Springtime Elbow (For Many, Pickleball Elbow)
⌚️ read time: 7 minutes
The temperature is warming up and Laurie simply can’t wait…she has her first pickleball match of the spring arranged this coming Saturday with her friends. So she’s been at the court every evening with her husband to get her form back for the weekend outing.
But today she woke up with a nagging pain in her elbow. She thought it would go away, but it even hurt to pick up her coffee mug this morning. Now it’s dinnertime and she feels like she can hardly lift a jar. What is going on?? She pulls out the ice and the ibuprofen and sits down at the computer to look up how to fix this before Saturday…
If there’s one group of fanatics who check the weather religiously even more than golfers, it’s all my pickleball addicts out there. You know who you are, and I know you are chomping at the bit for spring pickleball season to arrive!
But this goes for my gardeners, spring clean up-ers, golfers, and tennis players too. As excited as you may be, you should also know what might be lurking in the weeds. Listen up!
There might not be another condition I see more in my clinic during spring and fall than this one: lateral epicondylitis. Call it lateral epicondylitis, tennis elbow, lifter’s elbow, pickleball elbow…pick your favorite.
Tennis elbow is an extremely common upper extremity condition. In some populations, the estimated lifetime risk approaches 40-50%!
Seriously, think about that. Every other person gets this at some point during their life.
What does that mean in practical terms?
Oprah would say ‘You are at risk, you are at risk, you are at risk….everybody’s at risk!’
So take this seriously. Learn a few things here today and keep yourself on the court. If you want an even deeper dive, I have a longer article I previously wrote on lateral epicondylitis here.
Pickleball elbow is a tendinitis of the muscles that extend your wrist (and fingers)
As I mentioned above, the technical term is lateral epicondylitis.
This is a very common tendinitis of the connection between your upper arm bone (humerus bone) and the muscles of your forearm. Specifically, the muscles involved are the muscles that help you extend your wrist and fingers.
All of the muscles that help you perform these two actions start at an anchor point on your humerus bone near the outside of your elbow (see below).
• The wrist & finger extensor muscles attach at yellow arrow.
• Most feel pain through red arc, and even down the forearm.
Whether from poor form, overuse, or just bad luck, lateral epicondylitis is the accumulation of small tears in the muscles/tendons where they attach themselves to the outer elbow.
This constantly happens in our muscles all over our body, but one of the main reasons this is such a problem in the elbow is the relatively poor blood supply to these muscles. Poor blood supply means slowed healing…and prolonged pain.
It also doesn’t help that you extend your wrist and fingers to do just about anything in life. Just ask somebody with tennis elbow and they’ll tell you they can hardly pick up a cup of coffee.
Pain, pain, and more pain
Tennis elbow is a clinical diagnosis. This means there are no advanced tests needed.
If you haven’t had a specific injury, but you have tenderness directly over this bone-muscle interface on your outer elbow, you almost certainly have tennis elbow. There are very few other conditions with pain in this exact spot.
To seal the deal? Straighten your elbow and then extend your wrist. Have a friend try to resist against you extending (figure below). Repeat, but this time extend just the middle finger (yes, I know you know how to do that maneuver) and have a friend resist against you. Did either of those hurt your outer elbow?
Boom. Pickleball elbow (or, more technically, lateral epicondylitis).
This position is ‘wrist extension’
And no, you don’t need an MRI (a little pet peeve of mine when other docs order these for tennis elbow).
Don’t kill the messenger — but there is no overnight fix
Remember one thing:
Treatment of tennis elbow is almost entirely non-surgical.
That’s good news! Surgery for tennis elbow is only considered after more than a year of symptoms and failure of all other treatment options.
In fact, if you do nothing at all to help your symptoms, lateral epicondylitis will gradually resolve over the course of about a year, sometimes two. This will happen in nearly 95% of patients.
Obviously, you might not be thrilled about waiting a year to achieve relief from your very painful elbow symptoms.
I get it.
Everything we do for treatment is an attempt to shorten this timeframe and manage the symptoms. But if you have this condition, you need to understand that you may be in for it for a while.
But it won’t be forever.
Unlike a condition like arthritis, lateral epicondylitis does naturally heal!
Tough Love - Here’s What You Need To Do
Ok, here’s your tough love. Each of these probably deserves its own section of an article, but let’s leave that for future posts. You need the quick overview info today.
This is what you need to do immediately. It’s a lot — are you ready?
Stop the offending activity (yes, that means stop playing golf or pickleball. I know, I know you’re glaring at me).
Pick your favorite (or do all of these): ice, gentle massage, heat, topical menthol (ie, Icy Hot), CBD oil, diclofenac gel (ie, Voltaren), compression wraps, etc etc. None of them are the answer, but boy can they help with the discomfort.
You need a wrist brace, not an elbow brace. Yes, please read that again. Don’t buy what the internet markets you, those silly little forearm/elbow wraps. Remember, you now understand where this problem originates. And it’s in the wrist extensor muscles. So the answer is a wrist brace. This will prevent you from continuing to extend the wrist hundreds of times a day and over-stress those muscles — giving them a chance to heal.
Nighttime: Sleep in the wrist brace full-time for a minimum of 6 weeks.
Daytime: If you want the best chance of kicking this, wear it 24/7 for 3 weeks. Then slowly use it less and less during the day, letting pain be your guide. My full bracing framework is here.
Home physical therapy: You can get fancy with this and go to a PT or you can boil it down to 2 exercises and 2 stretches you can do at home (Go to page 3 of this link). If you’re religious about these, you will improve!
Use a can of soup as weight (instead of the bands pictured). Perform resisted wrist extension and flexion exercises. The key here is the slow count of 3 as you lower the weight (eccentric exercise).
Perform wrist extension and flexion stretches.
Consider working with a coach to check your pickleball/tennis/golf swing form. I hate to tell you, but many of these issues begin and end with proper mechanics (PS, does anyone know a coach who wants to sponsor this? 😀).
Did you notice I didn’t include injections? They delay recovery
You may be wondering about steroid injections. There are plenty of providers who still routinely perform injections for this condition.
However, evidence has been mounting that while steroid injections will temporarily make you feel better, they actually prolong the duration of your symptoms!
That means you'll feel great for about six weeks. But rather than resolving the condition over six months, it may take you nine months to a year. Or longer. When I discuss this with most patients, the majority decide that the tradeoff is not worth it.
And tennis elbow PRP injections are a whole separate Pandora’s box I will dedicate a full post to soon. Short answer: probably not worth it (yet).
By far the hardest part about tennis elbow is the waiting. It's very difficult to be patient when you're having significant elbow pain.
I get it.
My goal is to help you trust the process, educate you, and prevent you from doing more damage along the way. What I don’t want is for you to chase false promises and magic fairy dust on the internet (careful, there’s a lot of this out there, and it can be very tempting when you’re in pain).
Takeaways:
Tennis/pickleball elbow, or lateral epicondylitis, is a surprisingly painful condition that results from overuse of the wrist and finger extensor muscles
It is common for symptoms to last many months — and we don’t yet have any treatments that provide quick relief
Repeat after me. You need a wrist brace, not an elbow brace.
While we have lots of treatment options, steroid injections have recently been shown to prolong symptoms after initial improvement
As you can probably tell, there is a lot of information and even controversy that surrounds lateral epicondylitis. This is in part due to how common it is, as well as our inability to provide immediate relief with the treatments we have. This frustrates both you and me.
I get asked about tennis elbow all the time so look out for future articles going even deeper into various aspects of this condition, including therapy protocols, controversies around steroids, and PRP injections.
Hopefully we’ll have a breakthrough one of these days.
