Author’s note: This is the fifth part of a series specifically devoted to the elbow. Be sure to check out Part 1 (Functional Anatomy) , Part 2 (Pathology) , Part 3 (Throwing Injuries) , and Part 4 (Protecting Pitchers) if you haven’t done so already.
Today, I’m going to cover a pretty common, yet remarkably stubborn issue we see at the elbow: tennis elbow.
It’s also called lateral epicondylitis, although the -itis ending may not do it justice (as we discussed previously in this series) because it is likely more of a degenerative - and not inflammatory - condition in the overwhelming majority of those who experience it. To take this naming conundrum a bit further, while the term “tennis elbow” is used to describe pain on the lateral aspect of the upper arm near the elbow, tennis players often experience medial elbow issues as well (golfer’s elbow) secondary to the valgus stress one sees with the forehand and serve.
In a tennis population, “tennis elbow” emerges almost solely from backhands (with the one-handed version logically being much more problematic), which require huge contributions from the extensors of the wrist to not only hold the racket, but stabilize the wrist against the vibrations from the racket as it redirects the ball. The path of the ball against the racket creates a destabilizing torque that wants to force the wrist into flexion, and it’s the job of these extensors to resist that movement.
The logical question for many is why does the pain occur at the elbow when the forces are applied so much further down the arm? The answer rests with the zones of convergence topic from Part 1 : there are lots of tendons coming together in congested area, creating friction and negatively affecting soft tissue quality. At the lateral epicondyle, you have the common extensor tendon, which is shared by extensor carpi radialis brevis, extensor carpi ulnaris, supinator, extensor digitorum, and extensor digiti minimi (the extensor carpi radialis longus and brachioradialis attach just superiorly).
If this doesn’t convince you of both the preventative and rehabilitative role of soft tissue work, then you might as well be living life with a bag over your head. Yet, it amazes me how many treatment plans for tennis elbow don’t have even the smallest element of hands-on work. Here’s a little demo from Dr. Nate Tiplady , with Graston and ART.
Soft tissue treatments, flexibility work, and progressive strengthening exercises for these degenerative tissues get the ball rolling - and you can find thousands of foo-foo forearm exercises and stretches online. Additionally, as Mike Reinold has reported, there is some research to suggest that elbow straps are slightly effective in expediting the process.
And, eccentric exercise for the wrist extensors tends to show the most promise for tissue-specific return to function. This is all well and good - but I think it sometimes overlooks a big fat white elephant in the room.
I worked at a tennis club for eight summers when I was growing up, doing everything from court maintenance, to racket stringing, to lessons, to scheduling court time. Toward the end of my eight-year tenure (around the time that I started getting involved with the fitness industry), I started to notice some interesting patterns.
When I looked out on the courts, about 1/3 of the participants were rocking tennis elbow straps (the research actually shows that about 40-50% of recreational tennis players get tennis elbow). Yet, when I was in the office with some professional tennis match on TV in the background, I NEVER - and I really mean that I can’t remember a single time - heard of a professional tennis player missing time because of tennis elbow. How in the world would a pro - who might spend about 5-6 hours a day on the court - not break down faster than an elderly woman who plays a) 5-6 hours a week, b) at a slower pace, c) predominantly in doubles matches (1/2 as many ball contacts), and d) against competition that hits the ball much more softly than a professional opponent? It really didn’t make sense - until I got involved with exercise physiology. Why?
1. The members were largely over the age of 40 - meaning that they were obviously as an increased risk of degenerative issues like tennis elbow, especially in light of their activity patterns.
2. The pros were also younger, and the two-handed backhand is markedly more common in the newer generation of players. The one-handed backhand still predominates in the “old guard.” Research has demonstrated markedly more complexity in the swing kinetics for the one-handed backhand - so there are more ways for things to go wrong in this older population.
3. This is the biggest one: the pros usually had a solid foundation of conditioning, meaning that they had the strength, power, coordination, footwork, and technical mastery to hit the ball in a biomechanically safe position. Novice players with poor technique often hit the hit the ball with the wrists flexed and not neutral; in other words, they lead with the elbow instead of the racket, taking the wrist extensors outside of their ideal length-tension relationship.
In a non-tennis population, lateral elbow pain is almost always a function of overusing the grip and having some really nasty, fibrotic soft tissue accumulations at the lateral epicondyle. In a tennis population, it isn’t just an elbow problem; it’s something that speaks to a lack of preparedness of the entire body, both physically and in the context of insufficient technical mastery.
In my eyes, tennis elbow rehabilitation should be treated much like a return to throwing program for a baseball pitcher. The injured individual should take care of the soft tissue, flexibility, and strength issues at the elbow, but he/she should also get involved in a strength and conditioning program to improve ankle, hip, and thoracic spine mobility ; core and scapular stability ; and strength and power of the larger muscle groups at the hips and shoulders that should be creating the power instead of the smaller muscles acting at the wrist and elbow.
If you’re slow to rotate your hips, you’re going to hit the ball late (wrist flexed). If you lack hip mobility to rotate to the ball, you’re going to hit the ball late (or chew up your lower back). If you lack core stability to transfer force from the hips, you’re going to hit the ball late. If you lack scapular stability or rotator cuff strength, you’re going to hit the ball late. Does anyone see a pattern? This is about everything BUT the elbow!
Instead, what have we done? We’ve done exactly what lazy people always does: created gadgets to avoid actually having to work hard!
In the 1990s, racket companies introduced oversized rackets, which have a larger surface area to minimize mishits (which increase vibrational stress) and increase power (at the expense of control). Screw getting better at tennis or improving your physical fitness; we’ll just make tennis easier! As an interesting aside to this, strings break more frequently on oversized rackets as well - meaning that companies make more long-term on follow-up string purchases. This sucker is 125 square inches (as a frame of reference, Pete Sampras played with a 85-square-inch racket):
Also in the 1990s, the titanium tennis racket was introduced. These things are insanely lightweight - to the point that it requires very little physical exertion to swing if you are a 60-year-old woman in a doubles match. So much for exercise!
We’ve handed out tennis elbow straps like candy so that people can get back out to play as quickly as possible rather than getting their bodies right and then practicing with a qualified professional who can instruct them on proper technique as part of a return-to-hitting plan. The straps can be very valuable if used appropriately - but not if used as a crutch to “get by” with poor movement patterns and a lack of physical preparation.
Is anyone else shocked at how comparable the rushed and careless return to action in adult tennis players is to what we see with young athletes trying to come back too quickly from ACL tears, rotator cuff strains, or stress fractures? They say retirement is the second childhood; I guess they’re right!
So, here are some take-home points on tennis elbow:
1. Take care of tissue quality at the lateral epicondyle alongside any flexibility and resistance training exercises for the muscles of the forearm.
2. Condition the entire body as part of rehabilitation.
3. Ease back into tennis participation, and do so under the supervision of someone who can correct the faulty mechanics in your backhand. Along those same lines, consider switching to a two-handed backhand if you have a history of tennis elbow.
Stay tuned for Part 6 to wrap up this series.