The Beach Tennis Boom and the Rise of Overuse Injuries
Beach tennis is a rapidly growing racket sport — with more than 1 million regular practitioners in Brazil and expanding globally — and has brought with it an epidemic of repetitive overuse injuries that was previously confined to traditional tennis. The biomechanics of both sports impose similar demands on the elbow and shoulder, but beach tennis presents specific features (rigid stringless paddle, unstable surface, heat exposure) that amplify the risk.
The two most prevalent injuries in racquet sport athletes are lateral epicondylalgia ("tennis elbow") and subacromial shoulder impingement. Both involve overload of the wrist extensor/supinator muscles of the forearm and of the rotator cuff, respectively, with formation of myofascial trigger points that perpetuate pain and limit performance.
Lateral Epicondylalgia: Tennis Elbow
Lateral epicondylalgia — historically called "epicondylitis" — is a degenerative tendinopathy (not an acute inflammatory condition) at the origin of the wrist extensors, especially the extensor carpi radialis brevis (ECRB). Repetitive racquet impact transmits shear forces to the tendon insertion at the lateral epicondyle of the humerus. Over time, accumulated microtrauma degrades tendon collagen (tendinosis), drives pathological neovascularization, and sensitizes peripheral nociceptors.
The myofascial trigger points associated with lateral epicondylalgia are located in the wrist extensors (ECRB, extensor digitorum communis, supinator), the brachioradialis, and frequently the triceps. These trigger points are kept active by the repetitive overload of the sport and by sustained gripping of the racquet.
Biomechanics of Lateral Epicondylalgia in Racquet Sports
Repetitive ball impact on the racquet
Impact vibration is transmitted from the racquet to the wrist and elbow. In beach tennis, the rigid paddle (no strings) transmits up to 3x more vibration than a conventional tennis racquet.
Eccentric overload of the wrist extensors
On impact, the wrist extensors contract eccentrically to stabilize the joint. This repetitive eccentric load is the main driver of tendon injury, especially on a closed-wrist backhand.
Tendon degeneration (tendinosis) and trigger points
Cumulative microtrauma in the ECRB produces tendinosis with disorganized collagen. Trigger points form in the extensor muscle belly, referring pain to the lateral epicondyle and the dorsal forearm.
Peripheral and central sensitization
Chronic nociceptive input from the tendon and trigger points sensitizes second-order neurons at the C5-C7 spinal level, amplifying pain and lowering the grip threshold — patients report difficulty holding light objects.
Tennis Shoulder: Subacromial Impingement and Rotator Cuff
The serve and smash push the shoulder to extremes — combining maximal abduction, external rotation, and angular acceleration that can exceed 7,000 degrees per second. The deceleration phase (after ball contact) requires massive eccentric contraction of the posterior rotator cuff (infraspinatus and teres minor) to brake the motion. This repetitive eccentric overload drives rotator cuff tendinopathy and subacromial impingement.
The key trigger points in the tennis shoulder sit in the infraspinatus (anterior shoulder pain), subscapularis (deep posterior pain), teres minor, and posterior deltoid. When these trigger points activate, they reduce internal rotation range and create a biomechanical imbalance that perpetuates subacromial impingement — forming a vicious cycle.
SHOULDER TRIGGER POINTS IN TENNIS PLAYERS: LOCATION AND PAIN PATTERN
| MUSCLE | TRIGGER POINT LOCATION | REFERRED PAIN | CLINICAL TEST |
|---|---|---|---|
| Infraspinatus | Infraspinous fossa, medial to the spine | Deep anterior shoulder pain | Resisted external rotation |
| Subscapularis | Anterior surface of the scapula | Posterior pain, restricted internal rotation | Lift-off test |
| Supraspinatus | Supraspinous fossa | Lateral deltoid pain | Jobe (empty can) test |
| Teres minor | Inferior lateral border of the scapula | Posterolateral shoulder pain | External rotation in 90° abduction |
| Pectoralis minor | Coracoid process | Anterior shoulder pain and scapular protraction | Pectoralis minor length test |
Multimodal Approach: Acupuncture, Shockwave Therapy, and Eccentric Strengthening
Current evidence converges on a multimodal approach for lateral epicondylalgia and rotator cuff tendinopathy. Treatment combines medical acupuncture (trigger point needling and electroacupuncture) with extracorporeal shockwave therapy — indicated by the physiatrist — and supervised eccentric strengthening exercises.
- Trigger point needling in the wrist extensors (ECRB, extensor digitorum communis, supinator): deactivates the source of referred pain and restores muscle length
- Electroacupuncture at points such as LI10, LI11, TE5, and LU5 or LI15, SI9, SI11, and GB21: modulates segmental pain via inhibition at the C5-T1 spinal level
- Focal extracorporeal shockwave therapy (prescribed by the physiatrist): stimulates remodeling of degenerated tendon collagen and functional neoangiogenesis at the epicondyle and rotator cuff
- Progressive eccentric strengthening: targeted exercises (Tyler twist for the elbow, eccentric external rotation for the cuff) that drive tendon collagen to reorganize
- Sport technique correction: especially backhand biomechanics (a two-handed backhand cuts load on the epicondyle by 50%) and serve mechanics
- Racquet check: weight, grip, string tension (or paddle type in beach tennis) — factors that directly modulate how vibration transmits to the upper limb
Return-to-Sport Protocol
Return to tennis or beach tennis after treatment should be gradual and based on objective criteria of functional recovery. Premature return is the leading cause of recurrence and chronicity.
Phases of Return to Sport
Phase 1
2–4 weeksPain control and trigger point deactivation
Relative rest from the sport (maintain conditioning with activities that spare the elbow and shoulder). Trigger point needling and electroacupuncture 2x/week. Progression criterion: pain at rest < 2/10 (VAS).
Phase 2
3–6 weeksEccentric strengthening and mobility
Begin progressive eccentric exercises. Acupuncture 1x/week. Shoulder mobility training (especially internal rotation) to restore joint biomechanics. Criterion: pain-free grip > 80% of the contralateral side.
Phase 3
2–4 weeksGradual return to sport
Light forehand strokes, then two-handed backhand. Gradually increase intensity and volume. Biweekly maintenance acupuncture sessions. Criterion: can play 30 min without pain flare.
Phase 4
OngoingCompetitive return
Return to full training volume and competition. Monthly maintenance sessions with preventive needling. Periodic technique and equipment reviews. Monitor for early signs of recurrence.
Myths and Facts
Myth vs. Fact
Tennis elbow is an inflammation that resolves with anti-inflammatories
In the chronic phase, lateral epicondylalgia is a tendinosis (collagen degeneration), not a tendinitis (inflammation). NSAIDs do not work in the chronic phase. Effective treatment combines needling, shockwave therapy, and eccentric strengthening.
Corticosteroid injection cures tennis elbow
Corticosteroid injections provide short-term relief (4-6 weeks), but studies published in the <em>British Journal of Sports Medicine</em> show worse long-term outcomes (12 months) compared to placebo. Corticosteroids can inhibit collagen synthesis and weaken the tendon.
Beach tennis causes fewer injuries than tennis because the ball is lighter
The rigid beach tennis paddle (no strings) transmits far more vibration to the upper limb. The unstable sand surface also demands greater compensatory muscle activation, and doubles play forces abrupt lateral movements.
Frequently Asked Questions
Frequently Asked Questions
It depends on severity. In mild cases, play can be maintained with reduced volume and intensity. In moderate to severe cases, a 2-4 week pause is recommended for the trigger point deactivation phase, with a gradual return guided by the physician.
A typical protocol involves 6-10 needling sessions (3-5 weeks), followed by eccentric strengthening and gradual return. Most patients return to sport without pain in 6-8 weeks with an integrated approach.
Yes. Monthly preventive needling of the wrist extensors and rotator cuff keeps the muscles free of latent trigger points, preserves range of motion, and lowers overuse injury risk.
Extracorporeal shockwave therapy uses acoustic energy pulses to stimulate tissue regeneration. The physiatrist prescribes it as an adjunct for chronic tendinopathies. Combining it with medical acupuncture is synergistic.
A counterforce brace with a pressure pad over the muscle belly of the extensors can reduce overload at the epicondyle during play, but it does not treat the cause (tendinosis and trigger points). It is an adjunct during return to sport, not a definitive treatment.