TennisOne Lessons

Chronic Tennis Elbow

Monty Basnyat

Take a look around your club these days and your likely to see an awful lot of arm bands circling the forearm just below the elbow. The reason for this is tennis elbow. Interestingly, on the pro tour, where the forces generated by the players are far greater, tennis elbow is almost unheard of. Even at the club level, it is rare to see tennis elbow among the better players. However, despite great leaps in racquet and string technology, (or, because of such equipment improvements), among 3.0 to 4.0 players, tennis elbow is almost epidemic. The obvious reason such players make up the bulk of tennis elbow recipients is the lack of proper tennis techniques.

Two Types of ‘Tennis Elbow’

It should be understood that there are two forms of ‘tennis elbow’. The first one is “Medial Epicondylitis,” a condition more often referred to as ‘golfer’s elbow’ as it is seen among golfers as much as—if not more than—tennis players. This pain is on the bony part of the elbow that is closest to the body. It is also referred to as ‘servers’ elbow’ as the pain is usually felt during or after a session of serving, but also can be—and often is—inflicted when players use poor form on their forehand. I will talk more about this ailment in a moments.

The second type of tennis elbow is the more common type among tennis players. True ‘tennis elbow’ is pain that emanates from the bony protrusion on the outer portion of the elbow, that little bone that sticks out on the outer side of the elbow, away from the body. The pain here can commonly be traced to poor form on the backhand; volley and groundstroke.

It is believed that almost 50% of active tennis players will experience tennis elbow at some point in their tennis careers. Frequent rotary motions of the forearm can cause this Epicondylitis, (a strain to the tendon that attaches the forearm muscles to the lateral and medial epicondyle on either side of the elbow.) If not treated the dull annoying pain will linger for months at a time. Sometimes the pain can be so severe, players have to give up playing tennis (or golf!) to get relief. Oftentimes they can barely lift a glass of water, let alone a tennis racquet.

Why Me?

Many players believe vibration of the racquet and strings is the culprit for your tennis elbow which explains the plethora of dampeners on the market – sorry, this is a myth and anyway, studies show those dampeners do little more than change the sound the ball makes when it contacts the strings.

The reality of the matter is that a combination of elements contributes to the problem.

• Overwork is one of the common causes of the injury. The repetitive twisting and rotating of the extensor muscle can cause tissue damage resulting in tennis elbow. But you don't have to play every day to get it. Players who don’t play for weeks at a time and then play for six to eight hours during a weekend can overwork the arm also. It should be noted that, ‘overworked’ in this case is usually not just the amount of use, it is being overworked through the improper use of various techniques. Where the pros can be seen hitting tennis balls 4 to 6 hours a day, it is their proper use of form and mechanics that separates them from the typical tennis elbow injuries we see among the public and private courts around the world.

• Improper biomechanics causes undue stress and shock mostly absorbed by the forearm.

  Lack of Muscle Development and Stretching – Even though the modern racquet is made with space age technology and can do a lot of the work for you, players still need to develop the forearm and surrounding muscles to be able to withstand the repetitive motion and stress caused by the collision between racquet and ball. In fact it has been said that the modern breed of tennis racquets, with stiff, light-weight frames contribute more today to tennis elbow than those of several decades ago. When you first start to play or warm up, your muscles (and connective tissues) tend to be cold, rigid, and stiff. When muscles and tendons are not warmed up, they tend to be more delicate and fragile, presenting more susceptibility to strains when stressed at this stage.

• Improper technique causes the shock and awe effect – Learning to stroke the ball properly is vital. Improper biomechanics causes undue stress and shock mostly absorbed by the forearm. This is the reason you rarely see a 5.0 plus player with a tennis elbow. Majority of the players walking around the clubs and the park courts with an arm brace are the 2.5 to 4.0 players.

Four Reasons Players Develop Poor Biomechanics

1. The Monkey See Monkey Do Tendency
   

   This is a common problem on the forehand side. Many of the 2.5 and 4.0 players hit the forehand using some variation of the continental grip. They watch the pro players on TV and want to copy what they do. They copy the loop take back (this is a good thing) and they copy the windshield wiper type of follow through that a lot of the pros use.

   Pro players generate power by swinging with their bodies not just their arms.

   Unfortunately, these recreational players don’t prescribe to the proper grip and overall swing mechanics and footwork patterns that the pros employ when hitting their colossal forehands! Thus, they end up with weak grips, late swings, and wristy movements that place a great deal of strain on the elbow.

   Even more prevalent are those who use improper backhand techniques. The vast majority of recreational players, those who have never taken tennis lessons, tend to use one-handed backhands on their groundstrokes. Again, these players use improper grips and swing patterns on both their backhand volleys as well as their groundstrokes, often resulting in late hits. Such action causes the player to try and ‘catch up’ their racquet by flipping their wrist and arm through the shot quickly. These combined actions place a tremendous amount of stress on the tendon connected to the outer part of the elbow. If there is one reason to take tennis lessons, it is to learn how to hit effectively and efficiently in order to reduce these common and relatively avoidable injuries.

2. All Arm, No Hips
   

   Pro players swing with their bodies not just their arms. At the club level, more often than not, just the opposite is true. When a player uses only the arm when stroking the ball and does not synchronize the stroke with the hip and shoulder rotation, the tendency is to muscle the ball over the net. This excessive squeezing of the racquet by tightening the wrist and forearm creates stress on the elbow. Do that for two hours of play for three days a week and you can pretty much predict the results.

   Likewise, when players over-rotate their hips and fail to synchronize their stroke with properly with the legs and hips, the player usually tries to ‘catch up’ their racquet by ‘flipping’ it through with their wrist. Again, such actions place a great deal of strain on their forearm and elbow.

3. The Alligator Arm Syndrome
   
   This is a common tendency you see among 2.5 to 3.0 players, where on the serve, the player fails to get full extension. Contact is made with a bent arm and the vibration and stress from the contact is all taken with the elbow. When a player makes contact with the bent arm, there is very little usage of the shoulder and trunk rotation. 100% alligator arms equals 100% tennis elbow.
   
   

   Click photo: Stretch the forearm muscles before exercising or playing.

   The root cause of this swing pattern is the use of the eastern forehand grip on the serve. This grip tends to make the player swing the elbow forward and then down first, with the racquet trailing. Using a continental grip on the serve and proper service mechanics helps the player learn to use the acceleration of the racquet to hit the ball—instead of trying to ‘muscle’ the ball over. Good servers can literally swing while holding the racquet loose in the grip. This is because a proper swing pattern allows the racquet to gain momentum and hit the ball with far less necessary strength.

4. A Lot of Poking and Not Much Stroking
   
   For the one handed backhand player, a full shoulder and hip turn is needed to execute the shot properly. If a player does not turn completely, they end up arming the ball - poking at it rather than stroking it. Too much poking causes a jarring and undue stress on the elbow, leading to pain. Likewise, when players tend to bend the elbow too much on backhand volleys, the natural tendency is to straighten the elbow right at contact. This motion, added to the use of an eastern backhand grip, tends to make the racquet swing on an angular path whereas the racquet face literally faces well to the players side and then must rotate quickly right at contact to gain the desired direction. Such motion is a prime culprit to tennis elbow!

4. Improper Tools for the Trade
   
   Playing with soft balls, stiff, hybrid strings, dead strings, racquets strung too tight, a stiff racquet, or grip that is too big can apply the finishing touches to the tennis elbow syndrome. Talk to a tennis professional regarding grips, racquets, strings and, of course, technique, and you can save yourself a lot of pain!

   Click photo: Wrist Curls and Reverse Wrist Curls.

I Don’t Have It and I don’t Want It!

If you take a few precautions before you leap whole heartedly into the tennis world, you can prevent the problem before it occurs. And that is a lot better than treating the symptoms. Just ask anyone wearing one of those arm bands.

Stretch and Strength Train

Here is a great stretch before you start your workout. Hold your playing hand out straight with the palm of the hand facing the sky. With your non-dominant hand, grab hold of the four fingers and pull them towards the ground (elbow should be locked) and hold for 15-20 seconds. Now repeat the process by starting out with the knuckles facing the sky and the palm facing down.

Once the stretch is complete grab a 1 – 10 pound dumbbell (depending on the strength of your forearm) and do 2- 3 sets of wrist curls, reverse wrist curls, reverse curls and twist reverse curls.

Good Form

Go to an experienced certified tennis professional and have your technique evaluated. Remember, the number one cause of tennis elbow is improper technique.

A few things your pro may look at:

• Grip
• Shoulder turn
• Contact point
• Swing - excessive rolling of the wrist
• Elbow during the contact of the serve
• Whether you would benefit by switching from the one handed to a two handed backhand.

Good Equipment

Your equipment is important. If you are still playing with a racquet you purchased during the first Reagan Administration, it is probably time to upgrade. You can pick up a good racquet for between $100-$200 price range.

String the racquet on the lower side of the recommended tension. High string tension makes the racquet feel like a stiff board while the lower tension makes it feel more like a trampoline.

Make sure you have fresh strings. If you play 2-3 times per week consistently, string your racquet every three months or so regardless of whether or not you break them.

You might want to switch to what is called a Tweener frame. A tweener frame is a cross between the thin player type racquets the pros tend to use and the Big Bertha, Granny Racquets that provide power that you can't control or use effectively. What I love about the granny racquets is that they are really easy on the arm and you can stroke the ball well with minimal effort. But be careful, depending on your level and style of play, the ball can come off the racquet like one of Barry Bonds home runs on steroids. The great thing about the tweener frames is that they provide the right amount of power and consistency without sacrificing control and the impact is very forgiving on the elbow.

Elbow brace - If you have tennis elbow an elbow brace can be a life saver. You can pick one up at your local sports store.

Dead balls - Avoid these like the plague. If you can squeeze the ball with ease, it is long past the time to open up a fresh can.

Use the correct grip size. You can go to the TennisOne Get a Grip section and find the proper grip size for you based on the size of your hand.

Ok, I got It, Now What?

If you already have tennis elbow (and my guess is that if you took the time to read this article, you probably do), don’t worry there is hope. The first order of business is rest and let the inflammation and soreness go down. This can take as little as three days or as much as three week or longer. Start icing immediately, 2-4 times per day. Don’t think, “I haven’t played so I don’t need to.” Even simple activities like writing, lifting, and gardening can aggravate it. So don’t skip the icing.

Keep stretching to break down the scar tissues. Take ibuprofen or other anti inflammatorys to keep the inflammation down. Go to a physical therapist or start the strength-training regimen described above.

If you’ve tried everything and still are plagued with intense pain, it may be time to check with your doctor about a possible cortisone shot or acupuncture treatment.

Your comments are welcome. Let us know what you think about Monty Basnyat's article by emailing us here at TennisOne.