Tendinosis can quietly develop in tennis players who repeatedly load the same tendon without enough recovery. At first, it may feel like a minor ache after playing. Over time, however, the pain can become persistent, strength can decline, and even ordinary tennis movements may become uncomfortable.
From a sports-medicine perspective, the goal isn't simply to tell a player to "rest." The tendon needs the right amount of load, progressive strengthening, adequate recovery, and correction of factors that may be repeatedly irritating it.
Quick Overview
Tendinosis refers to chronic structural changes within a tendon that can occur after repeated loading and inadequate recovery. The broader term tendinopathy is often used clinically because tendon pain and tendon structure do not always correspond perfectly.
For tennis players, commonly affected areas include:
- Elbow: Tennis elbow/lateral elbow tendinopathy
- Shoulder: Rotator cuff tendinopathy
- Knee: Patellar tendinopathy
- Achilles: Achilles tendinopathy
- Wrist: Extensor or flexor tendon problems
The important point is this:
A painful tendon is not necessarily a tendon that needs complete rest. It is often a tendon that needs better-managed loading.
What Causes Tendinosis in Tennis Players?
Tennis places thousands of repetitive loads on the upper and lower body.
A player may hit hundreds of forehands, backhands, serves and volleys during a training session. If the tendon is repeatedly exposed to more stress than it can currently tolerate, symptoms can develop.
Common contributors include:
1. Sudden increases in playing volume
Going from two tennis sessions per week to five or six can overwhelm a tendon that has not adapted to the additional workload.
2. Repetitive high-intensity strokes
Heavy serves, powerful forehands, repeated overheads and aggressive topspin can increase tendon loading.
3. Inadequate recovery
Training hard every day without sufficient recovery can prevent the tendon from adapting.
4. Strength deficits
Weakness in the forearm, shoulder, trunk, hips or legs can change how forces are distributed during the tennis stroke.
5. Technique and biomechanics
Poor stroke mechanics may increase unnecessary stress on certain tissues.
6. Equipment factors
Racket weight, balance, grip size, string type and string tension can influence how a player experiences impact. Equipment is only one factor, however—it is rarely the sole explanation for a tendon problem.
7. Age and training history
Tendons adapt more slowly than muscles. Players who have accumulated many years of repetitive loading may need more deliberate recovery and strength training.
Symptoms of Tendinosis
Tendon problems usually develop gradually rather than from one dramatic incident.
Typical symptoms may include:
- Gradual aching around the tendon
- Pain during or after tennis
- Morning or post-rest stiffness
- Local tenderness
- Reduced strength
- Pain with gripping, pushing or pulling
- Reduced ability to generate power
- Symptoms that become worse after increasing tennis volume
A particularly important warning sign is progressively declining performance.
If you normally serve comfortably but increasingly find yourself unable to generate power because of pain or weakness, don't simply keep playing through it.
Why Tennis Elbow Is So Common
Despite its name, tennis elbow does not occur only in tennis players.
It commonly involves the tendons of the muscles that extend the wrist and fingers near the outside of the elbow.
Repeated gripping and wrist/forearm loading can stress this region.
Tennis players may notice pain when:
- Hitting a backhand
- Serving
- Gripping the racket
- Opening a jar
- Lifting objects
- Shaking hands
- Performing resisted wrist movements
The pain can become especially frustrating because the player may still be able to hit the ball—but with increasing discomfort.
How Is Tendinopathy Diagnosed?
A diagnosis usually begins with a clinical examination.
A doctor or physiotherapist may assess:
- Location of pain
- Tendon tenderness
- Muscle strength
- Joint movement
- Pain during resisted movements
- Tennis technique and training history
- Recent changes in workload
Ultrasound
Ultrasound can sometimes demonstrate tendon thickening, altered tendon structure and other abnormalities.
MRI
MRI may be useful when deeper structures need evaluation or when the diagnosis is uncertain.
However, imaging findings should be interpreted carefully.
A tendon can look abnormal on imaging without causing pain, and a painful tendon does not always require imaging.
Treatment: The Goal Is to Build Tendon Capacity
The most important concept in tendon rehabilitation is progressive loading.
Instead of repeatedly irritating the tendon with tennis and then resting completely until the pain disappears, rehabilitation generally aims to gradually increase the amount of load the tendon can tolerate.
Stage 1: Reduce Irritating Activities
You don't necessarily have to stop all exercise.
Instead, temporarily reduce activities that substantially aggravate the tendon.
For example:
Instead of:
2-hour match + 100 serves + intense drills
You might temporarily use:
30–45 minutes of controlled hitting + reduced serving + rehabilitation exercises.
The exact amount depends on the injury and individual response.
Stage 2: Isometric and Strength Exercises
Depending on the tendon involved, a rehabilitation program may initially use isometric exercises followed by progressive resistance training.
Examples can include:
- Wrist extension exercises
- Wrist flexion exercises
- Forearm strengthening
- Shoulder external rotation
- Calf raises
- Quadriceps strengthening
- Hip strengthening
The objective is to progressively increase the tendon's capacity.
Stage 3: Progressive Tendon Loading
As symptoms improve, rehabilitation can progress toward:
Isometric → slow resistance → heavier resistance → faster movements → tennis-specific loading
Eccentric exercises can be useful for some tendon conditions, but they should not be considered a universal "gold standard" for every tendinopathy.
The bigger principle is progressive, appropriately dosed loading.
What About PRP, Shockwave and Other Treatments?
Players sometimes ask about treatments such as:
PRP
Platelet-rich plasma injections are used for some persistent tendinopathies, but evidence varies depending on the tendon and condition. PRP is not a guaranteed tendon-healing treatment.
Shockwave therapy
Extracorporeal shockwave therapy may be considered for certain chronic tendon conditions and can be useful in selected patients.
Corticosteroid injections
Steroid injections may provide short-term pain relief in some conditions, but repeated injections can have disadvantages, including potential effects on tendon tissue. They should not automatically be considered the long-term solution for chronic tendinopathy.
NSAIDs
Anti-inflammatory medications can sometimes help with short-term pain management, but they should not be viewed as the treatment that rebuilds tendon capacity.
The rehabilitation plan remains central.
The Tennis Player's Return-to-Court Plan
Returning too quickly is one of the most common mistakes.
Phase 1 — Rehabilitation
Focus on:
- Pain-controlled strengthening
- Restoring range of motion
- Improving muscle strength
- Establishing tolerance to resistance exercises
Phase 2 — Mini-Tennis
Start with:
- Short-court hitting
- Lower intensity
- Relaxed technique
- Short sessions
Avoid immediately testing your maximum power.
Phase 3 — Controlled Baseline Tennis
Progress toward:
- Longer rallies
- Normal court position
- Moderate intensity
- Controlled groundstrokes
Initially reduce:
- Maximum-effort serves
- Repeated overheads
- Very high-intensity rallies
Phase 4 — Serves and Match Play
Gradually reintroduce:
- Half-speed serves
- Moderate serves
- Normal serves
- Controlled points
- Full match play
Don't jump directly from rehabilitation exercises into a three-set competitive match.
The Next-Morning Test
One of the most useful ways for a tennis player to monitor workload is to look at how the tendon responds later that day and the following morning.
If a tennis session causes a substantial increase in pain or stiffness that persists into the next day, your workload may have been too aggressive.
A commonly used rehabilitation approach allows some manageable discomfort during exercise, but the exact acceptable pain level depends on the tendon and rehabilitation program.
Don't treat "2/10 or 3/10" as a universal medical rule.
Your overall symptom response and next-day reaction matter more than a single number.
How Tennis Players Can Prevent Tendon Problems
Increase workload gradually
Don't suddenly double your tennis hours.
Strength train consistently
Tennis players benefit from maintaining:
- Forearm strength
- Shoulder strength
- Rotator cuff endurance
- Core strength
- Hip strength
- Quadriceps and calf strength
Recover between hard sessions
Hard tennis days should be balanced with easier training and recovery.
Check your equipment
If you're repeatedly experiencing elbow symptoms, have your racket setup evaluated, including:
- Racket weight
- Balance
- Grip size
- String type
- String tension
Equipment changes may help, but they should complement—not replace—rehabilitation.
Warm up
Before playing, gradually increase:
- Body temperature
- Shoulder movement
- Forearm activity
- Footwork
- Stroke intensity
Don't make your first serve of the day a 100% maximum-effort serve.
When Should a Tennis Player See a Doctor?
Seek professional evaluation if:
- Pain continues to worsen
- Strength is decreasing
- Pain interferes with normal daily activities
- Symptoms persist despite modifying tennis
- There is significant swelling
- You experience a sudden pop
- Bruising develops after an injury
- You suddenly cannot generate normal force
- You suspect a tendon tear
A sudden injury with a pop, significant weakness, bruising or loss of function is different from typical gradual tendinopathy and deserves prompt evaluation.
Final Advice From a Tennis-Medicine Perspective
Don't wait until tendon pain becomes severe before doing something about it.
The tennis player who continues increasing volume while ignoring progressively worsening tendon pain can eventually reach a point where even everyday activities become uncomfortable.
The smarter approach is to identify the problem early, temporarily modify the workload, strengthen the affected tendon and surrounding muscles, and then progressively rebuild tennis-specific capacity.
Remember:
Rest can calm symptoms.
Strength can build capacity.
Progressive loading can prepare the tendon for tennis again.
And most importantly:
The goal isn't simply to become pain-free on the couch. The goal is to build a tendon that can tolerate the demands of tennis again.
Medical disclaimer: This article is educational and does not replace an examination by a sports-medicine physician, orthopedic specialist, physiotherapist, or other qualified healthcare professional. Persistent, severe, or worsening tendon pain should be professionally assessed.