Counterforce strap bracing refers to a nonelastic strap placed around the proximal forearm (Fig. 10.3), with the intended therapeutic effect of reducing stress on the lateral epicondyle by decreasing force transmission across the extensor muscle tendon unit. Meyer et al. performed a combined cadaveric and clinical study showing a 13–15 % force reduction of the ECRB origin. Snyder-Mackler and Epler demonstrated a statistically significant decrease in ECRB and EDC muscle force recruitment with the counterforce strap, when compared to no strap, as measured by electromyography [17]. By inhibiting muscle expansion, the strap decreases the magnitude of muscle contraction, thereby reducing the tension at the musculotendinous junction proximal to the band [18]. Furthermore, the direct compression provided by the strap creates a secondary origin of the extensor tendons, which increases surface area and decreases stress and microtrauma experience by the true origin at the lateral epicondyle.

Struijs et al. performed a clinical trial randomizing 180 patients to a forearm band-type splint, physical therapy, or a combination of these and showed no significant differences at 26 and 52 weeks with regard to pain, disability, and satisfaction [19]. Success rates at 52 weeks ranged from 85 to 89 % within the three treatment groups. The same authors performed a meta-analysis that included all randomized clinical trials describing individuals with diagnosed lateral epicondylitis and comparing the use of an orthotic device as a treatment strategy [15, 20]. Only five studies met their inclusion criteria; overall, there were few outcome measures, large heterogeneity, and limited long-term results. None of the included studies investigated an orthotic as an isolated treatment modality. They stated no definitive conclusions could be drawn concerning the effectiveness of orthotic devices and that more well-designed randomized clinical trials of sufficient power are warranted [3, 15, 16, 20].

Altan and Kanat performed a short-term study of counterforce bracing versus a resting wrist splint and showed significant improvement in all parameters including pain at rest, pain with movement, and hand grip strength in the sixth week for both groups [21]. Comparison of the two groups showed significantly better improvement in resting pain with the wrist splint; otherwise other parameters were the same.

Van De Streek et al. from the Netherlands conducted a study comparing the effect of a forearm-based hand splint compared with an elbow band (counterforce brace) as a treatment for lateral epicondylitis. In this study they explored a new fabricated hand splint (thought to give more rest to the extensors of the wrist versus a cock-up splint) to an elbow band [22]. This was a randomized clinical trial with 43 patients. They were instructed to wear the braces for as much as possible for 6 weeks, with no other interventions. The outcome measures included maximal grip strength and patient-rated forearm evaluation questionnaire (PRFE). This study shows that the hand splint is no more effective than the elbow band as a treatment for lateral epicondylitis.

Garg et al. performed a randomized controlled trial (level of evidence II) investigating the clinical outcomes of a wrist extension splint with that of a counterforce forearm strap [6]. Among the 42 patients (44 elbows) investigated, they found that both modalities improved the Mayo elbow performance (MEP) and American Shoulder and Elbow Society (ASES) elbow assessment scores in the sixth week. The overall function was similar between the two groups. There was no significant difference measured between the braces with the ASES (p = 0.60) nor MEP (p = 0.63) scores. However, within the ASES derived score, pain relief was significantly better with the extension splint group (p = 0.027). No other variables were statistically significantly different. They concluded that the greater degree of pain relief with the wrist extension splint may be due to improved immobilization of the wrist extensor muscles in a resting position.

Derebery et al. reviewed the potential disadvantages of bracing in lateral epicondylitis, particularly in cases involving workers’ compensation [5]. They found that patients treated with splints had higher rates of limited duty (p < 0.001), more medical visits and charges (p < 0.001), higher total charges (medical and PT, p < 0.001), and longer treatment durations (p < .01) than patients without splints. They concluded that splinting patients with epicondylitis may not optimize outcomes, including rates of limited duty, treatment duration, and medical costs. This article was unique in that it illustrates the variable of worker’s compensation and potential negative impact on clinical outcomes.

Luginbuhl et al. performed a randomized study comparing the effect of the forearm-support band versus strengthening exercises for the treatment of lateral epicondylitis [9]. Twenty-nine patients with thirty tennis elbows were randomized into three groups of treatment: (I) forearm-support band, (II) strengthening exercises, and (III) both methods. Patients were evaluated at various time points over 1 year. At the latest follow up, there was a significant improvement of the symptoms compared to before treatment (p < 0.0001), considering all patients independently of the methods of treatment. However, no differences in the scores were found between the three groups of treatment (p = 0.27), indicating that no beneficial influence was found either for the strengthening exercises or for the forearm-support band. Improvement seems to occur with time, independent of the method of treatment used.