Why call it Tennis Elbow when “Pickl-elbow” is so much more apropos?
[Too busy to read the details? Skip right to “7-Steps” at the bottom of this article…and refrain from looking incredulous when the instructions don’t entirely make sense]
The medical community traditionally called it “Lateral Epicondylitis”.
Athletes call it “tennis elbow”.
I prefer “pickl-elbow” because that's my new sports passion and A LOT of pickleball players have elbow pain!
But what we’re really talking about is a tendonopathy of the forearm "extensor" muscles.
Fancy names, made simple.
tendon = the sinewy end of a muscle group that anchors to a bone
opathy = diseased condition of tissue
itis = inflammation
osis = diseased state
brachi = upper arm segment
radial = outside part of the lower arm, the smaller or the 2 bones being the radius
brachioradialis = muscle that runs from the upper arm bone to thumb-side of the lower arm bone (pictured here)
The main action of the brachioradialis is to flex the lower arm towards the upper arm, especially in palm down position— think “hammering action”.
Where there’s pain, there isn’t always “itis”.
In the case of “tennis or pickl-elbow”, there is rarely inflammation and rarely is there a tear so the proper terminology is “lateral epicondylosis” or “branchoradialis tendonopathy”.
It takes time…
Most people who develop lateral epicondylosis, experience worsening symptoms over time due to some sort of chronic “gripping action” - whether that’s a hammer or a pickleball paddle.
Chronic injures like a tendonopathy are a function of cell regeneration not keeping up with cell degeneration.
Think of how often in any day you use your wrist muscles - typing, making dinner (stirring, chopping), opening mail, holding a book - almost everything with arms involves hand grip. So it’s really no wonder that another few hours of pickleball can really tips the scales towards overuse.
Acute injuries like a tear, or worse yet, a rupture of the tendon are distinctly different.
Pictured above is a common extensor tendon tear - 80% off the bone to be exact. How do I know, you may ask. Because that's me! (pre-injury on the left/post-injury on the right)
There was an audible pop with instant pain and subsequent swelling. This injury DOES require immobilization just as a fracture or significant sprain would.
Treating Pickl-Elbow? Do the opposite of what you’ve been doing!
Sometimes “conventional wisdom” just isn’t wise. And in the case of R.I.C.E. (rest, ice, compression, elevation), even the doctor who coined this acronym in the late 1970’s has long since admitted that subsequent research proved it wrong. Here’s an article by Dr. Mirkin, clarifying.
1. Stop icing
Icing will “feel” productive by numbing pain for 20-30 minutes but tissue cooling slows cellular healing.
2. Do not immobilize the joint
In other words, get rid of the elbow brace.
Healing is stimulated by light use, whereas lack of use decreases circulation thus healing.
Rest is fine in the acute stages of any injury but thereafter, gentle use is better.
3. Stop your strengthening exercises.
Or at least stop for now. The elbow pain needs to (mostly) subside before exercises can be included.
If you rate the pain at a minimum of 5/10 then it needs to get down to 2/10 before doing exercises.
3. Avoid cortisone injections!
Cortisone introduces strong inflammatory suppression when/where the products of inflammation are needed most and in the long run may ensure permanent elbow pain unnecessarily.
Researchers showed many years ago that cortisone suppresses healthy cell regeneration (ie. collagen) and may expedite tendon rupture, especially during athletic pursuits.
1. Orchard JW et al. Cortisone injections for tennis elbow should be an “avoid, rather than a recommenced procedure. Med J Aust. 2017 Nov 20;207 (10):453
2. Yi R et al. Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis. Hand (N Y). 2018 Jan;13(1):56-59
Don’t associate less pain with healing, especially when it’s artificial.
Ice, NSAIDs, Cortisone- we're looking at YOU!
These all have an immediate effect on the perception of pain but the price is postponed healing.
Make peace with inflammation and pain.
Mother nature is so much smarter than the conscious part of the human brain.
We think we know what’s better for us but the built-in "movement deterrents" of inflammation and pain force the human to behave properly.
If however we take measures to eliminate the inflammation and pain, that leads down a path towards further tissue damage as the natural mechanisms are over-ridden.
Healing requires inflammation and blood flow that brings hormones (ie. IGF) to the injured area!
A. Paddle Sizing
Here is a video, by a pickleball player who also is a hand specialist. This is a great explanation as to how paddle grip size can be a factor in elbow pain.
B. Eliminate the death-grip
As part of “grip re-education” kinesiology tape can be very useful.
Do-It-Yourself: Mobility and Stretching Program
1. windshield wiper- side-to-side movement at the wrist (slowly and 10X each)
2. hammer- imitate the action of hammering, just from the wrist (slowly and 10X each)
3. door knob- imitate the action of using a door knob (slowly and 10X each)
1. pulsing the joint - with the opposite hand, grab your sore elbow, let your fingers find the head of the radius bone and gently pump the joint
2. pin and stretch - sit forward on the chair, still with elbow bent but ability to stretch the arm out fully
-using the thumb of the opposite hand, start above the sore elbow
- pin down the bulky part of the muscle
- keeping firm pressure, straighten your elbow and at the very end fully bend your wrist down
- this will feel tender where your thumb is holding the tissue (we’re looking for “good pain” similar to a firm massage)
- it should take a full 5-6 seconds for the full stretch from elbow to wrist
-bend your elbow again and move your thumb slightly lower on the muscle and repeat
- continue moving one thumb’s breadth down the bulk of the forearm muscle almost to the wrist
3. “milk” the muscle - this may work best with a bit of hand lotion
- starting at the elbow and gliding down to the wrist, use your thumb to firmly massage the forearm muscle
- do this slowly and note any painful and/or lumpy spots in the muscle
This whole routine will take about 10 minutes and will likely leave your elbow feeling a bit irritated. That’s OK…remember inflammation is not the enemy!
Are you experiencing significant pain while trying to perform normal daily activities?
If you can’t use scissors or grip your zipper to do up your jeans, then a more detailed examination is in order.
Discuss a diagnostic ultrasound with your family doctor to rule in/out a tear.
If there is a tear, you’ll need to stop playing for a period of time ~ 6 weeks : (
If, not, then continue to play (carefully) with the knowledge that the pain may not correlate to the severity of the injury.
- Focus on changes to your grip and stroke mechanics.
- Alternate playing days
- Don’t play so hard!
Recognize that it can be prudent to take time off and focus on another fitness-enhancing endeavour such as full body mobility but in particular the shoulders and hips.
Regarding Treatment- Here’s what the research shows.
This 2020 clinical review (a compilation of many independent studies) is the current research on treatment options for lateral epichondylosis.
3. Cutts S, et al. Tennis elbow: A clinical review article. Journal of Orthopaedics, 2020, vol 17, p.203-207
4. Tseng C, et al. Topical Cooling (Icing) Delays Recovery From Eccentric Exercise-Induced Muscle Damage, Journal of Strength and Conditioning Research, May 2013
So there you have it. A high view of why your elbow hurts and what you can, and should NOT, do about it.