PREVENTING Elbow Pain in Pickleball

Pickleball is one of the fastest-growing sports in the U.S., and while it’s a great way to stay active, it has also brought a surge in elbow pain cases — most often lateral epicondylalgia, commonly known as ‘tennis elbow.’ This condition is not limited to tennis players; in fact, pickleball’s unique mechanics and repetitive nature make it a prime contributor. If you're starting to have elbow pain when holding your coffee cup in the morning, this applies to you.

What is a Tendinopathy?

A tendinopathy refers to a spectrum of tendon pathology that ranges from acute irritation to degenerative breakdown. Unlike the older concept of ‘tendinitis’ (pure/acute inflammation), modern research shows that most chronic tendon issues are not driven by inflammation alone, but by structural and cellular changes within the tendon. Key features include:

• Collagen disorganization (fibers lose alignment)

• Neovascularization (new, fragile blood vessels)

• Decreased load tolerance (difficulty absorbing/releasing force)

• Thickening or nodularity in chronic cases. In pickleball, the extensor carpi radialis brevis (ECRB) tendon is most commonly affected.

But what causes this tendinopathy to develop in the elbow as it relates to pickleball?

Common Causes of Elbow Pain in Pickleball

1. Repetitive Backhand Strokes – Poor mechanics overload the wrist extensors.

   1. Each backhand requires eccentric loading of the wrist extensors. Poor stroke mechanics (leading with the wrist vs. shoulder) amplify tendon strain.

   2. Studies show that repeated eccentric overload is the primary driver of lateral epicondylalgia.
      

2. Improper Grip Size – Too small or too large of a grip increases strain.

   1. A grip that’s too small increases muscle activation in the forearm extensors, leading to excessive tendon stress.

   2. A grip that’s too large reduces fine motor control, forcing compensatory overuse of other muscles.
      

3. Sudden Spike in Play Volume – Tendons adapt slowly and need gradual loading.

   1. Playing 5 days a week after months off is a classic setup for tendinopathy. It's the classic saying "if you don't use it, you lose it." Your tendons require a gradual build up to the demands being placed on them. Overdoing it will only lead to a breakdown of those tendons.
      

4. Excessive Grip Pressure – A ‘death grip’ increases sustained load.

   1. Many new players hold their paddle in a “death grip.” This sustained contraction of the wrist extensors increases tendon load with every swing.
      

5. Lack of Conditioning – Weak forearm/shoulder muscles shift stress to the elbow.

   1. If the forearm and shoulder muscles are weak, the small extensors at the elbow take on more stress than they’re designed to handle. Similar to the concept above, your body should work as one unit to reduce loads in other parts of the body. (e.g. If you're about to smash a volley, you should be driving the power from your hips into your arms vs just your shoulders due to the amount of force required to generate the swing.)
      

Proper Grip Size for Pickleball Paddles

Grip size is one of the most overlooked factors in elbow health.

The Formula: Measure from the tip of your ring finger to the second crease of your palm. This gives a ballpark grip circumference.

The Fingertip Rule: When holding the paddle, you should have about a ¼–½ inch gap between your fingertips and the base of your palm.

Too Small = Excessive muscular contraction → more stress on tendons.

Too Large = Loss of control → compensatory overuse of other muscles.

Strength Principles to Protect Your Elbow

Strong forearms = resilient tendons. Evidence strongly supports a progressive loading approach over passive treatments alone.

1. Eccentric Loading

   1. The gold standard for tendinopathy.

   2. Example: Wrist extensor eccentric curl. Hold a dumbbell with your palm facing down, use your opposite hand to lift into extension, then slowly lower over 3–5 seconds.

   3. 3 sets of 15 reps, daily.
      

2. Isometric Training

   1. Sustained holds at mid-range extension can reduce pain and improve tendon capacity.

   2. Example: Press the back of your hand into resistance (like a table or band) and hold 30–45 sec, repeat 5x.
      

3. Grip Strengthening

   1. Use putty, towel wringing, or hand grippers to build tendon and muscle endurance. Squeeze only with the amount of pressure that doesn't cause pain. Sometimes this means 50% effort.
      

4. Shoulder & Scapular Stability

   1. A weak shoulder complex transfers excessive load to the elbow.

   2. Include external rotations, Y-T-W raises, and serratus anterior strengthening.
      

5. Gradual Load Progression

   1. Tendons hate surprises. Slowly increase game frequency, duration, and paddle intensity. Depending on how long the elbow pain has been present may determine how long it will take to heal and feel better.
      

What to Do if Elbow Pain Arises

• Relative rest, not total rest: modify painful activities, don’t stop all movement.

• Ice/compression: useful for pain relief post-play.

• Counterforce strap: may offload the tendon.

• Seek Physical Therapy: joint mobilizations, soft tissue work, radial head mobilization, progress tendon loading, address biomechanics, individualized plan of care.
  

How Can Hybrid Physical Therapy Help?

Pickleball should be fun, NOT painful. By understanding tendon health, choosing the correct grip size, strengthening your forearms and shoulders, and addressing issues early, you can prevent elbow pain and extend your time on the court. If you’re already dealing with persistent elbow pain, don’t wait until it sidelines you. We're here to provide the best, evidence-based, care available.

Let Hybrid Physical Therapy be the ones to optimize your performance.

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