Pain on the outside of the elbow is classically called “tennis elbow” or tendinitis. Although, people who don’t play tennis can also have this pain from grip-heavy or repetitive activity. There are also many structures that can cause this same pain, outside of the usual tendinitis.
Tendinitis is thought to be caused by increased inflammation due repetitive stress in the area and micro-tears to the muscle. It is acute, meaning it just happened. However, many folks that we see have had symptoms for months (sometimes years!!) and so the process is different and chronic. We call this tendinosis. There is no longer acute inflammation or swelling, rather long term changes to the tissues in that area from improper healing and continuous repetitive trauma.
The area that is irritated to cause the pain at the outside of the elbow is called the extensor tendon. That is, the common tendon where all of the smaller forearm muscles that extend the wrist, join at the elbow.
Often times, players who are playing frequently throughout the week without proper mobility and recovery plans will present with this issue. Over-gripping the racket is also another major cause.
If the muscles and therefore the tendon or irritated, a great place to start for self-care would be to perform the forearm release (seen below).
Doing this for two minutes, 1-2x/day, can have a positive impact on the pain you feel.
So while many tennis players have pain at their elbow, only a fraction will actually have “tendinitis”.
Another tissue that is often the culprit is the nervous tissue. Nerves course throughout our entire body for muscle function, sensation, etc. Irritation of the nerve, from repetitive activities or rubbing against another structure can send pain signals to the same area. However, treating the muscle in this case will not clear up the symptoms.
The major nerve that runs by the outside of the elbow is called the radial nerve. Muscles nearby are commonly overused in tennis and can be the cause of the symptoms. Irritation of this nerve can also begin at the neck, but that is a discussion for another time!
I often see players who are changing their grip or adding more top spin to their balls tend to have more issues with nerve irritation.
The best way to address the radial nerve irritation is a radial nerve glide (see video below). Try 15 of these before a lesson or match to improve the mobility of the nerve and decrease the pain. With nerve glides, keep the tension that you create 5/10 tension/pulling or less to avoid extra irritation!
Try 15 of these before a lesson or match to improve the mobility of the nerve and decrease the pain. With nerve glides, keep the tension that you create 5/10 tension/pulling or less to avoid extra irritation!
While both of these strategies above are a great way to decrease your pain, the best way to keep it from happening again is to address the shoulder. Shoulder weakness changes how your arm (elbow and wrist) move through space. With tennis players, overhead strokes and serving can be particularly irritating if proper shoulder position, strength and control are not achieved.
Does your back look like this? Notice how the inside edges of her shoulder blade are prominent? Not ideal. That demonstrates weakness in muscles that are essential for overhead movement.
You can begin to address this weakness and shoulder position with a simple and effective exercise called the single arm punch out. It strengthens a muscle called the serratus anterior to help normalize scapular position. Try 2 sets of 15 reps per side, 3x/week. This is a great warm up on the court or at the gym!
Thanks for reading,
Dr. Jackie, PT, DPT
Warm-ups are important for a few reasons: increase tissue temperature and extensibility, increase heart rate to prep the system for intense exercise and prep specific movements that will be performed at higher speeds. Most often, people do not warm up either for lack of time or lack of knowing where to start! If you have a particular area of pain or tightness, you may want to spend more time there. Otherwise, moving through movements of the whole body is ideal.
For each of the exercises below, I will use the width of the court, going back and forth between exercises.
Try this simple yet comprehensive workout:
Jog Forward 50% max effort (width of tennis court)
Slowly back pedal (back to starting line)
Jog Forward 60% max effort
Slowly back pedal
Run forward 75% max effort
Run forward 75% max effort
Side shuffle (facing opposite way from last time)
Inchworms- moving slowly and deliberately; keep the legs as straight as possible for a good hamstring and calf stretch. Once walked out to the plank position, do a push up (can drop to knees if needed) then walk feet to hands.
Toy Soldiers- standing upright, hands out stretched in front; kick opposite foot to opposite hand; alternate feet and move forward with each repetition.
Walk on toes- just like it sounds, walk on tippy-toes with small steps.
Walk on heels- walking on heels, taking small steps.
World’s Greatest Stretch- a great warm up tool because it hits three areas that need attention for tennis players- hips, hamstrings and back! Go through ten reps of each movement then switch legs.
3-way lunge- also addresses multiple areas, particularly glutes, hamstrings, quads and adductors. Perform 6 reps in each direction per leg.
Leg swings- hold on to something stable at your side; swing leg forward and backward, letting gravity carry it back down. Also, swing to right and left. Preform 10 repetitions each direction.
Arm swings- open arms wide then swing across the front, one arm over the other until your fingers contact your back, swing back to front and cross over the opposite way. Also, swing arms up overhead and then back down past the hips. Again, allow gravity to do the movement, no forcing the range of motion! Perform 10 reps in each direction.
After this warm-up you should notice that your muscles feel warm, heart rate is up, breathing has increased and you are ready to increase the intensity of your movement. A proper warm up may decrease the likelihood of an injury and will get you ready to perform more quickly!
Good luck this tennis season! If you missed the first parts of this 4-part series, be sure to check those out. At Athletes’ Potential we help tennis players resolve pain, improve performance and prevent injury. Like what you’ve read? Give us a call!
Dr. Jackie, PT, DPT
Building a solid foundation is important for any structure. Therefore, maintaining healthy, mobile and strong feet is a foundation that athletes cannot ignore. This becomes particularly important for athletes who require agility—moving laterally, side to side, sprinting, shuffling. The problem is, we rarely focus on our feet, unless they already hurt!
I challenge you to add at least one foot mobilization or exercise into your daily routine. Your tennis game will thank you.
Ankle mobility - The ability of your ankle to dorsiflex fully (toes up) is ideal for proper biomechanics during running and cutting. Without proper length in your Achilles, injuries and tendonitis are more likely. The first step is to check your ankle mobility. The wall test is our favorite.
Place your foot a hand width from a wall (in a lunge position), with the foot in that position drive your knee toward the wall making sure that your heel stays down. Can it touch the wall? Due to the structure of the calf musculature, you may find that you lack mobility more when your knee is straight. Be sure to check out your dorsiflexion side-to-side by using a yoga strap or dog leash. If you seem to be lacking range of motion here, try these two mobility exercises:
Foot mobility and strength - The foot is very complex with 26 bones and 33 joints. It is important that the joints maintain the ability to glide on one another so that our feet can conform to uneven surfaces and absorb shock as we run and jump. Years spent in hard dress shoes, high heels and flip flops can take a toll on our feet. So when we lace up the tennis shoes and play a hard 2 hour match, the feet were not prepared! Simply being able to separate the movements of the big toe from the little toes can improve your foot mobility, strength and control.
My favorite set of exercises is Toe Yoga (video below). Try these out, you might be surprised how tough it is!
The great toe - The big toe (or great toe) may seem trivial to some but is essential for function of the foot. More specifically, the importance of great toe extension. Without mobility here, the natural mechanism of the foot is interrupted. This can lead to pain on the outside of the foot, pain of the other metatarsals (top of the foot) and recurrent plantar fascia pain. If your great toe isn’t so great and is lacking some range of motion, try these out:
As you add these to your daily routine, remember that there is no quick fix but you are taking the right steps! If you have knee or hip or back pain, you still need to start at the foundation. The biomechanics of the foot drives the whole system. Try these out for a few weeks and notice the change. You won’t be disappointed!
Thanks for reading,
Dr. Jackie, PT, DPT, OCS, CSC
Your hip and spinal rotation are the power house of each stroke. The winding-up and subsequent uncoiling of the kinetic chain allows tennis players to add velocity to their stroke. Without the ability to fully rotate the spine side-to-side, much of the torque will be dispersed down to the hips and knees or up through the shoulder and elbows. So if you have nagging aches and pains in those areas, your lack of rotation could be the issue. Let’s check out the amount of hip and thoracic rotation that you have side-to-side.
When checking internal rotation, sit on a table or box so that your feet are not in contact with the ground. Internal rotation is the motion when your foot moves outward from your body when your hips and knees are bent. We like to see 40-45 degrees, as in the picture below. Be sure that as you rotate your hip, you don’t bring your booty off the table and lean to make it go further! Limited here? Try out the mobility exercise for internal rotation. Always retest your rotation afterward so you know if the mobilization is valuable!
External rotation would be the opposite, so as if you were crossing one leg over the other the ankle resting on the thigh of the other leg. If this is tough, your external rotation may be limited. This is less common but still possible! The best mobility piece for this is the Lateral Hip Release (video below). Try it out! Remember, test- mobility- retest.
If you sit a lot throughout the day or just generally have tight hip flexors, this could impede your ability to extend your hips fully. My favorite go-to for this is the Couch Stretch (video below). Most people would benefit from spending 2 minutes in this stretch daily. It will undoubtedly add power to your strokes and serves!
The thoracic spine is specifically important for rotation due to the structure of the vertebra. If there is limited rotation in the T spine, we will tend to look for more rotation form the lumbar spine and hips. The way the lumbar vertebra are stacked on each other, rotation is very limited; thus, repeated rotation with a tight T spine can lead to low back and hip pain.
I would not be shocked to see that most tennis players will have a greater amount of rotation or more ease of rotation to their forehand side (so left rotation in right handed athlete). This is a structural change that can happen over time as muscle for rotation in one direction are recruited more frequently that muscles for rotation the opposite way. But what about the backhand? If you feel that you lose a lot of power with the backhand stroke, it could be due to a rotation restriction.
Take a look at your spinal rotation mobility to each side. Laying on your side, knees up at 90 degrees, rotate your back to the floor so that your arms make a T. The top knee should stay stacked on the bottom and both shoulder should touch the floor. If this is challenging, we modify this just a bit to an exercise working on spinal rotation throughout the whole movement: The Windmill (video below). With this variation, you can use breathing to gain a bit more range and get the shoulder closer to the floor. If you get stuck with your arm overhead and you are unable to touch the hand to the floor, then pause there, take a deep breath and on the exhale gently push into a bit more rotation.
To incorporate hip extension and thoracic rotation, I suggest adding scorpions (video below) to your mobility routine. They will also hit the shoulder with a nice stretch across the front. If you’re short on time- hit a set of 10 to each side before grabbing the racquet!
Notice that although we are adding power to your stroke, there were no strengthening specific exercises. The first step is to chip away at long standing range of motion deficits you have may have. Having proper hip range and spinal rotation will allow you to unleash your potential from the power house of the body. Once range of motion has been addressed, other areas to explore are strength and control. However, skipping the mobility piece will only allow you to layer on strength in the shortened range of motion. To be resilient, mobilize then strengthen!
Thanks for reading,
Dr. Jackie, PT, DPT, OCS, CSC
The elbow is affected so often by tennis that it was named after the sport! Tennis elbow, or lateral epicondylalgia, is pain at the outside part of the elbow. Its sibling, golfer’s elbow, is pain at the inside of the elbow. Despite the names, tennis players are susceptible to both.
Many times, the treatment will focus solely on the elbow. Decreasing inflammation, resting the muscles that insert at the painful area and strengthening can all be helpful, but what is the root of the issue? Something that can be overlooked is shoulder dysfunction causing pain down the kinetic chain. Check out the picture of the athlete serving below. The arm acts as a whip-- drawing the hand back and then unraveling with force the whips the elbow forward so the hand and racquet will follow. If the shoulder lacks the proper stability in these end ranges and with quick change of direction, the elbow takes the force.
We want our shoulders to be strong through the stroke but it starts with being strong as stabilizers. An easy go-to for shoulder stability are carry variations. Farmer's carry (see video below) and overhead carry are great places to start, then you can try a waiter’s carry. This moves the weight out front so that there is more stress to the shoulder musculature. If you try this variation with a kettlebell and hold it bottoms-up (see picture below video) it will be more challenging and work on grip strength! As you get tired, your elbow will tend to drift outward and down, so walk while stabilizing the bell only as long as you are able to keep the correct form.
Movement must be added to make it effective for the tennis player. The control of the arm to accelerate and then quickly decelerate comes from the posterior rotator cuff. Those muscles at the back of the shoulder put the brakes on the arm; without control here, again the elbow suffers but you may also feel pain in the back of the shoulder.
A very effective protocol is banded rotator cuff strengthening in multiple different angles. My two favorite are the WY Negative and the Snow Angels:
The WY negative strengthens the external rotators, demands stabilization overhead with arms straight and requires posterior cuff control as your lower slowly. No other banded exercise that I have seen is as effective and comprehensive for the tennis athlete. The best band tension to use for this exercise is 3-7#, so much lighter than you might imagine! Around 10-20 repetitions at a time is a great goal, although you may need a break or two when you first start.
Another great shoulder stability exercise is the Snow Angel. Again, with the light band and perform 10 repetitions at a time. This exercises forces you to pull back on the band and sustain tension while moving overhead and back down. Try it out!
The subscapularis is one of the rotator cuff muscles that tends to be largely ignored but can be a culprit in shoulder pain with overhead athletes. When it is tight, it will limit external rotation, or the ability to bring your arm back to serve. It can cause pain at the back of the shoulder and sometimes that back of the wrist! The easiest way to get pressure and a stretch on the muscle is with a lacrosse ball. Check out the Subscap Smash (see video below). This is a great mobilization to add your warm ups or workout routine during tennis season.
The big picture here is that elbow pain is often a secondary symptom due to a primary cause at the shoulder. Direct trauma and inflammation to the elbow itself are possible but ensuring a strong foundation at your shoulder will protect the elbow joint over the long run. Try out these mobility pieces for a week or two and note any change that you have in your performance or symptoms. If you continue to have shoulder or elbow pain, reach out to us at Athletes’ Potential. We would love to get you back on the court pain-free!
Thanks for reading,
Dr. Jackie, PT, DPT
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Tennis players need a combination of speed, agility, flexibility and power to become successful at the sport. As with any overhead sport, it is not unusual to have shoulder and elbow pain, but tennis can be especially hard on the torso and lower body as well. Whether you are a serious competitor or a weekend warrior, there are a few key areas to keep supple and strong to avoid injury and improve skill.
Feet & Ankles: The ability to move laterally and sprint is essential for a tennis player. But how can you do this effectively with stiff, painful ankles and feet? My favorite way to mobilize feet and ankles is using a lacrosse ball. Mobilizing the fascia on the bottom on the feet can decrease foot pain and allow for more range of motion of your big toe- which is a big deal for push off! Pressure-based soft tissue work to the calves can decrease tightness and pain in these areas as well. Many people ask if a tennis ball would be sufficient, but it’s too soft! Our recommendation is using a lacrosse ball for 2 minutes in each area, per side, daily. Try it before and/or after a match and see which timing works best for you!
Hips: Pain in the hips can occur with faulty movement patterns or tightness elsewhere, but I want to focus on hip strength. I’m always surprised when athletes come in and have poor balance on one foot or less than ideal hip strength. Running and cutting is essentially moving from single leg stance on one side to single leg stance on the other. Without balance and control in this position, your knee will take a beating. Do you ever have sore knees? Don’t blame your knee, first look at your hip! A great exercise for single leg balance and hip strength/control is the single leg deadlift. There are many ways that you can adapt it to make it more or less challenging. When you try it, notice what happens at the knee. With poor control and strength at the hip, your knee may be moving in towards the other or shaking a bit. This is not ideal and likely the root of the knee issues. Work these into training days, 8-10 repetitions for 2 sets will be a good place to start. They can be sneaky and make you quite sore the next day!
Thoracic spine: Having the ability to rotate the torso is important for power production in concert with the hips. A stiff spine will disrupt the power couple and the hips will have to compensate. As mentioned before, dysfunction at the hips can then cause knee pain. Disrupting this kinetic chain can have severe effects on your tennis game! My go-to for thoracic spine rotation is the open book. This works well as a warmup exercise. As you rotate through the exercise, be sure to keep the knees stacked so that the rotate comes from the spine and not the pelvis turning!
Shoulder: Undoubtedly, shoulder strength is an important variable for efficient strokes but it can also directly affect elbow pain. Similar to the hip and knee relationship, if there is shoulder weakness then the elbow can take the brunt of the force. The rotator cuff is made up of four small muscles that stabilize the shoulder joint. Without strength of these muscles, the prime mover muscles then must take over for stabilization. When this happens, there will be less power production at the shoulder. Dysfunction at the shoulder can effect nerves passing through the area with may cause elbow pain. To keep the shoulder stabilizers strong and healthy, the exercise that will give you the most bang for your buck is the WY negative using a small band. This covers external rotation (cocking back before serving), overhead stabilization and posterior cuff control during deceleration. What was that last part? The muscles at the back of the shoulder work to slow the shoulder after the acceleration to hit the ball. A good indicator of dysfunction here is pain at the back of your shoulder.
Elbow: The elbow is effected so often by tennis that it was named after the sport! Tennis elbow, or lateral epicondylalgia, is pain at the outside part of the elbow. Its sibling, golfer’s elbow, is pain at the inside of the elbow. Despite the names, tennis players are susceptible to both. As mentioned before, it can be coming from up the chain- cervical spine or shoulder. The pain can also be coming from down the chain- wrist. The forearm muscles that move the wrist connect from the elbow and run to the hand. After hundreds of reps during a match or practice, forearm muscles can become irritated and tight. The triceps also crosses the elbow joint and can be a culprit with elbow pain. This muscle extends the elbow, so are very active with backhands and serves. Early on, the best focus of your time with elbow discomfort is soft tissue work using a lacrosse ball. After pinning down the ball in an area of tension, it is important to move the wrist and elbow to give the muscles a stretch.
If you are a tennis player looking to improve your game or ebb nagging pain, give these self-management techniques a try! By keeping the body mobile and strong you will have less pain and improved function. At Athletes’ Potential we work with multiple tennis athletes in all skill ranges that want to get back to the court quickly and feel better than ever. Not sure? Give us a call. We would love to chat with you and find the best fit.
Thanks for reading!
Dr. Jackie, PT, DPT, OCS, CSCS
Dr. Danny and staff's views on performance improvement, injury prevention and sometimes other random thoughts.