Home Baseball Content Understanding Elbow Pain – Part 5: The Truth About Tennis Elbow

Understanding Elbow Pain – Part 5: The Truth About Tennis Elbow

Written on May 25, 2010 at 4:37 am, by Eric Cressey

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.

Layout 1

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.

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19 Responses to “Understanding Elbow Pain – Part 5: The Truth About Tennis Elbow”

  1. Amy Says:

    Great insight into a common problem! I am a former tennis player who had “tennis elbow”. I went to doctors and physical therapists who treated the pain in the elbow and not the root of the problem. Of course this is 10 years ago and things have really changed. I am also a strength coach and love the information you provide. Thanks!

  2. john Says:

    Great article. Dead on. I’ve been a full-time coach for 13 years and played D1 and some smaller pro stuff. Had 60+ hour weeks oncourt teaching and playing and NEVER had tennis elbow. I’ve helped students rehab and prehab various injuries and to repeat….technique is huge. I have tiny, 10 year old girls hit with way more pace than most of the guys at my club. Good to see a fellow lifter with a backround in tennis. The scapula articles and the “efficient athlete” series have done WONDERS for my joints and helped me rehab a winged scap(sucked) without pt. Your work has motivated me to take my profession to a new level and hopefully getting my CSCS this summer. Thanks–I dig your work and perspective!!

  3. Tony Ricci Says:

    I wonder how much of the external massage/friction increases circulation to the area. I had medial epicondylitis for years without anything working. It almost froze me out of every activity I’d ever done. Prolotherapy fixed me more completely and faster than anything I’ve ever experienced. My coworker had lateral epicondylitis and the injections fixed a four year agony for him within days. It is miraculous. Preventing reoccurance by addressing the other parts of movement is a good progression I think.

  4. K Says:

    Thanks Dr. Cressey, Excellent info! keep it comin’..

  5. Mike Reinold Says:

    Eric, nice article. One area that I also often think that is related to lateral epicondylitis and is often overlooked is cervical radiculopathy. Any issue from the neck around C6 & C7 can decrease the ability to generate wrist extension and grip strength. This over time will cause an overload and tendinopathy. This is one of the many reasons that “tennis elbow” is so challenging to treat! Just makes us remember to look elsewhere sometimes. Good article. Best,

    Mike Reinold

  6. Jeff Beard Says:

    Eric: As a former physical therapist I used to see a lot of Tennis Elbow injuries and I can not emphasize enough about the importance of soft tissue work in conjunction with ice and strength training; not to mention looking at exercise specific movements as related to a given sport or overuse activity. I have always taken a holistic approach to addressing a given activity. Thanks for the review!

  7. Jake Says:

    You missed a huge part when discussing lateral elbow pain, 80% of the elbows I see in my PT clinic are either referred pain from neck (see Mike Reinolds post), or an abducted ulna. Both will be picked up by a “good” PT and the later is very easy to correct if trained. Following the technique symptoms are reduced 75%-100% unless it has been a greater than 2-3 month issue then the true tendonosis has set in and more soft tissue/RICE is recommended, or just get an injection. Generally when the biomechanical fault “abducted ulna” is corrected there is no “Cause” for trauma, and issues will resolve themselves without soft tissue work, but that requires more rest.
    Great series on elbow pain.

  8. Eric Cressey Says:

    Mike and Jake – both great points. Left out the neck stuff because I didn’t want to get too far ahead of myself and make this sucker too long.

    Jake, excellent stuff about the abducted ulna. Have read a bit about it in the past, but I haven’t seen anything definitive about actual causes. Are you seeing these post-traumatically? Or, do you have insidious onset cases? If so, are there particular occupations or sport patterns that are presented with this malalignment?

    Thanks for your contribution.

  9. Vin Says:

    Although probably not as often as recreational players, pros do develop tennis elbow. Two people I can think of off the top of my head are Andy Roddick and Wayne Ferreira, both of which have two handed backhands. (There’s a chance they may have had golfer’s elbow – I’m not entirely sure) In Ferreira’s case, I think his elbow was part of what encouraged him to retire. Pete Sampras also had tennis elbow, but this is not as surprising since he has a one handed backhand.

    However, with the pros, I think tennis elbow is much more likely to be a result of overuse than the poor technique or inadequate physical condition that is more likely to be the problem with recreational players.

  10. Cole Ellis Says:

    Great info on elbow injuries Eric. As an ART/Graston practitioner I obviously agree with the soft tissue component. Dr. Nate Tiplady is solid, met him last month in San Diego at the ART/Titleist workshop. Just wanted to comment on cerical radiculopathy contributing to problem. Work with UCSD and a similar condition presented itself. The soft tissue work, and strengthening has made a huge difference and we got a reduction in symptoms when we started to work on cervical retraction. Her posture is poor, and now that she is “aware” of maintaing a neutral head posture things are getting better. Ankle and hip mobility was also an issue, we have been working squat patterns and this has helped as well. I agree, improving functional movements, technique and using the entire body is key…

    Keep up the great work


  11. Timothy Harris Says:

    Eric, thanks for all the great work you do to help educate and inform your fans. Keeping along the lines of Mike’s differential diagnosis of lateral epicondylitis, radial tunnel syndrome (supinator syndrome) often gets junked in by doctors and physical therapists. RTS presents with a deep ache in the lateral compartment of the forearm over the wrist extensor group. As the posterior interosseus nerve becomes compressed mostly due to hypertrophy of the suppinator, weakness of the thumb abductor and wrist extensor may become noticeable. Often there will be no pain with palpation over the lateral epicondyle. A good diagnostic test used by physical therapists is resisting forearm suppination for 30(+) seconds which will provoke the symptoms.

  12. Jake Says:

    When I was in Texas saw a lot of tennis players and suprisingly golfers with it. Generally with the golfers they were beginners and had taken a big divot and 4-5 holes later they began having pain. Now in ND i see a a predominant ice fishing correlation :). Poor mechanics seem to express themselves in many ways. As far as causes go? some times trauma sometimes over/misuse. Carpenters and electricians are the predominant occupation that i see with it. I do get some “moms” that come in and say they noticed it when they were pulling the milk out of the fridge one day, and gradually got worse.

    Most of the time I get them 2-3 months post onset, so yes lots of eccentrics and soft tissue work. But being able to correct the ulna and have them leave feeling much better without having to do the deep soft tissue stuff till they believe in me makes things easier.

    I will generally get a couple of repeat offenders, but they come once syptoms begin, and once corrected generally don’t have to come back in to see me after 1st appt.

    Tim, great info on RTS.

  13. Chris Says:

    Eric, your article is right on the money. I’m currently in therapy for tennis elbow and am going throught Graston and ART with a top PT/Chiropractor in upstate NY (his specialty is rehabing pitchers). He is also prescribing exercises with a focus on the eccentric motion, as well as general strength and conditioning. I already train in a gym regularly, but am sure my condition was degenerative as well as due to poor form. Will be dedicated to rebuilding the elbow and am already seeing results(3 weeks into therapy). Thank you for putting accurate, useful information out so others can benefit.

  14. linda Says:

    I am a librarian with tendonitis. I found your video on u-tube and it has helped me greatly. Thank you. Oddly enough, shelving books can be as wearing as tennis !

  15. austin Says:


    What is your opinion of the eccentric work for medial and lateral aspects of the elbow? Would the traditional wrist curl and reverse wrist curl work just as well if not better than the bar type products that are popular on the internet?

  16. alan Says:

    have you ever self-administered Graston using the edge of a table? Tried it for some soreness just now and it felt pretty good.

  17. Eric Cressey Says:

    If it’s the edge of a table, it’s not Graston! I would be very careful, as the medial elbow is a very delicate area where the ulnar nerve is exposed.

  18. Katelyn Says:

    You are blowing my mind. Excellent and applicable stuff!

  19. Eric Cressey Says:

    Thanks, Katelyn!

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