Jonathan Su, DPT
Jonathan Su, DPT, a physical therapist, yoga therapist, and former U.S. Army officer based in the San Francisco Bay area. Dr. Su is author of 6-Minute Fitness at 60+ and 6-Minute Core Strength. SixMinuteFitness.com
Tennis elbow is the scourge of the courts. Golfer’s elbow causes more suffering on the links than sand traps. And pickleball elbow is surging right along with that sport’s rising popularity.
Elbows receive less attention than many other joints—that’s because they rarely experience major problems that require orthopedic surgery. But elbows often become very sore, and tennis, golf and pickleball players aren’t the only victims—repetitive use of tools including hammers and screwdrivers can cause elbow pain, too, as can lifting weights.
Here’s what you need to know about elbow pain, including an effective treatment strategy for golfer’s, pickleball and tennis elbow—from physical therapist and fitness coach Jonathan Su, DPT…
Most elbow pain is a result of either tendinitis, inflammation of a tendon due to overuse…or tendinosis, degradation of a tendon due to age or chronic overuse.
Telling these two conditions apart can be tricky. Tendinitis is more likely than tendinosis to produce swelling and acute pain, but symptoms are sufficiently similar that they’re often conflated. The treatment for the two conditions is the same, but the timeline differs. For tendonitis, resting for a few weeks is recommended. Tendinosis does not require rest.
When the pain occurs is a clue. Tendinitis typically flares up following overuse of a tendon, such as an elbow becoming tender or painful after playing pickleball for hours every day for a week. Tendinosis can produce discomfort even without recent overuse.
The following is a seven-step plan for overcoming elbow pain as well as strategies to reduce the odds of developing elbow pain in the first place…
1. Make a preliminary diagnosis of tendinitis or tendinosis. Tendinitis should be the leading suspect if elbow pain occurs mainly or entirely after you overdo it with a tendinitis–causing activity, such as tennis or golf, and/or there’s swelling and the pain is acute. What to do: Take a break from the activity for at least a few weeks, ideally for a full month. Take an over-the-counter anti-inflammatory medication, such as ibuprofen, and ice the elbow as necessary to reduce the pain and swelling. Note: Before starting any treatment plan, it is a good idea to check with your doctor to make sure your elbow pain is not caused by a condition other than tendinitis/tendinosis, such as arthritis of the elbow joint or a fracture.
Tendinosis is the more likely if you’re over age 40 and the elbow pain occurs whenever you engage in tennis, golf, hammering nails or some other elbow-intensive activity—even when you don’t overdo it. What to do: Take an over-the-counter painkiller, such as acetaminophen, aspirin or an NSAID, as necessary, and experiment with applying ice or heat when the elbow aches to see which works better for you.
If you’re not certain whether the cause of your pain is tendinitis or tendinosis, take an extended break from any activity that causes you pain. If the pain returns the first time you resume this activity, it’s likely tendinosis…if not, it’s probably tendinitis.
Helpful: Golfer’s elbow, officially known as medial epicondylitis, is tendinitis of a tendon on the inside of the elbow. Tennis elbow, officially known as lateral epicondylitis, and pickleball elbow are typically tendinitis of a tendon on the outside of the elbow.
2. Minimize wrist activity when you engage in activities that cause elbow pain. The less your wrist bends or turns during repetitive activities, such as your tennis swing or hammering, the less the strain on your elbow tendons. Reducing wrist action can help whether you’re trying to control tendinitis or tendinosis…or if you don’t have either and want to keep it that way. It might seem counterintuitive that changing how the wrist moves is a key to overcoming an elbow problem, but the tendons involved extend from the elbow down the forearm to the wrist and fingers. A club pro or coach might be able to help you minimize the wrist action in your swing, or try to reshape your swing on your own. Your goal should be to create power from your core, not from wrist movement. Wearing a brace that holds your wrist relatively straight can be useful for activities like hammering. Helpful: If tennis elbow is the issue, adopting a two-handed backhand can reduce elbow strain.
3. Switch to a thicker grip. Wrapping your hand around the grip of a golf club, hand tool or tennis or pickleball racket tends to cause less tendon strain when the grip is thicker than with a thin one. Thicker grips are especially likely to benefit people who have relatively large hands.
4. Do daily exercises to strengthen often-ignored wrist and forearm muscles. Developing these muscles can reduce the strain on nearby tendons. Example…
Hold a very light dumbbell—one or two pounds is plenty—loosely in your hooked fingers, then position this forearm on a table with the wrist extending beyond the edge. How this forearm is oriented on the table depends on the location of your elbow pain.
If your pain is on the outside of your elbow and/or your goal is to reduce the odds of developing tennis or pickleball elbow, the palm of the hand holding the dumbbell should face down toward the floor.
If your pain is on the inside of the elbow and/or your goal is to reduce the odds of developing golfer’s elbow, the palm should be facing up toward the ceiling.
Now flex your wrist to move the hand and dumbbell as far up and down as possible without lifting your forearm off the table.
Do a set of 20 reps, take a short rest, then do a second set. Perform this exercise once or twice every day, increasing the weight of the dumbbell as necessary to prevent the exercise from becoming too easy. Ideally you should do both the palm-up and palm-down version regardless of the location of your elbow pain—doing just one of these could eventually cause an imbalance in your forearm muscles.
Caution: If you are currently experiencing elbow pain from tendinitis, wait a few weeks for this pain to subside before beginning these exercises.
5. Do elbow tendon stretches. Extend your painful arm straight out in front of you.
If you’re prone to pain on the outside of the elbow, such as with tennis/pickleball elbow, bend your wrist to point your hand and fingers down toward the floor so the palm faces back toward you, keeping the arm and elbow straight.
If you’re prone to pain on the inside of the elbow, such as with golfer’s elbow, bend your wrist to point your hand and fingers up toward the ceiling with your palm facing away from you, keeping the arm and elbow straight.
Whichever way your fingers are pointed, use your other hand to pull those fingers back toward your body until you feel a good stretch, then hold for 30 to 60 seconds.
6. Roll the tension out of stiff forearm muscles. Excessive tension in forearm muscles can increase stress on elbow tendons. If your forearm muscles feel stiff or knotted, place the forearm on a table and roll a baseball back and forth across the stiff muscle—that is, roll the ball perpendicular to the forearm, not up and down the length of the arm. It’s a simple but effective form of do-it-yourself massage.
7. See a doctor who specializes in sports medicine if the strategies above don’t control your elbow pain. This doctor can provide a precise diagnosis and offer additional treatment options. Example: If you’re suffering from tendinosis, one counterintuitive option might be to intentionally stimulate inflammation in the painful tendon. One technique is instrumented-assisted soft tissue mobilization (IASTM) such as scraping that could be applied by healthcare practitioner such as a physical therapist. Controlled micro trauma is applied to the affected area with the edge of a hard tool. Inflammation kickstarts the body’s healing process, which can reduce the tendon-fiber disorganization that causes tendinosis.
