I have deliberately waited to present this month's column. At the outset, I must state much of what I present is theory not fact. It is, however, theory that is the result of observation, personal experience, testing (albeit not truly scientific) and most important, results.

If you have ever played the game of tennis for any length of time, you have probably experienced the horrific ailment known as tennis elbow. This painful and debilitating situation can literally prevent us tennisphiles from being able to play our wonderful sport... sometimes for long periods of time. Indeed, some of us never seem to completely recover from this phenomenon.

Well this month, I will put forth what I know and what I believe about this terrible injury. At the very outset, I must put forth this disclaimer: Only a health care professional can diagnose and treat "tennis elbow." If you even suspect that you are suffering from tennis elbow, your best course of action is to seek immediate help from your physician or other health care professional. Unfortunately, many players who suffer this ailment do not seek professional help. Please do not make this mistake. Doctors and others have tests, medicines and treatments that can and do help!

Having said this let me put forth my thoughts.

I should begin my discussion by explaining how I arrived at examining this phenomenon, and specifically how I have attempted to study tennis elbow.

Unfortunately, I have suffered tennis elbow twice in my tennis life. In each instance, the pain was significant, and my ability to play was significantly impaired. Both of these episodes took some time to truly "heal." Truly, I hope to never suffer this ailment again!

As an NCAA coach, I had several players who became victims to tennis elbow. In one instance, the player was forced to take an extended hiatus from this wonderful game. The team suffered as he was one of our better players.

As a tennis teacher, I have had many people come to me over the years seeking advice about tennis elbow. My heart always goes out to these players, as I know what pain and frustration they experience.

Given all of this, I have done as much reading on this topic as I could get my hands on. In addition, I have used video analysis to examine my own situations, and the situations of those whom I have coached/taught. This latter methodology has provided me with some insights that may be new to the reader.

I encourage each reader to explore any reputable information available on tennis elbow. Internet sites like Wikipedia and WebMD provide some very interesting data and medically relevant information. This said, I remind the reader, again, that only medical professionals are in a position to accurately diagnose and treat tennis elbow.

TYPES OF TENNIS ELBOW

Tennis elbow in its most common form is tendinitis. Usually, this primary type of tennis elbow presents itself as if the actual elbow bones are hurting. In reality, this is not the case. Rather, the tendons near the elbow bones are inflamed.

A second, and less common, form of tennis elbow presents itself as pain that is located above the elbow. Players experiencing this variety usually complain that their forearm and elbow "crease" (located above the wrist area) are painful. Again, this form of ailment involves soft tissue and not the actual bones in the elbow.

The pain associated with either of these types is usually chronic. Players may experience pain while playing, or they may only really notice the pain after completing a tennis session. The pain can be simply annoying, or in some instances, the pain is really quite excruciating. Not tending to tennis elbow will result in continued pain and may lead to more serious injury. This is not an injury to take lightly.

Most material on tennis elbow only identifies only the former of these two varieties. However, the latter (forearm or crease variety) is in my mind another kind of tennis elbow that does affect some players. So for our discussion, I am using tennis elbow to refer to either variety, despite the fact that the latter variety is above the elbow itself and associated more with the forearm area.

WHAT CAUSES TENNIS ELBOW?

There is no single cause for either form of tennis elbow. Even if an individual does not play tennis, he/she can develop this ailment.

However in my cursory (and admittedly non-scientific) studies, there seems to be patterns that are typical for tennis players that may lead to one or the other form of tennis elbow.

When questioned, many players will identify some "change" or unusual "event" that lead to the beginning of tennis elbow.

For example, players when questioned will state that they were in the process of changing something about a stroke when tennis elbow first appeared. The player may have been altering her/his grip, attempting to impart more spin or power, or perhaps, she/he was attempting to improve the finish associated with a particular stroke.

Sometimes when questioned, players will mention that they had recently changed racquet frames when the tennis elbow first became evident. Almost without fail, players who fall into this category will state that they do not believe that the new racquet frame had any bearing on the elbow situation. Usually, this is because it takes some time before the effects of the frame are fully realized.

Allied with this, some players will state that they recently changed to a different string type. Although they will state that the tension remained the same, the type of string did change. Again, they do not see a connection to their tennis elbow. Often times, they played with the new string for quite a period of time before the tennis elbow emerged.

String tension changes can be the culprit. Sometimes, players will raise their string tension in a quest for more control. It is possible that this rise in tension can bring about an episode of tennis elbow.

Although many players may not recall a specific instance, it is common that an errant hit can bring about tennis elbow. A mishit (away from the sweet spot on the string bed) or a series of mishits can result in causing some variety of tennis elbow. Sometimes the mishit can be "systemic." By this, I mean that the player repeatedly hits a specific stroke (e.g. an overhead smash) in manner that results in a mishit (away from the sweet spot) each time the stroke is executed. If this particular stroke is repeatedly hit, the likelihood of temporary or more lasting tennis elbow increases.

Of course, playing too much can be the sole cause behind tennis elbow. If a player is constantly practicing and competing, the wear and tear of constant use can be the cause behind an episode. Serious players who practice and compete non-stop are likely candidates for some form of tennis elbow.

In addition to the above, my video studies reveal to me that there is another primary reason for the emergence of tennis elbow. Simply put, my studies show that hitting a stroke with the racquet head ever so slightly in front of the wrist (at the moment of contact with the ball) can result in tennis elbow.

Let me attempt to clarify what I mean. Normally, a player will hit every stroke with the racquet head slightly behind the wrist at the moment of impact. It is my contention that every stroke in this great game of ours needs to be hit with the racquet head ever so slightly behind the wrist when making contact with the ball.

My theory is that the wrist, elbow and arm need this "behind the wrist" position to impart power without as much "shock and vibration." If the racquet head creeps in front of the wrist at impact, the trauma to the wrist, elbow, arm and shoulder are greatly increased.

To illustrate what I mean, try this experiment. Take your racquet and hold it as if you were going to hit a forehand groundstroke. Now, find a net post, or a door jamb that you can push the racquet head against. Position the racquet head so that it is slightly behind (away from the post or jamb) your wrist. Push forward with the racquet as if you were going to hit a ball. Notice the feel. You can probably push really forcefully with the racquet in this position. You may noted that as you push forward, the racquet head increasingly moves to a position behind the wrist .

Now, repeat the same experiment. But, this time make certain that the racquet head is ever so slightly in front (toward the post of jamb) of your wrist. Again, apply pressure. Your will probably find that it is more difficult to apply the same amount of pressure in this latter case, and I would not be surprised if you experience some discomfort in your wrist, elbow or arm as you use this second racquet head location.

Using slow motion to view past videos of my strokes (some taken when I was experiencing tennis elbow), I began to see that some of my strokes were different when I was hitting without any pain in my arm. From my analysis, I saw that I was inadvertently making contact with the ball with my racquet head ever so slightly in front of my wrist when I had tennis elbow. When I view the same strokes during times when my arm and elbow was healthy, I would be making contact with the ball with the racquet head ever so slightly behind my wrist. For me, the culprit stroke is my forehand.

During the last year, I conducted the same video experiment with a player who was experiencing tennis elbow. Sure enough, there was the same "slightly forward" position of the racquet head when this player was hitting forehands. We worked on correcting the stroke, allowed for some rest, and when the pain had completely dissipated, I videotaped the player again. Now, the player was hitting with the racquet head slightly behind his wrist. To this day, the player has not had another episode of tennis elbow.

Now, I am the first to admit that the above is not "proof" and is more anecdotal than scientific. However in discussing this topic with pros who teach at some of America's best tennis academies, I have learned that this is their belief as well.

The difference between hitting with the racquet head properly behind the wrist and hitting with the problematic "forward" position of the racquet head is not perceptible by the normal eye. So, it is not surprising that players with tennis elbow never notice this slight difference in positioning. Indeed, it is not something that one would normally think about as a cause.

So, why does the positioning change in the first place? Well, I am not certain that I can answer that with authority. Using a new frame may cause this change. Redefining the mechanics of a stroke may account for this difference. Even changes in stance may be the culprit. I am not certain that there is a single answer to this question.

But, I am reasonably confident that my theory has merit. I know that I and those that I have "helped" benefit almost immediately when an effort is made to hit with the racquet head behind the wrist. In one case where the player's tennis elbow was not so severe, making certain that strokes were all hit with a "behind the wrist position" brought immediate and complete relief! No one was more amazed than I.

My studies show that most tennis elbow pain that is focused in the bone area of the elbow is related to improperly hit forehand groundstrokes, improperly hit forehand volleys, improperly hit overhead smashes and/or improperly hit serves using a continental grip.

Again my cursory and unscientific studies indicate that pain that is associated with the "crease or forearm" type of tennis elbow is related to improperly hit one-handed backhands, mishit backhand volleys and improperly hit serves using an eastern backhand grip.

Many players hit backhands today using a two-handed grip. My studies indicate that even if one mishits this stroke in the manner that I attribute to tennis elbow, there is little likelihood that this will result in a tennis elbow situation. In and by itself, this speaks to the value of the two-handed backhand. It may be that people experiencing chronic tennis elbow may benefit from using a two-handed forehand, as well.

SO WHAT SHOULD I DO TO GET RID OF TENNIS ELBOW?

Well, the first thing that any player should do is to seek professional health care advice! Avoiding this step is extremely foolish. Doctors can perform examinations, order tests, prescribe medicines and recommend physical therapy. Many health care professionals will insist that you reduce the amount of tennis you play or not play at all while the tennis elbow heals.

No serious tennis player likes to take a forced hiatus from training and competition. But, this may be exactly what is necessary to allow for a quicker recovery time, and more important, resting may be the only way to avoid further, more serious injury.

Conventional tennis wisdom recommends the following for minimizing the effects of tennis elbow. Actually, I believe each of these should be considered seriously.

1. Use a racquet frame that is less stiff. Every modern frame has a stiffness index. Stiffer frames tend to exacerbate tennis elbow. Changing to a more flexible frame may be the best long-term solution to reoccurring tennis elbow.
    
   Even in the days of wooden racquets which are less stiff than the modern, lighter frames; players developed tennis elbow. So, it is probably safe to assume that frame stiffness is not the only cause of tennis elbow.
 

2. Use a heavier frame. In addition to being stiffer, modern frames have been made very light in comparison to traditional, wooden frames. A lighter frame, in my mind, increases the likelihood that you may inadvertently hit with the racquet head slightly in front of the wrist.
    
   I would suggest that a player may want to add some lead tape to the racquet head at the 9 and 3 o'clock positions. Adding more lead tape to the shaft and/or grip may bring back the original balance to the frame. But, the overall weight of the racquet will have been increased.
    
   In addition to my theory about this practice minimizing arm problems, simple physics (power=mass x velocity) suggests that you will automatically increase your overall stroke power by adding such weight to the frame.
 

3. Use natural gut or a "soft" synthetic string. One of the best reasons to spend the money on natural gut strings is that these strings are least likely to contribute to a tennis elbow problem. Natural gut seems to "cushion" the impact of the ball resulting in what some term a "soft" string bed. Certainly, string sets that contain Kevlar should be avoided at all costs. I know of no "harder" string than Kevlar. Many of the modern, polyester strings are quite "soft" and forgiving. These polyesters are more affordable and may be more long lasting than natural gut. I like to use a hybrid combination of natural gut main strings and polyester cross strings. This combination provides me with a soft feel and better durability.
 

4. Lower your string tension. Reducing your string tension by 2 to 4 pounds can make your existing string choice "softer." Usually, this kind of change can be accommodated without losing control. The "softer" the string bed, the less likely it is that you will develop or exacerbate tennis elbow. I know of a senior player who is nationally ranked who uses a racquet with a 100 square inch head with natural gut strung at 42-45 pounds! I assure you that this player never has tennis elbow. He claims that he has learned to control the ball with at this tension and that he exerts less energy throughout a match. His experience gives food for thought about what tensions should be "recommended" by the racquet manufacturer.
 

5. Use a larger grip size. If you have had or have tennis elbow (either variety), making a fist and squeezing it hard will almost always cause some elbow pain. The tighter one grips a racquet handle, the more likely it is that he/she will experience tennis elbow pain. If you are currently using let's say a 4 3/8 inch grip (Level 3) you will benefit by moving up to a 4 1/2 inch grip. If you add another layer of over grip to your existing frame handles, you will achieve a one size grip increase. Of course, too much over grip dulls the "cuts" on the racquet handle and makes find one's grip more difficult. So in the end, you may be better off buying your present frame in a larger grip size.
 

6. Use a compression device. There are myriad bands, braces, etc. that are designed to help with tennis elbow. All of these work on applying compression to the affected area. In some instances, these do indeed help to minimize the pain while actually playing. However, these are not a cure for tennis elbow and may actually hurt in that they mask the pain. If you have fully recovered from a bout with tennis elbow and want to use such a device to prevent further injury, I know of no data that suggest that these devices do indeed prevent a reoccurrence. Still, there is probably no real harm in using such a contraption if it seems to help.
 

7. Strengthen your forearms. Maybe the best preventive measure that can be put into place to prevent tennis elbow is to spend time developing your forearms. Here again, a health professional is the best person to suggest what specific exercises you may want to do to help develop your forearms. All of the daily exercises that I do were taught to me by an athletic trainer. Physical therapists can also tailor exercises to meet your needs. Of course once you learn the proper exercises for your situation, it is still up to you to perform them regularly and faithfully!
 

8. Use ice after each practice session or competition. Ice used on a regular basis can greatly help with respect to tennis elbow. I like to take paper cups, fill them with water and place them in my freezer. When I ice, I peel off the paper cup and rub the remaining ice on the area(s) where I am experiencing or have experienced pain. I also have horrible knees. So, I ice my dominant arm's elbow and both of my knees every day after training. I find that it is just as important to ice when I am not experiencing any pain as when I am. Ice may be another useful preventative measure.
 

9. Stop when you are in pain. Chronic pain is an indication that something is wrong. Better to default an important match due to elbow pain than to continue and do more harm to your arm. No pain... no gain, is probably one of the most foolish statements ever made. Use your head and listen to your body. If it hurts a lot and/or hurts frequently, you have a problem that needs attention.
 

Essentially, there are two principle things that need to be done.

First, try to deliberately take the ball a little bit late. Usually, this simple action will automatically force you to hit with the racquet head slightly behind your wrist. I would recommend that you go to a backboard or wall and hit in this corrective manner. You may benefit by trying to bend your wrist back a bit as you move forward to make contact with the ball. Exaggerating this bent back wrist may be necessary at first. But over time, you will correct and begin to hit with the desired "slightly back" racquet head.

Allied with the above, hit forehand groundstrokes with a bit more open stance. Hit one-handed backhands with a slightly more closed stance. These changes will help to automatically correct a "forward racquet head" flaw.

Use a semi-western grip for forehand groundstrokes and a full eastern backhand grip for one-handed, backhand groundstrokes. These two grips tend to automatically help prevent the "forward racquet head" mishit. They are not so severe. Thus, players can usually adjust from an eastern forehand grip or full western forehand grip easily. If you are using a continental grip for your one-handed backhands, you will probably find the change to the full eastern a bit more difficult to adopt, but still, the change should not be too overwhelming.

With respect to volleys, make certain to keep the racquet head up. Good volleys (regardless of which wing) need to have the racquet head above the wrist. If you hit your volleys in such a manner, you will automatically find that you are also striking your volleys with the racquet head slightly behind your wrist.

Regarding serves, my suggestion is to toss the ball less in front of your body. Tosses that are way in front of the body frequently will lead to the racquet head making contact with the ball in a somewhat "forward" position." Most people serve with a continental or an eastern backhand grip.

The forehand grip serve (I call it the bad mitten-like serve) automatically prevents hitting the ball in this undesirable "forward" position. " However, I am not recommending that players switch to the forehand grip serve. Rather, it simply "proves" that when the racquet head is behind the wrist at the moment of impact, that there is less likelihood of tennis elbow pain.

If you have pain when hitting overhead smashes, however, you may want to switch to hitting these with a forehand grip. Although your movement to the ball will need to be altered a bit, this simple change can prevent mishits that arise from the racquet head being in front of the wrist at the moment of impact. This change may prevent you from really crushing your smashes, but if the change prevents tennis elbow, the trade off is worth it. Unless you play lots of doubles, you are probably not hitting that many overhead smashes anyway.

Please review this brief video that I made to help make my theory clearer:

I am hopeful that none of us have to experience the pain of tennis elbow.

I am confident that if you follow my advice you will be spared from this horrible ailment, and will find yourself becoming a tennis overdog in 2009!

PS. To those of you, who experiment with my "racquet/wrist" hypothesis, please send me your results, comments, etc. I am very curious to learn whether you find merit to my theory, given your experiences.