercise Recovery: Easing Forearm Soreness With Near-Infrared Care

Because all three exercises repeatedly load the forearm extensors in angles they don't normally work through, it's common to feel a muscle-soreness-like ache running from the outside of the elbow into the inside of the forearm right after exercising or the next day. In most cases, this is a normal response to the muscle adapting to a new direction of load, rather than a sign of tendon damage.

Applying near-infrared light to the outside of the elbow and the forearm extensor area, held 5-10cm (2-4 inches) from the skin, for about 10-15 minutes after exercising can serve as a recovery routine to ease that soreness. It's worth being clear that near-infrared light itself doesn't regenerate tendon tissue or treat pain, and it can't replace the exercise program — it's a supportive wellness measure only. Avoid it during acute inflammation (noticeable redness or warmth), and use it as a recovery aid only once post-exercise pain has settled down somewhat.