Elbow Pain

In this article I discuss elbow pain relating to both baseball and tennis. If you play other sports that involve throwing and are experiencing elbow pain, refer to the baseball section of this article. If you are playing other racket sports, refer to the tennis section.

Throwing Related Injuries

Major league and Little League pitchers have one thing in common:  they frequently develop pain along the inner side of the elbow.

The pain is caused by throwing, and therefore it is important to understand the mechanism and to be able to recognize and manage various injuries.    As the arm accelerates forward, the muscles along the inner side of the elbow become very active and stretch.

Four Phases of Throwing:

  1. Stance Phase.  The body is relaxed.
  2. Windup.  The shoulder lifts and rotates outward as the arm is cocked.  The muscles in front of the shoulders and around the elbow tighten.  Because of increased tension, muscle injuries can occur.  The muscles in front of the shoulder can be sprained, and the biceps tendon in the shoulder can become inflamed.
  3. Acceleration or forward motion.  Considerable force is generated across the shoulder and elbow during this short phase.  The shoulder moves forward and swings from outward to internal rotation producing a rather violent torque at the ball of the shoulder.  There is little active shoulder muscle contraction:  the arm is hurled forward by trunk rotation and trunk muscles.  Still, rotatory force at the shoulder joint may produce muscular injuries in adults and fractures in children.

The muscles along the inside of the elbow are very active during this phase and are tensed and stretched.  If the elbow is overused and abused, inflammation, pain, and tenderness result.

  1. Follow-through.  As the ball is released, there is an increase of shoulder activity.  Also, the powerful triceps muscle behind the arm contracts to straighten the elbow.  The forearm and wrist rotate if a curve of slider is to be thrown.  Sprains of the triceps muscle are common and, later, bone spurs may occur behind the elbow.  It has been reported that 50% of major league pitchers have permanent elbow deformities and are unable to fully straighten their arms.

The final release of the ball requires powerful bending of the wrist and fingers.  Their muscles originate at the bump at the inner side of the elbow.  Overuse can produce sprains or tears in the muscle origin, resulting in an inflammatory tendonitis.

In growing children, the muscle origin is attached to growing bone, which is weaker than mature bone.  As a result of the stress, the muscle tugs this growing bone away from the remainder of the elbow bone, thus ending in a small chip fracture.

Both conditions start slowly and develop gradually.  Pain is present at the inner side of the elbow and forearm.  Hard throwing aggravates the pain.  The bump ( medial epicondyle)at the inner side of the elbow becomes painful to touch.  X-rays of the elbow are useful because bony changes frequently occur—especially when the condition is chronic.  In adults, we may see calcium deposits or bone spurs.  Many major league pitchers have abnormal elbow  x-rays.  In children, fractures, or irregularity of the growth bone is imminent.  Sometimes the broken fragment may become displaced.  In several studies, x-ray abnormalities have been reported in a high percentage of Little League pitchers between the ages of 9 and 14, compared to children of the same ages who did not play baseball.  Stress is also considerably increased by throwing curves or other breaking pitches, which require greater work of the elbow muscles.


The adult condition is treated with rest from throwing for one to two weeks.  Initial treatment consists of application of ice packs several times daily, anti-inflammatory medication.  Possibly cortisone injections are used to control inflammation.  A sling may be worn to rest the arm.  Failure to rest may result in eventual scarring and permanent stiffness.  If the pitcher recovers, he can start tossing the ball gently, and muscle-strengthening and stretching exercises are recommended.  Hard throwing should be discouraged for about three weeks.  Failure to rest may result in eventual scarring and permanent stiffness.  Calcium deposits, bone spurs, and loose pieces of bone in the elbow joint can occur.  In extreme cases, surgery may be required to remove them.

Little Leaguer’s elbow is a more serious problem because of the potential for permanent growth damage and deformity of the elbow.  If a growth bone is injured beyond repair, growth abnormalities will ensue.  Accordingly, all throwing activity must be stopped for at least six weeks.  Anti-inflammatory medication and cortisone injections could be considered, albeit these measures are more commonly prescribed in adults.  The child’s ultimate return to pitching depends on improvement in symptoms and x-ray changes.  Rarely, if a broken growth bone is displaced, surgery may be necessary to pin it back.


Little Leaguer’s elbow can be prevented by pre-game warm-up exercises and limitations of excessive pitching.  A limit of six innings per week is required by Little League rules.  Curve ball pitching, which places increased stress on the elbow, should also be discouraged.

Tennis Elbow

One of the most frustrating problems for the tennis player is tennis elbow (lateral epicondylitis).  It is not an exceedingly painful or disabling condition, but it can produce enough discomfort to interfere with enjoyable or competitive playing.

Tennis elbow is caused by stress placed on the muscles of the forearm.  They are attached to the elbow by board tendons.  The bump on the outer side of the elbow is the lateral epicondyle and the tendon which attaches here is called the common extensor tendon (see diagram below). The muscles that connect to the common extensor tendon bend and straighten the wrist and turn the forearm.  When a ball strikes the racquet, its force is transmitted along the forearm to the elbow.  The tendons at the elbow become inflamed (tendonitis) and later, scarred.

Ninety percent of people with tennis elbow develop pain at the outer side of the elbow.  This results from stress on the muscles that straighten the wrist.  It occurs as a result of a faulty backhand with abnormal wrist movement.  Less commonly, the pain can be present at the inner side of the elbow due to the forehand or serve.  The serve may produce pain in players who snap their wrists while serving.


In mild cases, aspirin or anti-inflammatory medicines can be taken and ice should be applied after play.  Also a snug Velcro strap worn below the elbow may be helpful.  The brace works by limiting muscle expansion and pull at the elbow.  Partially avoiding using a painful stroke, such as the backhand, may also be needed.

In more severe cases, complete rest from tennis for a few weeks is necessary.  Rest subdues the inflammation and helps promote healing.  During this time physical therapy consisting of whirlpool and ultrasound is helpful.  Frequently, a cortisone injection may be beneficial.

Prolonged rest or immobilization of the limb is not recommended because muscle wasting will result.  Maintenance of adequate muscular strength is an important factor in treatment.  Graduated stretching and strengthening exercises should be done after the initial painful phase has ended.  Isometrics are initially done with the elbow and wrist straight.  When there is no pain from a firm handshake, strengthening exercises are started.  A three to five pound hand weight is used to strengthen the forearm muscles.  A good exercise is one which is performed with the forearm flat on a table and the wrist hanging over the edge.  A hand weight is held, and the wrist is flexed and extended.  The small muscles of the hand should also be strengthened by squeezing a tennis ball or by spreading the fingers against a thick rubber band.  People with tennis elbow have definite arm weakness, so a formal exercise program is most important.  In recreational players, the dominant arm should be 5% stronger than the non-dominant arm.  In competitive players, the dominant arm should be 10% strong.

After recovery, routine stretching and strengthening exercises should be continued.

Technical and Equipment Modifications:

At the top of the list is tennis lessons which may help alleviate poor technical habits, such as faulty arm positions during the backhand. Poor stroke techniques and mis-hits probably contribute to elbow problems more than anything else. Overheads or serves with the elbow flexed in a forward direction –adding to exaggerated spin or a whip motion can lead to tennis elbow.

Modifications in equipment are simple enough and most valuable:

  1. Surface:  A fast court such as grass or cement will speed the velocity of the ball and increase impact force generated toward the elbow.  Therefore, playing on slower surfaces, such as clay or Har-true is preferable.
  2. Balls:  Heavyweight, dead, or wet balls are heavier and therefore produce more force on the racquet.  Fresh, regular-duty balls are recommended.
  3. Racquet:  There is no conclusive evidence that one type of racquet is better than another.  However, the lighter, medium-flex, evenly-balanced racquets are probably best.  Oversized racquets are useful for increasing the “sweet spot,” thus making the ball less likely to hit the frame, producing less elbow stress. Vibration dampeners placed between the strings will help relieve stress.
  4. Strings:  Stringing patterns do not seem to matter, but mild to moderate tension on the strings (52 to 55 lbs) is recommended.  Gut is more resilient and slightly better than nylon, but the cost difference does not really justify the small advantage.  Therefore, use 16-gauge nylon.
  5. Grip:  A correct hand grip size will produce less stress.  Most players tend to use a handle that is too large.  The proper size can be determined by measuring the distance between the tip of the ring finger and the first palm crease.

As a last resort, surgery may be necessary in a patient who is resistant to treatment.  Although the surgery is relatively simple and frequently effective, most people recover without an operation.

To conclude, in all of these injuries, prompt recognition and treatment, as well as thoughtful medical and technical measures, is important to prevent permanent impairment.