As a junior tennis player I developed elbow pain at one point in my career. I couldn’t understand why I was diagnosed with “golfers elbow” when I clearly told the doc that I was a tennis player!
This blog post will cover the symptoms of golfers elbow in tennis players, the possible cause of this type of elbow pain and how we go about treating and rehabilitating this condition in our practice.
What is golfers elbow?
Golfers elbow is another name given to the medical condition Medial Epicondylitis. In this condition pain is felt on the medial side of the elbow (the side that is closest to the body when the palm of your hand is facing forward).
The structures frequently involved are the tendons of the pronator teres and flexor carpi muscles tendons which attach to the medial epicondyle of the elbow (the bony bump felt on the inside of the elbow). Exposure of these tendons to repetitive microtrauma can lead to breakdown of the collagen fibres that make up these tendons.
What are the symptoms of golfers elbow?
Symptoms include constant pain or tenderness over the medial epicondyle of the elbow. There may be pain referral down the forearm due to the development of myofascial trigger points (or knots) in the wrist flexor and pronator teres muscles.
Medial elbow pain is usually aggravated when performing resisted wrist flexion and forearm pronation (rotating your forearm so that your palm turns to face the floor).
A: Myofascial triggerpoints in the pronator teres muscle. B: Triggerpoints in the flexor carpi radialis brevis & longus muscles
What are the causes of golfers elbow in tennis players
Elbow pain is usually worse during the early acceleration phase of the serve or forehand. This is when the flexor muscles of the forearm are eccentrically lengthening and the forearm is supinated so that the hand and wrist are in a position to create wrist snap which helps generate racket head speed. An eccentric contraction is what we would call a “negative rep” in the gym, where the muscles are actively contracting but lengthening simultaneously. Eccentric contractions place more force on muscles and tendons than concentric contractions (where the muscle contracts and shortens).
Timing
Timing errors on your forehand can be a major contributing factor towards the development of golfers elbow. After you’ve taken your racket back in preparation for a forehand, the wrist flexor and pronator muscles eccentrically lengthen as you accelerate your racket towards the ball. The modern forehand relies on what’s called the stretch-shorten cycle where a muscle is rapidly stretched, energy is stored and it recoils like an elastic band. With good biomechanics and a proper forehand technique you’ll likely be striking the ball out in front of your body with your wrist in a more neutral position and the flexor and pronator muscles shortening to allow your racket to “roll over the ball”. If you’re late on your forehand and don’t make good contact in front of your body, you’re likely striking the ball next to or behind your body placing your wrist flexor and pronator muscles in extension on contact with the ball. This means that those muscles have a decreased ability to stretch further and absorb the force generated by the racket when making contact with the ball. This places more strain on the tendons of the elbow and increases your risk of injury.
Tennis racket stiffness
Tennis rackets have become lighter and stiffer over the years thanks to the use of carbon fibre and other composite materials. It’s been shown that rackets with higher stiffness ratings increase the speed that a tennis ball rebounds off the stringbed and makes a racket feel more “powerful”, but there’s a price to pay. A stiff frame won’t deform on contact as much as a flexible frame, meaning that more force, shock and vibration is transferred into the arm.
One of the most popular (and stiffest) rackets on the market is the Babolat Pure Drive. It has a stiffness rating of 71RA. Compare that to a racket like the Wilson Blade which is another popular racket but much more flexible with a stiffness rating of 55RA. How can you find the stiffness rating of your racket? Look at a website like www.tennisonly.com.au where they list the stiffness rating of each racket under the racket’s specifications.
Strings
Tennis string technology has evolved over the years. Strings used to be made out of materials like natural gut and synthetic gut (nylon) which were highly elastic in nature. Polyester strings were released into the market and became extremely popular amongst amateur and pro players. They were extremely stiff compared to natural gut but it was that property that gave players increased control and allowed production of extreme amounts of topspin. The issue with a stiff string is that more vibration is transferred through the racket into the players arm.
Modern polyester (sometimes referred to as co-polyester) strings have been created to be softer and more flexible than the early generation polyester strings but they still offer players more control than a synthetic gut or gut string. A solution to your golfers elbow may be to string your racket with a soft co-polyester string such as Solinco Hyper G Soft. Another option could be to use a thinner version of your current string. Alternatively you could try a hybrid string combination consisting of co-polyester string in the mains and a gut, multifilament or synthetic gut string in the crosses. Chat to your local pro shop to see what combinations they recommend.
This is an image of a useful tool that you can use to look up a string’s stiffness rating. Click this link to visit the Tennis Warehouse University string database page.
Here I’ve compared two co-polyester strings that are the same thickness (1.25 gauge), Luxilon 4G and Solinco Hyper G soft. Have a look at their stiffness ratings, the Luxilon 4G is 34% stiffer than the Solinco Hyper G. If you want to learn more about how they conducted the test, they explain their methods on the Tennis Warehouse University string page.
Worn out racket grips
Have a look at your tennis racket grip, if it looks like the picture below then it’s time for a new grip.
An old worn out grip will cause you to squeeze the handle tighter to prevent the racket from turning in your hand, ultimately placing more strain on the muscles and tendons of your arm.
Treatment for golfers elbow in tennis players
Out of all the possible risk factors listed above, the most important factor to consider is technique. There are players who have used a stiff racket and string combination for years and have never had an issue with golfers elbow.
Your tennis coach will be able to make changes to your technique that lead to power generation from the legs, transfer of power through the kinematic chain, and make contact with ball in a better position.
The next step would be to evaluate the player’s biomechanics and work on treating and rehabilitating any issues that are found.
Stubborn cases of golfers elbow may require some equipment changes. That might mean changing to a different racket with a higher flexibility rating or a softer string, or just replacing your old worn out tennis grip more frequently.
The role of the healthcare professional
In the clinic we take tennis players through the 14 physical screening tests that were developed by RacquetFit. These tests help us identify limitations in a players biomechanics. We use the findings of these tests to guide our rehab prescription to correct those issues. For example, we might identify an ankle mobility issue that is affecting the player’s ability to generate power from the ground, causing them to compensate higher up the kinematic chain.
Our go-to treatment method for treating golfers elbow in the clinic is shockwave therapy. Shockwave therapy uses high-energy acoustic pressure waves that promote the regeneration and repair of tendons and muscle. It causes an increase in collagen synthesis and reduces tendon pain. It also promotes the formation of new blood vessels that increase the blood supply to the injured tissue.
Dry needling can help release trigger points in the muscles of the forearm. However, this is not the treatment of choice for tendons or the pronator teres muscle due to their close proximity to major nerves and blood vessels near the elbow.
The application of a biomechanical tape such as Dyanimc Tape can help absorb some of the load placed on the wrist flexor and pronator tendons. This can be especially useful to manage the strain on the wrist flexor tendons during an acute flare-up of golfers elbow.
Rehabilitation exercises for golfers elbow
Tendons respond well to eccentric loading. An effective way to eccentrically load the wrist flexor muscles and tendons is by performing an exercise called the “tyler twist” with a rubber flex bar.
This takes a bit of practice to get right but once you understand the movement, it becomes a really effective way of allowing the muscle to lengthen while under tension (eccentric contraction).
Aim for 3 x sets of 10-15 reps daily. Progress to a stronger flex bar when you can easily perform the prescribed number of sets & reps.
Final thoughts
You may have the perfect technique and correct racket setup but muscles and tendons still need time to repair and recover. The body has an amazing ability to compensate up until a point. Pain is usually the last symptom and is an indication that the body is unable to compensate any further.
Every player’s physiology is different and the amount of load that their body is able to handle before pain or injury occurs is affected by various external factors such as diet, sleep & stress. This is where a collaborative effort between your tennis coach, strength & conditioning and healthcare professionals is vital.
We’ve helped a number of tennis players at our Brisbane practice. If you need help treating or figuring out what’s aggravating your elbow pain or if you want to understand how your biomechanics could be affecting your tennis game, please don’t hesitate to get in touch with us and we’ll be happy to assist you in getting back on the court.
About the author:
Dr Michael Benporath is a chiropractor with a postgraduate International Certificate in Sports Chiropractic. He is RacquetFit certified & has a special interest in tennis related injuries & performance optimisation. Michael practices at Prime Health Co. in Newmarket, Brisbane Northside.
