Pickleball Elbow: How It Differs from Tennis Elbow and How to Treat It

As pickleball continues its rapid expansion across Malaysia, with courts appearing at community centres, sports complexes, and private clubs throughout the Klang Valley, a particular injury pattern has emerged that deserves special attention. Players are increasingly visiting our clinic at Kinesio Rehab in Putra Heights complaining of elbow pain that they assume is tennis elbow, but on closer examination, the condition often presents differently. The term "pickleball elbow" has emerged to describe the unique elbow problems that arise from the specific demands of this sport. While it shares similarities with traditional tennis elbow, there are important biomechanical and clinical differences that affect how the condition should be treated. With over 13 years of experience treating upper limb conditions, I want to help players understand these differences and, more importantly, know what to do about them.

What Exactly Is Pickleball Elbow?

Pickleball elbow is a form of lateral epicondylalgia, which is pain and dysfunction at the outer side of the elbow where the forearm extensor tendons attach to the lateral epicondyle of the humerus. In this respect, it is clinically similar to tennis elbow. The tendons most commonly affected are the extensor carpi radialis brevis and, to a lesser extent, the extensor digitorum communis. These tendons are responsible for extending the wrist and fingers and are heavily involved in gripping and controlling the paddle during play.

What distinguishes pickleball elbow from traditional tennis elbow is the mechanism by which the tendons become overloaded. In tennis, the primary culprit is often the one-handed backhand, where the wrist extensors contract forcefully to stabilise the wrist against the heavy impact of the ball on the strings. In pickleball, the injury pattern is more complex, arising from a combination of high-frequency volleys, the unique properties of the solid paddle, and the distinct wrist mechanics used in the sport's characteristic dinking and flicking shots.

Biomechanical Differences: Pickleball vs Tennis

Understanding why pickleball creates different stresses on the elbow requires examining the biomechanical differences between the two sports. Several key factors set pickleball apart:

• Paddle vs racquet dynamics: A pickleball paddle is solid with no strings, meaning it does not absorb and redistribute impact energy the way a strung tennis racquet does. This transmits more direct vibration into the forearm with each ball contact.
• Higher shot frequency: Pickleball rallies typically involve more ball contacts per minute than tennis. The kitchen line dinking game, in particular, demands rapid, repetitive wrist movements that accumulate tendon load far faster than the longer rallies in tennis.
• Wrist-dominant technique: While tennis emphasises full-arm swings generated from the shoulder and trunk, many pickleball shots, especially dinks and drop shots, rely heavily on fine wrist control and short, quick paddle movements.
• Grip intensity: The lighter paddle can paradoxically lead to tighter gripping. Players unconsciously grip harder because the paddle does not provide the same tactile feedback as a heavier tennis racquet, increasing strain on the forearm muscles.

These biomechanical differences mean that pickleball elbow often presents with a broader area of tenderness, sometimes involving both the lateral and medial aspects of the elbow, and tends to develop more gradually than acute tennis elbow from a single heavy backhand session.

Recognising the Symptoms

Pickleball elbow typically develops gradually, with symptoms that worsen over weeks if the player continues to play without modification. Early warning signs include a mild ache on the outer elbow after playing that resolves within a day. As the condition progresses, the pain begins to appear during play, initially only during specific shots like hard volleys or overhead smashes, but eventually during most paddle contacts. In advanced stages, the pain extends into daily activities such as gripping a coffee cup, turning a door handle, or shaking hands.

Patients at our Putra Heights clinic commonly describe the following symptom progression:

• Stage one: Pain only after playing, resolving overnight. Most players ignore this stage entirely.
• Stage two: Pain during play that warms up and decreases, then returns afterward. Players start modifying their shots to avoid pain.
• Stage three: Pain throughout play and during daily activities. Grip strength is noticeably reduced, and the player may struggle with routine tasks.

Evidence-Based Treatment Protocol

Treating pickleball elbow effectively requires a structured, evidence-based approach rather than simply resting and hoping the pain resolves. While relative rest from aggravating activities is important in the acute phase, complete rest alone does not address the underlying tendon pathology and often leads to recurrence when the player returns to the court.

At Kinesio Rehab, our treatment protocol for pickleball elbow follows a progressive approach. During the initial phase, we focus on pain management through manual therapy, including soft tissue mobilisation of the forearm muscles and joint mobilisation of the elbow and wrist. We also assess and correct any contributing factors in the kinetic chain, from the cervical spine through the shoulder and down to the hand. Load management is crucial during this phase, and we work with the patient to determine which activities to modify and which to continue.

The rehabilitation phase introduces a progressive tendon loading programme. Isometric exercises, where the wrist extensors are contracted without movement, are typically the starting point because they provide pain relief while beginning the tendon strengthening process. We then progress to eccentric exercises, where the forearm muscles lengthen under load, which has strong evidence for stimulating tendon repair and remodelling. Heavy slow resistance training, combining concentric and eccentric phases at a controlled tempo, represents the gold standard in tendon rehabilitation and is introduced as the patient improves.

The return-to-sport phase is carefully graduated. We begin with gentle practice rallies using a lighter paddle, then progressively increase the intensity and duration of play over several weeks. Throughout this phase, we monitor symptoms closely and adjust the programme to ensure the tendon is being loaded appropriately without being overloaded.

The Role of Paddle Selection and Grip Technique

Equipment choices play a significant role in both the development and management of pickleball elbow. Paddle weight is perhaps the most important factor. A paddle that is too heavy increases the forces transmitted to the elbow with every shot, while a paddle that is too light may cause the player to swing harder and grip more tightly to compensate. Most physiotherapists recommend a mid-weight paddle, typically between 210 and 240 grams, for players recovering from or trying to prevent elbow problems.

The paddle core material also matters. Polymer core paddles tend to dampen vibration more effectively than nomex or aluminium core paddles, reducing the shock transmitted to the forearm. Handle length and grip circumference should be matched to the player's hand size. A simple test is to hold the paddle in your playing hand; there should be a finger-width gap between the tips of your fingers and the base of your thumb. If the grip is too small, an overgrip can be added to increase the circumference.

Grip technique is equally important. Many players grip the paddle too tightly, especially during tense rallies at the kitchen line. A relaxed grip that tightens only at the moment of ball contact significantly reduces the sustained load on the forearm muscles. Players transitioning from tennis or badminton often bring their previous gripping habits into pickleball, and retraining the grip pressure can be one of the most impactful changes a player makes for elbow health.