Tennis Elbow
The Racquet-Sports Elbow That Can Hit Pickleball Players Too!
You've been playing pickleball three times a week, your backhand is finally coming together, and then — right on cue — the outside of your elbow starts complaining.
Gripping your paddle hurts. Lifting a coffee mug hurts. Turning a doorknob hurts. Even shaking hands has become an adventure in pain management.
Welcome to tennis elbow — a condition that, despite the name, has absolutely no loyalty to tennis players. Pickleball players get it too, and in growing numbers.
What's Actually Going On?
Tennis elbow — formally known as lateral epicondylitis, though "tendinopathy" is now the more accurate term — involves irritation and degeneration of the tendons that attach the forearm extensor muscles to the bony prominence on the outside of the elbow, called the lateral epicondyle.
These tendons help you extend your wrist and fingers. Every time you grip a paddle, snap your wrist on a backhand, or lift something with your palm facing down, those tendons are working. When they're overloaded repeatedly without adequate recovery, microscopic damage accumulates faster than the tissue can repair itself.
The result is a tendon that is chronically irritated, structurally compromised, and — as you've noticed — not shy about letting you know.
How to Recognize It
Tennis elbow has a fairly distinctive presentation that makes it recognizable even before you see a physician.
- Pain on the outside of the elbow, over or just below the bony bump
- Tenderness directly over the lateral epicondyle
- Pain with gripping, lifting, or twisting — a paddle, a jar, a coffee mug
- Weaker grip strength than usual
- Discomfort with backhand shots in pickleball
- Pain that may radiate down the forearm
Symptoms often develop gradually rather than after a single dramatic incident. Many patients recall no specific injury — just a slow escalation from mild annoyance to genuine limitation.
Why Does It Happen?
Tennis elbow is fundamentally an overuse injury, though the underlying process is more degenerative than purely inflammatory — which is why rest alone often provides only temporary relief.
In pickleball, the backhand stroke is the most common culprit. Gripping the paddle too tightly, using a paddle that is too heavy or has too small a grip circumference, and a sudden increase in playing frequency are all contributing factors.
- Repetitive wrist and forearm use — pickleball, tennis, golf, gardening
- Overuse combined with inadequate recovery time
- Improper technique, particularly gripping too tightly
- Increased risk with age — most common in adults 40 and older
- Tendon degeneration rather than simple inflammation
How Is It Diagnosed?
Diagnosis is primarily clinical. Your physician will examine the elbow, identify tenderness over the lateral epicondyle, and perform provocative tests — resisted wrist extension and middle finger extension — that reproduce the characteristic pain.
Imaging is not always required. X-rays may be obtained to exclude other causes of elbow pain. Ultrasound or MRI can confirm tendon changes when the diagnosis is uncertain or when surgical planning is being considered.
What Actually Works
The good news is that the vast majority of tennis elbow cases resolve with nonsurgical treatment — though patience is required, because tendons heal slowly.
Activity Modification
Reduce or temporarily avoid activities that provoke pain. For pickleball, this may mean reducing playing frequency, adjusting your backhand technique, or taking a short break during a flare.
Counterforce Brace
A forearm strap worn just below the elbow can reduce the load transmitted to the irritated tendon origin during activity. Many players find this helpful for continuing to play at a reduced intensity.
Medications
Topical or oral anti-inflammatory medications may help manage pain, particularly during acute flares. They are not a substitute for addressing the underlying tendon problem.
Rehabilitation
Eccentric and progressive strengthening exercises — particularly the Tyler Twist protocol — are among the most evidence-supported treatments for tennis elbow. A physical or occupational therapist can guide a structured program.
Injections
Corticosteroid injections can provide short-term pain relief, particularly when symptoms are severe. Platelet-rich plasma (PRP) injections are used in selected cases, though evidence continues to evolve.
Surgery (Rarely Needed)
Surgical debridement of the degenerated tendon tissue is reserved for cases that have failed at least 6–12 months of appropriate nonsurgical treatment. Results are generally good in carefully selected patients.
What About Pickleball?
Pickleball is a forearm-intensive sport, and the backhand in particular loads the lateral elbow extensor tendons with every stroke. If you're developing tennis elbow, a few equipment and technique adjustments can make a meaningful difference.
Consider switching to a lighter paddle, increasing your grip circumference (a larger grip reduces the gripping force required), and adding a cushioned overgrip. On the court, focus on leading your backhand with your elbow rather than snapping your wrist, and avoid death-gripping the paddle between points.
A counterforce brace during play is a reasonable short-term strategy. A short break during an acute flare is far better than playing through worsening pain and converting a manageable problem into a prolonged one.
When to See a Doctor
- If pain on the outside of the elbow persists for more than a few weeks
- If symptoms limit daily activities or pickleball
- If grip strength is noticeably reduced
- If symptoms are not improving with rest and home care
- To discuss injection therapies or a structured rehabilitation program
Dr. Engasser's Perspective
Mark C. Engasser, MD
“Tennis elbow is a common and usually very treatable overuse injury. With the right combination of activity adjustment, bracing, and a focused exercise program, most people can get back to pickleball and stay there.”
Tennis elbow is one of the most common overuse injuries I see in active adults — and pickleball players are increasingly well represented in that group.
The encouraging part is that most people do very well with activity modification, a brace, and a focused exercise program. Surgery is rarely needed.
The less encouraging part is that tendons take time to heal, and impatience is the enemy of recovery. A few weeks of doing the right things is almost always better than months of playing through it.
A Closer Look at Tennis Elbow
Diagnosis, risk factors, surgery, recovery, and references
Diagnosis
The Cozen test (resisted wrist extension with the elbow extended) and the Mill test (passive wrist flexion with the elbow extended) are classic provocative maneuvers. Tenderness directly over the lateral epicondyle or the extensor carpi radialis brevis (ECRB) origin is the most consistent finding. Ultrasound can demonstrate tendon thickening, hypoechoic changes, and neovascularity. MRI shows tendon signal changes and partial tears when present.
Risk Factors
Tennis elbow is most common in adults aged 40–60. Repetitive forearm and wrist activities — racquet sports, manual labor, gardening, and computer use — are associated risk factors. Dominant arm involvement is more common. Smoking, obesity, and certain systemic conditions may impair tendon healing. A sudden increase in activity level is a frequent precipitant.
Surgery
Surgical treatment involves debridement of the degenerated ECRB tendon tissue at the lateral epicondyle. This can be performed open, arthroscopically, or percutaneously. The goal is to remove pathological tissue and stimulate a healing response. Surgery is generally reserved for patients who have failed 6–12 months of appropriate nonsurgical treatment. Outcomes are favorable in well-selected patients, with most returning to full activity.
Recovery
Nonsurgical recovery typically takes weeks to several months, depending on symptom severity and adherence to rehabilitation. Eccentric strengthening programs require consistent effort over 6–12 weeks to show full benefit. After surgical debridement, most patients begin gentle motion early and progress to strengthening over several months, with return to sport typically at 4–6 months.
References
- Bisset L, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939.
- Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751-1767.
- Raman J, MacDermid JC, Grewal R. Effectiveness of different methods of resistance exercises in lateral epicondylosis — a systematic review. J Hand Ther. 2012;25(1):5-25.
Medical Disclaimer: This content is for general informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment of any medical condition.
Medical Disclaimer: This content is for general informational purposes only and does not constitute medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.