Danny Dinh

My treatment philosophy is guided by 2 core principles: 1. I optimize my patients' recovery time frame as much as possible. 2. I empower my patients to be as independent in their rehab as much as pos...

How Tennis Players Can Overcome Tennis Elbow

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Danny Dinh
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Tennis elbow, the boogeyman of racket sports players. Being the most common overuse syndrome of the elbows, almost everyone has had some kind of contact with tennis elbow, either directly or indirectly. Unlike what its name suggests, tennis elbow can also occur in individuals who don’t play tennis. From janitors to electricians to hockey players, I’ve treated a full spectrum of patients with this condition. 

If you’re a tennis enthusiast, you may have heard of great players such as Venus Williams, Bjorn Borg, and Andy Murray suffering from tennis elbows as well.

In this article, we will demystify the tennis elbow. A warning: this article is a lengthy one! It is the longest article I’ve written so far, but I felt that each section is too important to leave out. It would be a disservice to my readers as well as to my case to take away vital information. 

It is divided into 2 main parts:

  1. An explanation of tennis elbow and a case study of a tennis player. As always, some details about the patient and their rehab were obscured and modified to preserve anonymity.
  2. A complimentary deep dive into the physical therapy concepts used to treat the patient in the case study.

Each part stands on its own, so feel free to jump to the section you’re more interested in. 

What is a tennis elbow?

Tennis elbow is also known as lateral tendinopathy. It is a condition involving the lateral tendons of the elbow, more specifically the ones responsible for wrist extension. Here is a practical video to help you palpate your lateral epicondyle, the origin of the muscles involved in tennis elbow: link

Tennis elbow is an overuse injury, which means an injury of the extensor tendons often created by repetitive contractions and manual tasks putting strain on these structures. Patients suffering from tennis elbow will often complain of pain when lifting objects with their palms turned down, opening tight cans, or playing racket sports. Note that injuries are multifactorial and that this is a simplification of the injury process, as other factors such as sleep, nutrition, and stress levels can impact injury risk as well.

Tennis elbow affects the extensor muscle group, which contributes to wrist extension. In this picture, the model’s hand is face down.
Tennis elbow affects the extensor muscle group, which contributes to wrist extension. In this picture, the model’s hand is face down.
Wrist extension is when you bring the back of your hand toward your forearm and is the movement most affected in tennis elbows.
Wrist extension is when you bring the back of your hand toward your forearm and is the movement most affected in tennis elbows.

The case

Now that you have a basic understanding of tennis elbows, let’s get into the thick of this article: our case study, Ms. T. (for tennis). Ms. T. is a university varsity tennis player in her 20s who had been living with right lateral elbow pain for over 11 years now. 

You read that right! 11 years of elbow pain, on and off. That pain would appear and disappear over the years, and only became a significant problem half a year ago. What was most confusing for her was that she had never had an accident playing tennis. She would watch her friends and partners sprain their wrists, knees, and their ankles every so often. Her? Never. 

For the first year or so, she thought it was just her elbow being tired. 

It felt more like a sore muscle than pain, so I wasn’t worried.

Her pain slowly developed over the years, and now it had a very distinct pattern: it appeared whenever she would hit a ball hard and intensified during her matches.

How this affected her

For many of my patients, pain is not their main issue. It is the consequence of pain that is: for Ms. T., her main goal in physio was not to get rid of her pain but to regain the strength and power that she had lost ever since her pain got worse.

The pain I can take, but letting my teammates down by losing points I should’ve won is a different thing.

Every patient is individual and every physical therapy treatment should respect that individuality. This is why I make my treatments goal-focused by helping my patients define their goals so that we may reach and surpass them. Ms. T.’s ultimate goal was to return to competitive play without this pain limiting her potential. For more information on this philosophy of mine, you can read my physical therapy philosophy articles (Part 1, Part 2).

What she tried before physical therapy

When her pain started impacting her games, Ms. T. did what any of us would do: she consulted Dr. Google. She deduced that she had a tennis elbow (as she had the right pain location and it is extremely common) and so she tried tennis elbow stretches and exercises that she found online. Instead of relieving pain, those exercises just provoked more pain. Unsure if that was normal, she stopped those exercises out of precaution.

Ms. T. took advantage of the university off-season and opted out of practice during the Summer to take care of her tennis elbow. She wisely recognized that although she had been suffering from this pain for years, she had kept playing tennis on an almost-daily basis, not even stopping when school was out.

She totaled over 3 months of not even touching the racket. It was pure torture, but she hoped it would help her return to her optimal performance when she came back to school and the next season would happen.

Once she resumed school and her practices with her team, her pain was gone. But that did not last: it only took 2 weeks to come back, and then it was as bad as it ever got. 

She knew she needed professional help.

The treatment

My treatment of Ms. T.’s pain consisted of creating a load management protocol for her tennis elbow and adjusting it to her unique parameters. A previous case study on a soccer player recovering from a knee injury also shows a different example of how I use the load management principle. 

If you find some of the concepts explained in the 3 phases of rehab too complex to understand, know that load management will be explained more thoroughly in a later section. If that is not enough to demystify this case study, please feel free to email or call me (my contact info is at the very bottom of this article).

From the get-go, I knew this would be a lengthy and arduous rehab process: you do not simply recover from an 11-year-old pain in a single therapy session. Fortunately for me, Ms. T. was up for it. As someone who had been playing tennis for almost 20 years, she was no stranger to adversity. She knew that this pain was something she had to overcome to get back to doing what she loved. From day one, she was completely on board with our plan.

Phase 1: Avoiding flare-ups and assessment of tolerable exercise intensity

We started by taking a 3-week break from tennis practice, as Ms. T. stated that she felt her elbow flaring up every time she went and that each flare-up was slightly worse than the last one. She still attended her team practices to work on cardio and leg exercises, but was not playing any tennis in those three weeks.

A 3-week break from tennis may sound extreme. Even missing one practice can make a difference for an athlete. It is not a suggestion I made lightly. Due to the many irritants in Ms. T.’s daily life (pain when opening tight jars or doing the laundry), I wanted to remove as many factors as possible to help us assess a baseline level of pain tolerance.

In our first session, we established a tolerable level of physical stress for Ms. T. This means an exercise intensity that was sufficient to provoke positive change but not so high that it would cause her elbow to flare up.

We define flare-ups as when an intolerable pain is produced by an activity, doesn’t leave even when the activity is concluded, and leads to the patient feeling worse the day after.

A pain of 2/10 that disappears as soon as the exercise is completed would not be considered a flare-up.

With this information, we created an exercise program consisting of light wrist extensor strengthening exercises to start adapting her tissues to this usually painful load. Instead of going to her practices, Ms. T. did these exercises for 3 weeks. 

The wrist extension curl with a dumbbell was one of the exercises in Ms. T.'s initial program.<br>
The wrist extension curl with a dumbbell was one of the exercises in Ms. T.'s initial program.

Phase 2: Returning to tennis practices

After the initial rest from tennis and the strengthening exercises, Ms. T.’s pain in her daily life was about 90% gone. It was a step in the right direction, but we were still far from done. Ms. T. had come to physical therapy to be able to crush it on the court, not in her house. On week 4 of rehab, we started a progressive return to tennis, starting with going back to practices. 

In her first few practice sessions, she only participated in half-court drills hitting junior tennis balls. Even at that low intensity, her pain was still provoked towards the end of the session. Unlike her practice sessions before starting physio, however, this pain was very transient: it only lasted 10 minutes at most. 

Day by day, she felt less and less pain hitting the junior balls and, eventually, progressed to participating in full-court drills.

On week 8, after almost a month of progressively increasing the intensity of her drills, Ms. T. took a big step forward in her rehab: she played matches with her teammates. In the beginning, she had to take multiple breaks in-between sets to let her elbow rest and even had to stop some matches when the pain would flare up too much. But, slowly and surely, she improved to the point of playing full matches without any extra breaks and only with slight elbow pain.

When returning to tennis, Ms. T. started by playing with junior balls in order to minimize the stress on her elbow.<br>
When returning to tennis, Ms. T. started by playing with junior balls in order to minimize the stress on her elbow.
She started by playing in half-court (staying in front of the service line) and then progressed to playing full-court.<br>
She started by playing in half-court (staying in front of the service line) and then progressed to playing full-court.

Phase 3: Return to competition

Between weeks 8 and 11, now almost freed from pain, Ms. T. increased the intensity of her game to the point where she felt she was playing at her best. In week 12, I gave the all-clear to participate in the season’s upcoming matches against other universities. 

Ms. T. missed almost 3 months of competitive matches and had to sit on the bench as she watched her teammates compete. We had discussed the possibility of returning to matches on week 10, but the decision was made together to wait an extra 2 weeks to decrease the chance of major flare-ups during official competitive matches. We wanted to make sure she played a few matches at high intensity with her teammates beforehand.

As with all my patients, I called Ms. T. 6 months after our last appointment. She told me she had integrated the tennis elbow strengthening exercises into her gym program and had had no pain at all since we last spoke.

Summary of the rehab plan

Weeks 1-3: pause from tennis, perform elbow strengthening program at home

Weeks 4: return to playing tennis in half-court with junior balls

Weeks 5-7: progress to participating in full-court drills with standard balls

Week 8-9: return to playing full matches against teammates at low intensity, with multiple extra breaks to monitor pain and avoid flare-ups

Week 10-11: progress to a higher intensity of play, with no extra breaks

Week 12: return to playing competitively against other schools, playing at full capacity

Ms. T. totaled 6 visits in physical therapy, spread over 12 weeks. This is higher than the 3-4 sessions that most of my patients average, but it was to be expected considering the long history of the pain and the high level of performance she had as a goal.

For the rest of this article, we will now move away from this case study and explore the physical therapy concepts used to treat Ms. T., starting with load management.

What is load management?

Load management is the reason why taking a 3-month summer break from tennis was not sufficient for Ms. T.’s condition to resolve. The IOC (Internal Olympics Committee) defines the aim of load management as “to optimally configure training, competition and other loads to maximize adaptation and performance with a minimal risk of injury”. 

For a person living with pain, proper load management adjusts the intensity of training to maximize improvements while minimizing flare-ups.

How was load management used in Ms. T.’s rehab?

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Let’s use the graph above from La Clinique du Coureur to explain load management visually. The green line is the minimum physical stress required for tissues to adapt and strengthen and the blue line is the level of stress produced by the current activity. The red line is the maximum stress before pain flares up and the tissues become irritated.

In a training session, you want to stay between the green and the red line, which is known as the adaptation zone.

Staying below the green line means you’re either not training or not training hard enough, so you won’t improve. Going above the red line means your activity is too intense and can lead to a flare-up. As you can see in the graph, the more time we spend in the adaptation zone, the more stress required to produce adaptation or cause a pain flare-up (the green and red lines are going up).

This graph is the reason why I recommended to Ms. T. to stop playing tennis for 3 weeks. After many weeks of training despite being in a great deal of pain, she was well past her “red line” and I knew that we would need to wait for things to settle. The tennis elbow exercises given to her to do at home served to load her elbow so as to produce healthy adaptations (staying above her “green line”.

Why is training in the adaptation zone better than complete rest after an injury?

Complete rest = staying below the green line and not getting any adaptations. Rest can be valuable for the pain to calm down after a flare-up, but rest alone will not lead to a full recovery in the long term. 

It is perfectly fine to take a couple of days off from exercise and sports following an injury. However, once the pain has calmed down and you feel secure in moving your body (and that serious injuries such as fractures or dislocations are off the table), it is ideal to restart gentle exercising, provided that proper load management is applied and that you are well monitored.

Training in the adaptation zone is superior to complete rest following an injury for the following reasons:

  1. It prevents your injured and your uninjured muscles from atrophying and losing strength.
  2. It allows you to slowly regain confidence in your capacities before attempting to return to sports. By performing tolerable exercises every day, you will be more in tune with your body and its limitations, which will better prepare you mentally for your ultimate goal of returning to the field.
  3. It allows you to test yourself to know exactly if you are on the right track. To explain this further: undergoing load management rehab with a physical therapist means trying different movements and activities even while you’re injured. This helps us see if your mobility, strength, and function are recovering as your pain level decreases. If we see that one aspect of your recovery is slowing down, we can adjust your exercise plan to stay on track!
  4. It empowers you to participate actively in your recovery rather than simply wait.

Good pain and bad pain

One key thing about load management is the differentiation between good pain and bad pain. This may sound counterintuitive, but not all pain is bad. Pain is a stimulus that your brain emits when it perceives a threat. However, after an injury, it can tend to overreact to any little movements out of precaution, even if those movements do not present any risk. This is called central sensitization, which is a hypersensitivity to stimuli from things that are not typically painful.

Think about it this way, after you burn your hand while cooking, just lightly brushing it with a cloth would elicit a lot of pain. Does this mean that that is dangerous? Of course not! Your brain is simple centrally sensitized to that stimulus and makes you interpret it as more harmful than it actually is.

Another example of sensitization is when we’re watching a movie and seeing someone get kicked hard in the stomach (or another place known to hurt a lot when kicked…). We may clutch at our stomach and “feel” the actor’s pain for a second, even though we obviously have not been harmed.

This is not to say that all pain is negligent and that you should see painful activities after an injury. What I teach my patients is the difference between good pain and bad pain.

Good pain during exercises or activities:

  • Easily tolerable and doesn’t worsen when prolonging the activity.
  • Makes you feel like you are regaining control and strength over your body despite being injured.
  • Leaves rapidly once the activity is done. An arbitrary benchmark to use is a 15-minute time limit for the pain to leave to still be called “good” pain.
  • Does not affect how you conduct the rest of your day.

Bad pain during exercises or activities:

  • Precedes a flare-up that persists for a long period of time even when the activity is done
  • Not tolerable and/or worsens when prolonging the activity.
  • Forces you to adopt uncomfortable positions and compensations during that activity. An example would be walking for too long after a knee injury leading to putting too much weight on the opposite leg.
  • Forces you to adjust the rest of your day due to the ongoing pain.

A proper load management rehabilitation plan, like the one given to Ms. T., aims to produce either good pain or no pain. This is not to say that all is lost if bad pain is produced. It only means that the “ideal load” has not been found yet and we need to reduce the intensity so that good pain is produced instead of bad pain.

After touching a hot surface, the incredible pain you feel might lead your nervous system to become centrally sensitized. Just looking at a fire might elicit some phantom feeling of pain in your fingers.<br>
After touching a hot surface, the incredible pain you feel might lead your nervous system to become centrally sensitized. Just looking at a fire might elicit some phantom feeling of pain in your fingers.

Moving forward

If any of the information or stories in this article speaks to you, feel free to check out my profile to read more of my articles or to book a 1-hour private room evaluation with me.

If you’d like to discuss any of the points raised in this article in more detail, I would love to speak to you. You can contact me by email at dannydinh.physio@gmail.com or by phone at 438-801-0417. I currently offer free no-strings-attached 15-minute phone call sessions to discuss how I can best assist you.

Further reading

Here are some suggestions of articles I have written recently, organized by topics.

An in-depth explanation of my physiotherapy philosophy: Part 1, Part 2

Neck pain: a case study, answering common questions from patients

Low back pain & sciatica: case study 1, case study 2, case study 3

Knee pain: case study 1

Shoulder pain: case study 1

An explanation of referred pain

Why choose telerehabilitation

7 reasons why I love my profession



Images courtesy of: Orlando Hand Surgery, Physiopedia, Research Gate, Wikimedia, Alpha Chiropractic

Disclaimer: All stories published on paperminds are educational in nature and do not represent medical advice. Stories are not a substitute for an assessment by a licensed health professional. You can book a professional directly via paperminds to get a more accurate picture of your problem.

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