RSM-SPM-015
Written by Hironori Ikeda, MSc Sports Medicine
RSM International Academy · Chiang Mai, Thailand
What Should You Assess When Tennis Elbow Keeps Returning?
The outside of the elbow settles after treatment, then hurts again during gripping or the same racket stroke. Before repeating the massage, identify what brings the familiar pain back: a harder grip, repeated wrist loading, a particular stroke or an increase in playing volume.
I start with the painful demand, then compare the forearm and shoulder under clearly defined conditions. Local tendon loading, proximal muscle function and radial-nerve problems require different reasoning; the location of pain alone cannot separate them.
This article explains how wrist-extensor anatomy relates to racket control, how to compare shoulder-to-wrist contributions, and when to choose massage, adjust loading or arrange further assessment. The final step returns to the original grip or stroke under matched conditions.
In This Article
- What Should You Assess When Tennis Elbow Keeps Returning?
- In This Article
- 1. Why Gripping Loads the Wrist Extensors at the Lateral Elbow
- 2. Shoulder-to-Wrist Comparison: Change One Part of the Painful Stroke
- 3. Lateral Elbow Palpation: Extensor Origin, Supinator and Radial Tunnel
- 4. Sports Massage for Recurring Tennis Elbow: Choose the Target and Review Loading
- 5. Re-test Grip and Wrist Load Under the Original Conditions
- Related RSM Clinical Blogs
- Supporting Clinical Notes
- Palpation, Contact and Re-Assessment
- Study Sports Massage at RSM
1. Why Gripping Loads the Wrist Extensors at the Lateral Elbow
Gripping involves the wrist extensors even when the wrist appears still. Extensor carpi radialis brevis (ECRB) runs from the common extensor origin at the lateral epicondyle to the dorsal base of the third metacarpal. It helps extend and radially deviate the wrist. During racket grip, wrist-extensor activity counters the wrist-flexion demand of the finger flexors.
I first compare a gentle grip with light resisted wrist extension, keeping the forearm supported and recording where the familiar pain appears. Local lateral-elbow pain during these demands makes the extensor region relevant, but neither maneuver identifies one tendon with certainty.
Ask whether symptoms return with more strokes, stronger gripping or the first session after rest. These are different exposure histories. I use that distinction to choose the initial loading comparison; tenderness alone does not tell me that the player needs deeper pressure.
2. Shoulder-to-Wrist Comparison: Change One Part of the Painful Stroke
A shoulder comparison matters when it changes the relevant demand. In a forehand, humeral rotation and horizontal adduction position the racket through acceleration while the forearm controls its orientation. The rotator cuff helps control the humeral head; serratus anterior links the ribs to the scapula and supports scapular movement as the arm reaches.
I compare comfortable shoulder internal and external rotation with the elbow supported, noting whether limitation or pain changes when the trunk stays still. During a slow, tolerable forehand, I then change one trunk-rotation cue while keeping the racket and stroke speed similar. I ask about the same elbow pain and perceived grip effort.
If the stroke becomes easier, I record the changed condition and investigate it further. I do not label an asymmetrical shoulder as the cause of tennis elbow or assume that a less painful demonstration measured lower tendon force.
The clinical literature supports considering proximal impairments alongside the elbow and wrist, but a proposed rehabilitation program is not proof that correcting the shoulder prevents recurrence. The RSM teaching question is practical: which comparison changes this player's familiar problem enough to influence the plan?
3. Lateral Elbow Palpation: Extensor Origin, Supinator and Radial Tunnel
Separate pain at the common extensor origin from pain farther down the proximal forearm. Radial tunnel syndrome typically presents with pain approximately 3–5 cm distal to the lateral epicondyle. The supinator lies beneath the superficial extensor region, around the proximal radius, with the deep radial branch/PIN closely related to it.
With the forearm supported, I locate the epicondyle before following the superficial extensor muscle region distally. I compare tenderness with the location recorded during wrist loading. Broad, controlled contact is a practical precaution; I do not press deeply into the supinator region to try to “find” the nerve. Spreading or electric symptoms mean stop that contact and reassess.
Radial tunnel pain and posterior interosseous nerve (PIN) motor syndrome are different presentations. PIN syndrome can produce objective weakness, often without prominent pain. New finger or thumb extension weakness, persistent altered sensation or marked loss of function calls for neurological assessment. Neither tenderness nor one painful resistance test establishes a nerve diagnosis, and these findings should not be managed by repeatedly increasing massage pressure.
4. Sports Massage for Recurring Tennis Elbow: Choose the Target and Review Loading
Massage should have a defined purpose in the session. If superficial extensor tenderness matches the painful gripping region and the neurological screen gives no reason to defer, I may use tolerable contact over the muscle belly. A short travelling stroke follows the superficial extensor contour, not a deeper path into the supinator region. With contact eased, let the wrist move through a small, comfortable flexion–extension range before restoring the recorded grip setup; do not add grip force simply because the forearm feels softer. A sensitive tendon attachment is not an instruction to apply harder friction.
The 2024 Cochrane review found low-certainty evidence that manual therapy and exercise may produce small short-term improvements over minimal treatment; those benefits were not sustained. Manual therapy compared with placebo relied on one small trial. These findings do not justify promising that sports massage repairs the tendon or prevents recurrence.
I also review playing volume and grip demands with the athlete and, where appropriate, the treating clinician or coach. If an agreed stance or trunk-rotation change helps a controlled stroke while the grip test remains painful, I record the stroke change and local load intolerance separately. That gives the kinetic-chain comparison a specific purpose without making the shoulder the presumed cause of every elbow problem. During a wrist-extension hold, the extensors maintain position against resistance; in controlled lowering, they work while the wrist moves toward flexion. Selecting and progressing such loading requires the individual's response. Persistent deterioration or objective weakness changes the priority from another massage to reassessment.
5. Re-test Grip and Wrist Load Under the Original Conditions
Repeat the baseline measure before changing the challenge. For pain-free grip testing, use a consistent handle setting and arm position; the guideline describes sitting with the elbow extended, forearm pronated and wrist slightly extended. Record force at pain onset and average three trials when tolerated. Do not force repeated testing through an irritable response.
If light resisted wrist extension was the chosen comparison, repeat the same forearm support, wrist angle, resistance and hold duration. For the controlled forehand, restore the original stance, racket, range and approximate speed. A softer grip or slower stroke is a useful load modification, but it is a different test.
I judge the session from the matched response and the subsequent activity pattern. Less pain immediately does not prove tendon healing or readiness for full-speed play. If symptoms return with the next usual session, review the actual stroke volume, loading progression and differential assessment. Include grip-heavy gym work, repeated lifting and forearm rotation at work in that review: unchanged court time does not mean unchanged forearm exposure. If those other demands have increased, coordinate the loading and recovery plan across the week before simply repeating the same local treatment.
Related RSM Clinical Blogs
Browse all Sports Massage clinical guides
▷ Medial Elbow Pain in Throwers: Valgus Load & Shoulder Mechanics — Sports Massage · Compare medial-elbow loading during throwing with the lateral-elbow demands of gripping.
▷ Lateral Elbow Pain in Racket Sports: Tendon or Radial Tunnel? — Sports Medicine Massage · Examine tendon and radial-tunnel findings in a racket-sport differential assessment.
▷ Tennis Elbow or Radial Tunnel? — Remedial Massage · Review how pain location and neurological findings change the interpretation of tennis-elbow symptoms.
Supporting Clinical Notes
Palpation, Contact and Re-Assessment
▷ Recurring Elbow Pain: Compare the Grip Task Before Blaming the Wrist
Study Sports Massage at RSM
RSM International Academy in Chiang Mai teaches therapists to connect sport demands, functional anatomy and clinical palpation with treatment selection and reassessment. For recurring racket-sport symptoms, the learning goal is to explain why a particular forearm or shoulder comparison changes the session.
Sports Massage — course details and application · Annual course schedule
The Trigger Point Therapy Course provides the clinical palpation foundation and is a prerequisite for Sports Massage. For broader overuse and kinetic-chain assessment, the Sports Medicine Massage Course builds on prior completion of Trigger Point Therapy, Deep Tissue Massage and Dynamic Myofascial Release.
About the Author
Hironori Ikeda, MSc Sports Medicine
Hironori Ikeda is the founder and lead instructor of RSM International Academy in Chiang Mai, Thailand. His teaching connects functional anatomy, clinical palpation and sport-specific assessment with reasoned manual therapy.