On the Stage or on the Court, Tennis Elbow Causes Pain

June 1, 2022

IM  -  

Tennis players may have earned the title for this painful condition, but tennis elbow is a common problem triggered by a tense grip on any tool or instrument. Combined with repetitive movement, the strain can cause swelling of the tendons that bend the wrist backward, away from the palm. Strenuous overuse, which results in tension in the hands and wrists, can lead to tennis elbow in musicians who play the violin, viola, and cello, causing inflammation, degeneration, and potential tearing.

Also known as lateral epicondylitis, tennis elbow is one of the most common painful conditions of the elbow. Inflammation and pain occur on and around the outer bony bump of the elbow where the muscles and tendons attach to the bone.

The muscles and subsequent tendons that attach at the lateral epicondyle extend to the fingers and wrist. If the muscles of the forearm are extremely tight, they can put more strain on the tendon, causing incorrect positioning, overuse, and lack of blood flow. 

Because of the extreme wrist angles while handling their instrument, guitarists and flutists are also prone to tennis elbow. Supinator muscles of the arm facilitate the twisting motion that turns the hand outward. While pain appears in the elbow joint, the root cause is often due to strain put on the muscles in the forearm from wrist and hand extension. Motions that involve a pronated or palm down wrist can exert enough stress and force on the muscles and tendons to tear the fibrous tissue.

Any musician can develop strain—even pianists—often from prolonged practice or a sudden increase in playing time and intensity. The main contributing factors are thought to be a combination of:

• Tension (grip) in the elbow while playing, especially forte.
• Regular gripping (or curling) action of the fingers.
• Over-extension of the wrist—playing with a low wrist.
• Rotating from a tense elbow.
• Repeated impact against the keys—playing repeated chords or octave with a tense arm.

For guitarists and string instrument players, repetitive arm movements can cause forearm muscles to become fatigued. A single tendon attaches this muscle to the bony bump on the outside of your elbow (lateral epicondyle). As your muscle gets tired, the tendon takes more of the load. This overloading can cause inflammation and pain, known as tendinitis. Over time, this overloading can cause a degenerative condition known as tendinosis. Together tendinitis and tendinosis can then lead to tendon tearing.

General Symptoms 

Most commonly you will have pain and tenderness on the outer side of the elbow and this pain may even travel down the forearm. Often there is pain and/or weakness with gripping and lifting activities. You may also experience difficulty with twisting activities during sports or even opening the lid of a jar. Tennis elbow symptoms tend to come on slowly. Pain may get worse over weeks and months.

Signs of tennis elbow include:

• Burning pain at the inner or outer elbow, wrist, or thumb.
• Occasional sharp twinges of pain at those locations (from the tendons, usually).
• Tension, weakness, soreness, and pain in the forearm muscles (either side).
• Stiffness, achiness, and soreness in those areas upon waking every morning, and after playing or practicing your instrument.

Tennis Elbow may be diagnosed with:

•An x-ray of the bones in your elbow will determine whether it’s lateral epicondylitis or arthritis.

•Magnetic resonance imaging (MRI) shows your tendons and the severity of damage. A neck MRI can show if arthritis or disk problems in your spine are causing your arm pain.

•Electromyography (EMG) of your elbow may reveal nerve problems causing pain.

Treatment—and Rest

Rest is often the best treatment. Playing through the pain will only worsen the problem. As you rest, remember that “absolute rest is rust.” Your tendons need some tension and motion. Some patients will find that their symptoms go away spontaneously. For others, therapeutic treatments are available. These might include:

• Activity modification: Initially, the activity causing the condition should be limited. 
• Medication: Anti-inflammatory medications may temporarily help alleviate the pain.
• Neuromuscular therapies: Stretching and/or strengthening exercises, ultrasound, or heat treatments may help the pain.

A home program of daily stretches is a good place to start. Stretching and strengthening the muscles and tendons involved are key to making this problem go away. When modifying playing and normal activity, learn to use your shoulder and upper arm muscles to take the strain off your elbow. Once your elbow starts feeling better you will be able to add some light strengthening exercises.

Patients that do not recover from the basic stretching and strengthening may need to have formal physical therapy or even a cortisone injection. Surgery is only considered when the pain is incapacitating, the injury has not responded to other treatments, and symptoms have lasted six to 12 months. Although surgery is usually performed in an outpatient setting, recovery time and physical therapy to strengthen and regain motion of the arm can take several months.

Though it can get better over time, without treatment, resting the elbow and avoiding activity that is painful is crucial. It may not be easy or even possible for a professional musician to make such a sacrifice—especially when the condition can last six months to a year—but the alternative could be career-ending. Speak with your physician, who can recommend a tailored treatment regimen, including physical therapy.

---