Tennis elbow

Tennis elbow

Mitsutoshi Hayashi

Mitsutoshi Hayashi

Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association

Tennis elbow

Disease Overview

Tennis elbow occurs when the wrist is used in sports or other activities and it is also called as humerus lateral (medial) epicondylitis. It is an inflammation at the insertion of the forearm extensor (flexor) tendon (the same as so-called tenosynovitis). It occurs most in playing tennis, followed by golf, badminton, kendo, and table tennis. It occurs not only in athletes, but also in those who engage in occupations that use the wrist, such as plumbers, cooks, and carpenters, and in kind of occupations holding heavy things.

Cause and mechanism of pathogenesis

Tennis elbow is caused by the occurring impact on the wrist at the moment of hitting the ball on the racket, and the stress extends to the insertion of the elbow muscle tendons. Compared to advanced players, beginners and intermediate players who are less likely to touch racket sweet spots tend to get injured, as it reflects “disorder due to unskillfulness of technique”. The underlying cause of injury is a fatigue disorder due to overuse.
The type of injury is broadly divided into a backhand type that affects the lateral side of the elbow (radial side) (Photo 1) and a forehand type that affects the medial side of the elbow (ulnar side) (Photo 2). The triggers include the material of the racket (quality of impact absorption), the hardness of the string, and poor impact absorption due to damage of the racket.

The extensor digitorum communis, which extends from the lateral epicondyle of the elbow, and the extensor carpi radialis brevis (longus), which dorsiflexes the wrist, are attached to the lateral epicondyle of the elbow, and the wrist’s motor impact is transmitted through the forearm to the elbow’s attachment site.


This symptoms include pain and tenderness over the elbow (lateral and medial) when gripping and moving the wrist. X-ray examination shows no abnormalities of the bones.

Magnetic resonance imaging (MRI) shows mild inflammation (hyper intensity).

Treatment and rehabilitation

In principle, the treatment is conservative one. Oral medicine and anti-inflammatory analgesic plaster are commonly used. When symptoms are severe, local steroid hormone injections are given, but be careful not to do frequently. Surgery is rarely performed.

Stretching Exercises

It is helpful to do flexion and extension of the shoulder, wrist, and fingers, as well as rotational stretching of the forearm before and after exercise. Specifically, for right-handed players, traction of forearm pronation (Photo 1) and supination (Photo 2) with the left hand in the right elbow extension position stretches the hand-elbow-shoulder. Dorsiflexion stretching of the wrist may also be helpful. I would recommend that the patient does these stretching exercises in play.

Tennis elbow 1

Photo 1: Internal stretch

Supination stretch

Photo 2: External stretch

Supports and Braces

Supports and braces (taping) are useful in impact absorption at the elbow and also required for wrist immobilization (Photos 3 and 4).

Elbow supporters

Photo 3: Elbow support

Wrist supporters

Photo 4: Wrist support

Muscular strengthening

Strengthening the wrist muscles by training as well as the elbow is getting more important. When a patient has pain, stretching exercises can be done as a main component. After the symptoms have subsided, a plastic bottle (Photos 5 and 6), about 1 kg of dumbbells, or tubes can be used to perform dorsiflexion, palmar flexion, or rotation of the wrist while the elbow is firmly secured to avoid stress.

Tennis elbow 4

Photo 5: Training for elbow muscle strength

Tennis elbow 5

Photo 6: Wrist strength training


If there is no pain, the time for practice should be shortened to avoid overuse fatigue problems. In addition, make sure to take icing on the elbow after exercise (Photo 7).

Elbow icing

Photo 7: Icing of the elbow


Recent trend

Backhand tennis elbow is decreasing in junior athletes because of the spread of two-handed stroke with bending the elbow. However, wrist disorders and medial elbow injuries are increasing due to rapid serves, smashes, and single-handed strokes with top-spin wiper swings. In the senior group, a large number of players are single-handed (with elbow extension) that leads to back-hand tennis elbows.

It is very common in the competitions with the instruments, as well as tennis using rackets that players tend to place more emphasis on techniques rather than enhancement of body flexibility. I have seen some athletes who are anatomically inflexible even in the top class at the medical checkup.


Results of a survey of 80,000 people about the longest-lived sports (2017, from the most authoritative British Journal of Sports Medicine).

The first place was tennis (racket sport) rather than running or swimming!
(the 2nd was running, the 3rd was cycling, the 4th was swimming and the 5th was aerobics)
Tennis is also associated with a low risk of cardiovascular disease!
Is it suggested that we had better continue some hard aerobic exercise such as tennis rather than walking?

Hitoshi Takahashi

Hitoshi Takahashi

Associate Professor, the Department of Regional Medicine, Teikyo Heisei University
A certified athletic trainer from the Japan Sport Association, a practitioner of acupuncture and a massage practitioner

Tennis elbow


I recommend stretching the muscle that could cause the injury. Supports or braces of the wrist and elbow are also helpful (refer to the Doctor's edition). If pain is caused by overuse, the amount of exercise needs to be adjusted. Strength training around the wrist is also helpful, as discussed below.

On-site evaluation and first aid

People who have severe stretching pain or pain on motion of the wrist may need rest. The same applies to people with severe epicondylar tenderness on the lateral (medial) side of the humerus. If the pain is severe, the affected area should be put on with ice and the wrist should be immobilized.

Closing and opening the hand repeatedly

This is a simple training of the forearm. Closing the hand trains the flexors and opening the hand trains the extensors. If you cannot take enough time to train, it may be good to do in a bathtub. The strength increases in water. It should be conducted before practice as warm-up. Before stretching the forearm, exercises should be performed 20 to 30 times, and as a training, the exercises should be performed about 100 times.


Training method

I would like to introduce muscle strength as conditioning (primary prevention and prevention of recurrence) for tennis elbow. Muscle strength training focuses on the muscles that flex (palmar flexion) and extend (dorsiflex) the wrist and the muscles that pronate and supinate the forearm. Shoulder weakness may also cause tennis elbow because it increases the burden on the elbow and wrist joints for the compensatory. Strength training for external rotation of shoulder is important, especially when backhand pain is present. Training should be performed three to four times a week, with stretching after training. The most important thing is to continue training. If the training is time-consuming, try using a racket after playing or taking time while bathing. Typical training types are listed below.

Wrist curls

Do two sets with a weight which you can curl 15 to 20 times, and add the weight as it becomes easier. It is a training for flexor muscles of the forearm such as the flexor carpi ulnaris to flex the wrist and the flexor carpi radialis. The point is to train the muscle contraction patterns of both concentric and eccentric contractions.

Concentric contraction is a contraction pattern in which a muscle shortens but exerts its strength.
Eccentric contraction is a contraction pattern in which the muscle exerts its muscle force while stretching.

Wrist curl training shows concentric contraction of the forearm flexors when lifting the dumbbell (wrist flexion) and eccentric contraction when reinstatement. In the case of tennis elbow, the forearm extensors and flexors may contract strongly, causing fine muscle damage at the origin of these muscles and cause the pain.

Dumbbell wrist curl

Tennis elbow 1

Hold the dumbbell and secure the forearm on the bench. Slowly flex (palmar flexion) the wrist from the point of extension (dorsiflexion). Start with the fingers straightened (with the palms open), along with training in grip strength.

Tennis elbow 2

Because the origin of the flexor arm is located on the medial side of the elbow joint (medial epicondyle of the humerus), it is recommended to raise the little finger side after flexion.

Racquet wrist curl

Tennis elbow 3

When using the racket, the swing (track of racket movement) should pass through the line from the right leg to the left shoulder. Do the same way on the opposite side.

Reverse wrist curl

Perform 2 to 3 sets with the weight you can curl 15-20 times, and add the weight as it becomes easier. The extensor carpi ulnaris, which is responsible for wrist extension (dorsiflexion), and the extensor carpi radialis are exercised. The point is to train the muscle contraction patterns of both concentric and eccentric contractions.

Dumbbell reverse wrist curl

Tennis elbow 4

Hold the dumbbell and secure the forearm on the bench. Slowly extend (dorsiflex) the wrist from the point of flexion (palmar flexion).

Tennis elbow 5

Because the origin of the extensor muscles of the forearm is located lateral side the elbow joint (lateral epicondyle of the humerus), slightly lift the thumb side after extension.

Pronation and supination

Perform 2-3 sets with the weight you could pronate and supinate, and add the weight as it becomes easier. It is the training of the pronator muscles acting on the wrist, and the supinator muscles acting on supination.

Pronation and supination with a dumbbell

Tennis elbow 7

Hold the dumbbell with the palm facing upward and place the forearm on the bench to secure it.

Tennis elbow 8

The wrist is pronated to 180 degrees from the palm facing upward.

Tennis elbow 7

Repeat this movement.

Pronation and supination with a racket

A racket can be used instead of a dumbbell (see Dumbbell section for more detail). The load is controlled at the position of the racket. Shorter grips (gripping at the closer part to the center of the racket) make the load lighter, and longer grips (gripping at the part farther from the center) make the load heavier.

Tennis elbow 9

Hold the racket with the palm facing upward, and place the forearm on the bench to stabilize it.

Tennis elbow 10

The wrist is pronated to 180 degrees from the palm facing upward.

Tennis elbow 9

Repeat this movement.

Training of the flexors

Tennis elbow 11

Training of the extensor group

Tennis elbow 12

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