Author: Yagil Epstein October 20, 2021
As a tennis fan, player and coach, I can appreciate those moments when random body parts hurt on and off the court. We get to the court, pull out our racket and start hitting tennis balls with our friend without warming up. After a quick mini tennis, if we’re lucky, we move to full court and start rallying. We shank a few balls and reach for a few others and all of a sudden, our elbow starts hurting. We decide to continue playing since well, the weather is nice and the wind this calm. By the end of the hit things seem to be okay until we cool down and suddenly the injury is now. About half of tennis players will experience some form of tennis elbow at some point in their careers based on research gathered from the International Tennis Federation.
What exactly is tennis elbow and can you only get it from playing tennis.
Tennis elbow is also known as lateral epicondylalgia or lateral elbow tendinopathy. The name developed in the 1880s when a research paper first mentioned this injury as “lawn-tennis elbow”. It was described as frequent use of a backhand leading to a strain of the forearm musculature. At that time there were only a few known cases of the injury. Nowadays we have learned that this injury can occurs more with other repetitive movements than with tennis. The most prominent bone at the outside of your elbow is called the lateral epicondyle. This bone has many muscles attaching to it coming all the way from the fingers, wrist, and forearm. When we repetitively use these muscles or excessively strain them above capacity, we can create an injury to the area. Some examples include poor strokes in tennis while reaching for a ball or lifting a heavy bag in an awkward manner from the ground to the counter. People who use their hands a lot for work such as painters or hairdressers can also develop these symptoms. Even golfers can develop tennis elbow (in contrast with golfers’ elbow) as they impact the ground with their clubs. The bottom line is anyone can develop lateral epicondylalgia if they either overuse or overexert these tendons.
How to confirm you actually have tennis elbow?
There is no perfect test to confirm you have tennis elbow but certainly multiple tests can give you a good idea. If your pain is located specifically around the lateral epicondyle (usually 1-2 cm below this bone) that is a good starting point. You may also have pain when stretching your wrist downwards and pulling on that same region. Finally, you will usually have pain when contracting the wrist extensors, the muscles that help bring the wrist up against gravity with the palm down. These muscles are working when you grab something from the top of a shelf, type on the computer or shake someone’s hand. With tennis the one handed backhand, serve and overhead all stress the wrist extensors the most biomechanically.
There are many other injuries that can mimic these symptoms but if 2 or more of these are present along with a recent history of overuse of the area, tennis elbow is a likely possibility.
Preventing lateral epicondylalgia with proper equipment
Tennis racket
- bigger sweet spot: a racket that has a larger and more flexible sweet spot allows for better absorption of the ball on the racket even if you hit slightly off-center.
- Proper grip size for your hand - A grip that is too big or too small will inevitable force your wrist muscles to overwork and compensate by either squeezing the racket tighter or putting the muscles at a mechanical disadvantage when hitting the ball. To determine the proper grip size, measure the distance in inches between the tip of the ring finger to the long crease of the palm (2nd crease from the fingers) with the fingers together and relaxed.
Tennis strings
- Low tension and thinner strings allow for better shock absorption of the tennis ball similar to jumping on a loose trampoline
Tennis balls
- New balls that are dry and pressurized allow for less stress through the arm as they are lighter and more aerodynamic
Should I try using a brace?
Recent studies indicate mixed evidence on the effectiveness of orthotics or taping for lateral epicondylalgia. However, if you put a brace on properly and it does help relieve pain or increase the strength in your wrist significantly (15-20% minimum), you may consider using it specifically during tennis or with other wrist dominant activities. The brace spreads out the stress on the elbow more widely from the attachment site. I would highly recommend weaning yourself off of it as quickly as possible by following the suggested exercises or seeking professional treatment.
When can I return to tennis?
Generally, a quick and easy way to test things is by squeezing a ball with your arm outstretched. If it is pain free over multiple repetitions (30 times) then you are ready to try a progressive return to the court. Remember tennis is very repetitive and one contraction may be ok but multiple ones over time may hurt. Other activities that were sensitive during the injury should also be relatively pain free throughout 2-3 days. Try to listen to your body!
What exercises can I try if I think I have tennis elbow
Wrist stretching
Stretching the wrist downwards with the palm facing down can elongate the muscles and help release some tension developed over the attachment sites at the elbow. 2 sets of 30 seconds or 3 sets of 20 seconds is recommended. 
Wrist strengthening
**These exercises should be done progressively and done with minimal or no pain. Using a small weight or elastic tubing of about 2-3 lbs. of resistance, raise your wrist upwards 4 seconds against gravity all the way and control the descent down to the bottom for 4 seconds. This can be done with the wrist facing down and up.
Ideally 10 reps of 2-3 sets daily is recommended with a break of 1-2 minutes between sets. If it is too painful, you can just hold it up at the top for 30-60 seconds for 2-3 sets daily. Be sure to keep the wrist in neutral (3rd knuckle in line with the center of the forearm). This should initially be done with the forearm supported on a table, your elbow bent 90 degrees like the letter L with the arm and your body straight in an upright posture. To progress you may straighten the elbow further or add additional resistance. 
Wrist control exercise
With the forearm supported on a table, the palm facing down and the fingers relaxed, slowly raise the knuckles upwards to create a small tent with the hand. This movement helps dissociate the fingers from the wrist which decreases stress to the lateral epicondyle. Perform 10 repetitions for 2-3 sets daily. 
Pain relief
Icing: Although there are mixed opinions on the value of icing, when you have a new acute pain, ice is recommended for about 15-20 minutes over the region. Remember to keep a thin barrier between the ice and the skin.
General tips for prevention or return to tennis
- Progressive return: gradually increase court time, start with limited movement to the ball to perfect the form and progress from 30 minutes to 1 hour +.
- Warming up: this can be general for the entire body or more specific to the wrist. Circles or quick stretches at the wrist can help increase the circulation within the muscle and activate your body.
- Improving technique: sometimes getting a lesson or two at the start of the season can help improve your tennis form. Using your body while hitting the ball, contacting the ball in front of you or even supporting the racket longer with your non dominant hand during a backhand can all help diminish unnecessary stress to the elbow. Occasionally a transition to a 2 handed backhand may be necessary and discussed with your coach if deemed appropriate.
- Continuing exercises long term: The exercises provided are good for an acute injury but also for long term success at preventing its return.
- Changing tennis equipment: as mentioned earlier proper equipment does limit the risks of overuse to the wrist extensors during tennis strokes and can be valuable and necessary for certain cases of lateral epicondylalgia.
- Decreasing stressors outside of tennis: Sometimes the problem can be exacerbated by external factors such as work ergonomics or even vibrations when riding a motorcycle. Activity modification may be necessary on those fronts as well.
When is it time to seek professional advice?
There are no miraculous quick fixes to any injury and that includes tennis elbow. If you develop signs and symptoms of tennis elbow the first step is acknowledging the injury. You must immediately try to limit the inflammatory process from kicking into high gear. Rest, proper medications suggested by a pharmacist or doctor and activity modifications are all good starting points. If you’ve tried the above recommendations and the pain is not improving/ increasing, it’s time to seek proper medical advice. A physiotherapist can assess the injury further and confirm it is indeed a tennis elbow. Certain specific manual techniques, modalities or additional recommendations may be necessary to complete your recovery. Above all, we know how important tennis is to your well-being and will try to provide the quickest path forward back onto the court.
Yagil Epstein is an orthopedic physiotherapist practicing in Montreal, Quebec Canada. He runs a private practice, Physio 360 and teaches part time at the school of Physical and Occupational therapy at McGill University. Yagil evaluates and treats patients of all ages with orthopedic injuries while also creating customized training programs for prevention of reinjury. Yagil has a special affinity towards tennis
as he used to teach and continues to play recreationally. To reach him for any questions please visit his website www.physio360.ca or contact him directly at 514-944-8138.
References
- Bohy, Samantha (20 September 2017). Wrist extension with Resistance. Digital image.
University of Michigan health system. https://www.midmichigan.org/app/files/public/29882/Wrist-Strength-Exercises.pdf
- Coombes et al. Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic and Sport Physical Therapy. Nov 2015. Vol 45, 11.
- How to measure your grip size. Digital image. Anthem Sports. Anthem Sports 2020.
https://www.anthem-sports.com/tennis-racket-grip-sizes
- Tennis Elbow (2019, November). Retrieved from https://www.itftennis.com/media/2293/injury-tennis-elbow.pdf
- Thurston A.J. The Early history of Tennis Elbow: 1873 to the 1950s. Australian and New Zealand Journal of Surgery. March 1998. Vol 68, 3. 219-224
- Ziegler, Jane. (16 July 2019). 5 Awesome Stretches for Wrist and Elbow Pain. Digital image. Niel Asher Continuing professional education. https://nielasher.com/blogs/video-blog/117438533-5-awesome-stretches-for-wrist-and-elbow-pain
