Newswise — Risk factors for higher incidence of tennis elbow, a painful tendon condition, among recreational tennis players include frequency of play, wrist stretching before matches, and using a one-handed backhand and Kevlar racquet strings, according to a new study presented this week at the Association of Academic Physiatrists Annual Meeting.

Tennis elbow is common, and proposed risk factors include play frequency, technique, and equipment characteristics. However, this is the first study to examine the presence of specific factors like forehand or backhand grip preferences, racquet string composition, and stretching habits of tennis players. Do modern tennis trends, including more prevalent use of two-handed swings and high-tech string materials, affect the risk of tennis elbow? These researchers wanted to know more.

As a tennis player myself, I found among active players and coaches, there is a high degree of variability in opinion on what causes tennis elbow and how to approach potential treatment options with respect to equipment and technique modification,” said Bobby Song, MD, a physiatrist at Baylor College of Medicine. “The most popular notion is that increased ‘stiffness’ of the equipment can increase the shock forces that travel from the stringbed to the elbow on impact which is thought to contribute to this condition. While tennis elbow has long been thought to be a degenerative, overuse related condition, we found it curious that higher level tennis players tended to not be affected as much. As a result, we hypothesized that there was also a component of improper technique as well which led us to investigate certain technique characteristics in addition to that of the equipment alone.”

While past clinical trials that investigated proposed contributors to tennis elbow individually, this is a large-scale, cross-sectional study attempting to determine whether all of these factors are significantly correlated to this diagnosis, he added.

Researchers surveyed active tennis players from four U.S. tennis clubs and two tennis databases. Participants were asked if they had ever been diagnosed with tennis elbow (TE), as well as questions on basic demographics, level and frequency of play, and characteristics of their tennis equipment and technique. Players with TE were given questions specific to their situation at the time they were diagnosed, while others were instructed to answer questions about current tennis technique and setup.

Out of 1,937 questionnaires emailed, 402 players responded, including 368 males and 34 females. Of these 402 players, 248 or 61.7% had been diagnosed with TE. Respondents’ average age was 38.7. The average age of those diagnosed with TE was 41.6, while the average of those never diagnosed with TE was 33.9.

There was a higher incidence of TE in those who had played tennis for more years, played more frequently, stretched their wrists prior to play, and used a one-handed backhand. Equipment choice may also be a risk factor: they found higher incidence of TE in users of Kevlar string racquets and the lowest incidence among players with racquets strung with full synthetic gut.

Players’ gender, skill level, forehand and backhand grip preference, grip size, use of a vibration dampener, and racquet string tension, weight, head size and stiffness were not statistically significantly associated with tennis elbow, the study found.

“What if that physician had a more robust understanding of tennis and recognized that such a multifactorial condition may instead be treated more effectively with technique and equipment modification? That physician may be able to, for example, recommend that the patient switch to a two-handed backhand or alter their string preference to combat symptoms,” said Dr. Song. Available treatments for TE, such as anti-inflammatory medications or bracing, do not necessarily address the underlying cause of the pain, he noted. “By potentially taking away the insulting factor through changes in form or equipment, the patient may be able to continue playing and not be forced to undergo invasive modalities or even take time off.”



The Association of Academic Physiatrists (AAP) is a professional society with a mission to create the future of academic physiatry through mentorship, leadership, and discovery. Its members are leading physicians, researchers, educators and in-training physiatrists from over 40 countries. The AAP holds an Annual Meeting, produces a leading medical journal in rehabilitation: AJPM&R, and leads a variety of programs and activities that support and enhance academic physiatry. On February 9-13, 2021, the AAP is hosting its first-ever virtual Annual Meeting, Physiatry ‘21. To learn more about the association, the specialty of physiatry and Physiatry ‘21, visit and follow us on Twitter at @AAPhysiatrists.


Meeting Link: Physiatry '21, February 2021