Tennis elbow (in tennis players)

Tennis elbow (TE) affects up to 40-50% of all tennis players in their lifetime. In tennis, repetitive strokes place large demands on the wrist extensor muscle group. Backhand strokes have been shown to invoke higher stresses on the elbow than forehand strokes.

The force imparted by the ball onto the racquet during a backhand stroke is transmitted via wrist extensors to the common extensor tendon origin on the outside of the elbow. When overloaded greater than capacity, the tendon begins to break down and lead to tissue disruption, hence the feeling of pain and weakness around the elbow.

Every aspect of the game of tennis is a variable that could potentially influence force transmission to the elbow and extensor muscles. This includes external factors such as properties of the racket, ball, court surface and game conditions then player dependent variables including grip strength, posture, technique and experience.The following is a summary of the current research into the development/risk factors of tennis elbow in tennis players however a lot is still unknown on the topic and more research is needed.

Double-handed vs single handed backhand?

In two-handed backhands, the impact of the ball on the racquet is dissipated through two arms, with greater force through the left arm (in a right hand dominant player). This may achieve a lower force transfer to the dominant elbow than in single-handed backhands.


An increase of wrist extension was found in more experienced tennis players just prior to ball impact compared to novice players who strike the ball with their wrist in more flexed position at impact.

Experienced players were also found to use a tight grip on impact of the ball then immediately release grip during the follow-through phase of backhand. This quick release grip was found to reduced 89.2% of load in the lateral elbow compared to recreational players who maintained maximal grip strength throughout the follow-through phase.

Racquet string tension?

Lower string-tensions are known to provide more power with higher tensions offering greater control. One recent study compared string tensions of 45Ib, 50Ib and 55Ib and found lower string tensions transmit less force to the elbow in backhand strokes. (Conversion used 1 lb = 4.444 N).

Grip size?

When gripping the racquet the forearm extensor muscles activate to counter-balance the force of the flexor muscles. A study found grip size too small or too big increases the amount of grip force during forehand strokes hence increases the load to the forearm extensor muscles. Click here to find out your ideal grip size.

Muscle capacity ratio of forearm flexors to extensors?

In players with tennis elbow a study found the ratio of extensor/flexor muscle capacities was imbalanced compared to players without tennis elbow. Compared to healthy non-players, healthy players presented higher extensor muscle capacities and greater capacity ratios showing that playingtennisgenerates specific adaptations of muscle capacities.

6 modifications to try if you are a tennis player with tennis elbow:

  1. Adopting the technique seen in advanced players- less wrist flexion at ball contact in backhand.
  2. Release forearm muscle/grip tension directly after contact in follow through phase of backhand.
  3. Adopt double-handed backhand or more emphasis on left hand during double-hand backhand (for right hand dominant players).
  4. Reduce string-tension.
  5. Find the correct grip size. Take note of the thickness of new grips and over-grips as this will increase the perimeter of the racquet handle.
  6. Improving flexor/extensor capacity ratio with specific forearm strengthening exercises.

If these modifications do not help and your elbow pain persists make sure to see our tennis physiotherapists for more advice and a rehabilitation plan.


Chung, K. C. and M. E. Lark (2017). "Upper Extremity Injuries in Tennis Players: Diagnosis, Treatment, and Management." Hand Clin 33(1): 175-186.

Eygendaal, D., et al. (2007). "Biomechanics of the elbow joint in tennis players and relation to pathology." British Journal of Sports Medicine 41(11): 820.

Mohandhas, B. R., et al. (2016). "Racquet string tension directly affects force experienced at the elbow: implications for the development of lateral epicondylitis in tennis players." Shoulder & Elbow 8(3): 184-191

Rossi, J., et al. (2012). "Characterisation of forces exerted by the entire hand during the power grip: effect of the handle diameter." Ergonomics 55(6): 682-692.

Rossi, J., et al. (2014). "Potential effects of racket grip size on lateral epicondilalgy risks." Scand J Med Sci Sports 24(6): e462-470.

Vigouroux, L., et al. (2016). "Assessment of the risk and biomechanical consequences of lateral epicondylalgia by estimating wrist and finger muscle capacities in tennis players." Sports Biomechanics: 1-18.