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Tennis Elbow


Tennis elbow is the term used to describe pain related to the attachment of the extensor muscles of the wrist that attach on to the outer side of the elbow.


It is a common complaint reported to occur in 45% of those who play tennis daily and 25% of those who play once or twice a week.  It is particularly common over the age of 40 and rare under 20.


Males and females are equally affected.

Hitting a tennis ball travelling at 30 mph is equivalent to lifting a 25kg weight and therefore the forces generated by unaccustomed or excessive playing can lead to strain or microscopic tearing of the muscle attachment.


There are a number of factors that will lead to 'tennis elbow' and if these are not corrected then the condition will not improve or recur (see diagram below).




A common scenario is the beginner, who may have some poor technique, but in his desire to improve practices excessively.


A coaching session devoted to one component of the game e.g. serving or backhand can lead to excessive loading of the muscle attachment.


A graded increase in the amount of playing with a variety of strokes is the key.

Poor Technique

  1. Backhand - dropping the racquet head and leading with the elbow increase the strain on the muscle origin.  Sudden braking mid stroke in drop shots increases the load suddenly and can cause microscopic tearing.  Developing two-handed backhand may help.

  2. Forehand - excessive roll in attempting to hit top spin forehand.

  3. Serve - attempting excessive slice or flicking of the wrist.

  4. Good footwork and timing are important so that the player approaches the ball correctly and hits it 'sweetly' rather than relying on power.

  5. The shoulder and whole of the body should take part in the stroke so that 'braking' does not occur when the ball is hit.

Equipment Factors

  1. Racquet - a mid-sized graphite racquet requires less strength to grip and control.  A large sweet spot helps - hits outside this area increase torsion.

  2. Stringing - tight stringing increases the impact and tension forces.  With established symptoms, racquet should be strung to 52-55lb.  Gut stringing is preferred over nylon.

  3. Grip size - not too large or too small.  One method of determining the appropriate grip size is to measure the distance from the tip of the middle finger to the palm crease (as indicated in the diagram).  This distance should be the same as the circumference of the grip.

  4. Balls should be light. Wet or dead balls increase the load.

  5. Court surface should be slow in order to decrease the velocity of the ball.  Fast surfaces such as grass or concrete cause the ball to hit the racquet with increased force.


Neck Stiffness


Tennis elbow is commonly associated with stiffness in the neck or upper back which may cause some restriction of the nerves into the upper limb.


Treatment will also aim to ensure normal nerve mobility from the neck into the arm.

Treatments from the Doctor / Physiotherapist

  1. Laser or ultrasound therapy may be helpful in the early stages.

  2. Anti-inflammatories - If the pain is severe or constant Non-steroidal anti-inflammatory drugs may help.  These may be taken by mouth (Nurofen, Ibuprofen) or applied as a cream or gel (Ibuleve, Oruvail).

  3. Soft tissue therapy (massage) – frictions or manipulation.

  4. Acupuncture – to the tight forearm muscles, the attachment of the tendon can be helpful.

  5. Steroid injection - these are usually effective but are not the sole treatment but part of a treatment and rehabilitation programme.  Pain often recurs a few months after injection because the causative factors have not been identified or a gradual rehabilitation programme has not been followed.  After injection the symptoms may be worse for 24 - 48 hours before gradually improving over the next few weeks.  Risks of injection include infection and thinning of the skin over the injection site.

  6. PRP injections – Injection of platelet rich plasma from a sample of your own blood can help to stimulate  healing of the damaged attachment. Injections are normally performed under ultrasound guidance.

  7. Surgery – is rarely required but may needed in resistant cases.

Getting Back to Playing


Managing a graded increase In loading is the key to success!

Stretching - healing tissue contracts and is less flexible than normal.  It is important to commence a gradual stretching programme so that the wrist and elbow can be taken through the full range of movement without re-tearing the healing tissue.

Using the opposite hand bend the hand forward at the wrist until a stretch is felt without pain.  Hold for 10 - 15 seconds, release for 5 seconds and repeat 10 times.  Perform 2 - 3 times a day.  Perform with the elbow bent and straight.

Strength Training


Isometric exercises -  The wrist is extended against a resistance applied with the opposite hand so that no movement occurs.


Hold for 10 seconds and relax for 10 seconds.


Can be performed in three different positions - wrist flexed, wrist neutral and wrist extended.


10 repetitions of each 2 -3 times a day.


Dynamic exercises - Using a 1 - 2 kg. weight the wrist is extended and flexed slowly in a controlled manner.


20 repetitions 2 - 3 times a day.  Increase the load gradually if the exercise can be performed without pain.

  1. Apply ice after activity for 10-15 minutes.

  2. Graded return to activity - tennis can be continued but avoiding strokes which cause pain.

  3. Consultation with coach if technique is thought to be a factor.

  4. Use of a counter-force brace - a variety of types exist but essentially they are placed 1 - 2 in. below the elbow over the muscle in order to disperse the force of contraction on the muscle attachment.

  5. Practice backhand without racquet initially.

  6. Introduce backhand on court - slowly progressing from gentle hitting from service line back to full stroke.

  7. Service - try releasing thumb and index finger from racquet handle to reduce strain on muscle origin during service in early stages of rehabilitation.


If you would like to make an appointment or have any questions please contact the administration team.Telephone: 01323 745970 • E-Mail:

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