Tennis elbow or the medical term, lateral epicondylitis (LE), is the most common cause of lateral elbow pain. Although it has “tennis” in the name, tennis elbow can be caused by any repetitive activity involving the wrist extensors. Tennis players account for only 10% of lateral epicondylitis cases1. Other causes of LE include: weeding, typing, use of hand tools, painting; as well as certain professions such as dentists, musicians, and carpenters1.
One of the most common misconceptions about LE is that the pain associated with the condition is due to inflammation of the tendon(s); however, histological studies looking at the condition have found little to no evidence of inflammation in the area. Instead, this condition is more related to a tendinosis or chronic degeneration of the tendon(s) at the lateral epicondyle of the humerus.
The clinical presentation of lateral epicondylitis can include: pain in the lateral/upper elbow radiating into the forearm which is worsened by activation of the wrist extensors, especially with combined elbow extension. It can also include weakness with gripping, tenderness with palpation to the lateral elbow, and can be associated with numbness/tingling in the elbow or forearm. Common aggravating factors include: holding a cup, turning a key, opening a door, or lifting.
For tennis players, a combination of mechanics, swing pattern, and equipment can all be risk factors for developing LE. In tennis, all strokes involve significant use of the wrist extensors, which puts increased strain on these muscles. It has been shown that LE has a significantly higher rate of occurrence in recreational versus professional tennis players, likely due to poor mechanics and techniques2.
If you are a recreational tennis player here are 3 major considers for your swing…
1. Point of Contact:
- At the point of contact between ball and racquet, be sure the ball is in front of your body by stepping into the ball rather than hitting it behind you which will put increased force on the elbow.
- Stepping into the ball will also ensure hitting the ball in the “sweet spot”, not on the lower half of the strings which increases vibration into the arm.
- Just prior to contact of the ball, be sure to “close” to the racquet face to improve the contact surface of the ball on the strings.
2. Follow Through:
- Based on EMG testing, professional players do a significantly better job at reducing the impact transition from the racquet to the wrist and elbow2. Therefore, it is important to quickly release the grip after hitting the ball to complete your follow through to reduce unnecessary stress on the wrist extensors.
3. The Backhand:
- Poor wrist mechanics during the backhand is shown to increase the prevalence of LE. A recent study showed that recreational tennis players hit their backhand with the wrist flexed 13 degrees, while professional players hit with their wrist extended 23 degrees2. With the wrist in extension, more power is generated and less counterforces are put on the wrist extensors.
- Also, there is a much higher prevalence of LE in those who hit a one-handed backhand; therefore, you may want to consider switching to a two-handed backhand if you have issues with chronic LE.
Next, let’s talk about equipment…
1. Grip size:
- The proper way to measure your grip size is from the proximal palmar crease to the tip of the ring finger, along its radial border. Over the years, the average grip size has reduced from a 4-5 to a 2-3. However, “Hatch et al recently studied its effect on forearm muscle firing patterns, and concluded that over‐ or undersizing the recommended racquet grip size by 6.35 mm does not alter forearm muscle activity significantly and therefore might not represent a clear risk factor for tennis elbow.2” It is most important to get the grip size that feels the most comfortable to you.
2. Dampener or no Dampener?
- Vibration is something commonly thought of as a factor which increases the strain on the elbow. A dampener is something that tennis players often use to reduce vibration; however, “a recent study has shown no significant differences in amplitude of vibration at the resonant frequency for the wrist or the elbow when damped and non‐damped impact were compared. They also noted no significant differences in discomfort ratings between damped and undamped impacts.2” Instead, vibration is shown to be reduced in players with increased body weight and more experience.
3. Racquet and String
- A heavier racquet reduces strain/vibration on the elbow as well as racquets made with graphite or epoxies. A large racquet head size will also better absorb vibrations from hitting the ball.
- A looser stung racquet reduces vibration as well as a racquet with increased string count. Softer strings such as natural gut will put less strain on the elbow than a polyester sting.
4. The Court
- Clay courts reduce spin rate on the ball; therefore, reduces impact when hitting the ball compared to hard courts.
Lastly, what can you do to treat your tennis elbow…
LE is a self-limiting condition, meaning that without any formal treatment, it will heal within 12-18 months3. However, there are many treatments available to reduce pain quicker and reduce the risk of pain coming back which are focused on strengthening, flexibility, and patient education.
Physical therapy focused on wrist flexibility, shoulder strengthening, wrist eccentric strengthening and body mechanics has the best long term effects for LE. NSAIDS, especially, injections have great short term effects. While the evidence on bracing is inconclusive. There are also surgical options available if necessary, which are shown to have good outcomes.
In summary, if you are a tennis player who has had or is currently experiencing tennis elbow, be sure to assess your mechanics, swing pattern, and equipment. Seek treatment options with good evidence including physical therapy and injections to get you back in game!
References
- “Lateral Epicondylitis (Tennis Elbow).” JHM, 8 Aug. 2021, www.hopkinsmedicine.org/health/conditions-and-diseases/lateral-epicondylitis-tennis-elbow#:~:text=Lateral%20epicondylitis%2C%20or%20tennis%20elbow,become%20sore%20from%20excessive%20strain.
- De Smedt T, de Jong A, Van Leemput W, Lieven D, Van Glabbeek F. Lateral epicondylitis in tennis: update on aetiology, biomechanics and treatment. Br J Sports Med. 2007 Nov;41(11):816-9. doi: 10.1136/bjsm.2007.036723. Epub 2007 Jul 6. PMID: 17616547; PMCID: PMC2465303.
- Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev. 2017 Mar 13;1(11):391-397. doi: 10.1302/2058-5241.1.000049. PMID: 28461918; PMCID: PMC5367546.
