Padel Elbow: Prevention and Treatment

Elbow pain is the most common injury in padel, affecting roughly 20% of all players at some point. Understanding why it happens and how to prevent it can keep you on court and pain-free.

Medical disclaimer: This article is for informational and educational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional before starting any exercise programme or treatment plan. If you experience persistent elbow pain, seek evaluation from a sports medicine physician or orthopaedic specialist.

What Is Epicondylitis

Epicondylitis is a degenerative condition of the tendons that attach forearm muscles to the bony prominences (epicondyles) of the elbow. Despite the name “tennis elbow,” it is not an inflammatory condition — it is a process of tendon degeneration (tendinosis) caused by repetitive micro-trauma.

Lateral Epicondylitis (Tennis Elbow / Padel Elbow)

Affects the tendon of the extensor carpi radialis brevis (ECRB) on the outer side of the elbow. This is the more common form in padel, especially among beginners. Repetitive backhand strokes with a flexed wrist create eccentric stress on the wrist extensors, gradually damaging the tendon.

Medial Epicondylitis (Golfer’s Elbow)

Affects the flexor-pronator tendon on the inner side of the elbow. More common in advanced players who execute powerful overhead shots (smashes, viboras, bandejas) — the combination of wrist flexion and forearm pronation stresses the medial side. Accounts for 10–20% of epicondylitis cases.

Why Padel Is Particularly Risky

Padel has a higher incidence of elbow injuries than tennis and squash (systematic review, 2023). Several factors contribute:

• No strings — the solid racket face transfers more impact directly to the arm
• Small court (20 × 10 m) — more shots per unit of time than tennis
• Wall play — frequent overhead shots and rapid direction changes
• Eccentric contractions — repeated deceleration after ball contact stresses tendons
• The area where the ECRB tendon attaches is naturally low in blood supply, slowing repair

Statistics

Beginners are more prone to lateral epicondylitis (poor backhand technique). Advanced players are more prone to medial epicondylitis (powerful overhead shots).

Risk Factors

Technique

• Hitting with a flexed wrist (especially on backhand)
• Late contact with a bent arm
• Gripping too tightly — increases load on wrist extensors
• Excessive force without adequate control

Equipment

Training

• Overplay (>2 hours of repetitive hitting daily)
• No warm-up before playing
• Rapid increase in frequency or intensity
• Insufficient recovery days between sessions

Prevention

Correct Technique

• Contact the ball with an extended (not flexed) wrist, especially on backhand
• Hit with a straight arm at the point of contact
• Maintain moderate grip pressure — do not squeeze
• Learn proper biomechanics for backhand and overhead shots

Racket Selection

For players concerned about elbow health:

• Core: Soft EVA or Ultra Soft EVA (absorbs vibration)
• Shape: Round (low balance = less torque on the arm)
• Weight: 340–360 g (lighter is easier on joints)
• Surface: Fibreglass (softer than pure carbon)
• Grip size: Correct measurement — when holding the racket, your little finger should fit between your fingertips and the base of your thumb

Overgrip Maintenance

Replace your overgrip every 5–10 hours of play (for recreational players, every 2–3 sessions). Consider an absorbing undergrip for additional cushioning. Padel overgrips are thicker and softer than tennis overgrips because the racket has no strings to absorb shock.

Warm-Up (10–15 Minutes)

1. Light cardio (3–5 min): jogging, shuffles, skipping
2. Dynamic mobility (3–5 min): shoulder circles, elbow rotations, wrist circles
3. Forearm stretches: extensors and flexors — 30 seconds each side
4. Shadow strokes: forehand, backhand, smash without a ball (~1 min)
5. Light rally: gradually increasing power

Static stretching should be done after playing, not before.

Strengthening (Preventive)

Regular strengthening of the forearm extensors and flexors, rotator cuff, and scapular stabilisers significantly reduces injury risk.

Treatment

Phase 1: Acute (First 1–3 Days)

Follow the PEACE principle:

• Protect — reduce load, avoid activities that cause pain
• Elevate — raise the arm above heart level when resting
• Avoid anti-inflammatories — NSAIDs may slow tissue healing in the early phase
• Compress — elastic bandage or brace
• Educate — understand that the body heals itself; avoid overtreatment

Ice can be used for pain relief (15–20 minutes, up to 3–4 times daily).

Phase 2: Early Rehabilitation

Isometric exercises (pain-free muscle activation without movement):

• Press the back of your hand against a table — hold 10 seconds × 5–6 reps, 3–4 times daily
• Squeeze a ball or towel — hold 10 seconds × 5–6 reps, 2–3 times daily

Progress when you can fully extend the wrist without pain.

Phase 3: Eccentric Exercises (Core Treatment)

Eccentric loading is the most evidence-based treatment for tendinosis.

Eccentric wrist extension with dumbbell:

1. Sit with forearm resting on thigh, palm down, wrist hanging over the knee
2. Use the other hand to help lift the wrist up (concentric phase)
3. Slowly lower over 4 seconds (eccentric phase)
4. 3 sets × 15 reps, daily, 7 days a week
5. Start with 0.5–1 kg, increase by 0.1–0.5 kg per week as tolerated
6. Expect improvement after 4–6 weeks

Tyler Twist (with FlexBar): A proven protocol (Tyler et al., 2010) showing 81% pain improvement (vs. 22% control) and 79% strength improvement (vs. 15%) over an average of 7 weeks.

1. Hold FlexBar in the affected hand with wrist extended
2. Grip the other end with the healthy hand
3. Twist the FlexBar with the healthy hand while keeping the affected wrist extended
4. Extend both arms forward
5. Slowly allow the FlexBar to unwind — the affected hand moves into flexion (eccentric phase)
6. 3 sets × 15 reps daily, each rep lasting 4 seconds

Phase 4: Strengthening

When you can perform 5 kg × 20 reps of eccentric extension without pain:

• Concentric/eccentric wrist extension: 3 × 10–15 with 1–5 kg
• Wrist flexion: 3 × 10–15
• Pronation/supination with dumbbell: 3 × 10–15
• Grip strengthening: 3 × 15, hold 5 seconds
• Rotator cuff with resistance band: 3 × 10
• Scapular stabilisation rows: 3 × 10

Bracing

A counterforce strap worn 2 fingers below the painful point reduces tendon load by 13–15%. Wear during activity, remove during rest and sleep. Effective as a short-term adjunct (2–12 weeks) alongside exercises.

When to See a Doctor

• Pain does not improve after 1–2 weeks of rest and home treatment
• Pain worsens despite rest, ice, and anti-inflammatories
• Inability to hold objects (a cup, a pen)
• Numbness or tingling in the hand (possible nerve involvement — up to 15% of cases have concurrent radial tunnel syndrome)

Red flags (seek immediate medical attention):

• Significant traumatic injury
• Fever
• Joint swelling
• Severe night pain that does not subside
• Progressive neurological symptoms

Advanced Treatments

If conservative treatment fails after 3–6 months:

• Shockwave therapy
• Ultrasound therapy
• PRP (platelet-rich plasma) injections — evidence of effectiveness
• Corticosteroid injections — short-term relief but may worsen long-term outcomes; avoid repeated injections

Surgery (debridement of the ECRB tendon) is a last resort after 6–12 months of failed conservative treatment, with 80–90% success rate.

Return to Play

Gradual Return Protocol

1. Week 1: Shadow strokes, light rally (20 min, 50% power)
2. Week 2: Rally for 30 min, controlled backhand
3. Week 3: Practice match (30–40 min, 70% intensity)
4. Week 4: Full match with symptom monitoring
5. If pain returns → go back one stage for a week

Preventing Recurrence

• Continue preventive exercises 2–3 times per week even after full recovery
• Use a counterforce strap during the return phase
• Review your equipment (softer core, round shape, correct grip size)
• Warm up before every session