Medial Elbow Microinstability in Tennis: A Narrative Review and Proposed Tennis-Specific Load – Adaptation Continuum

DOI: 10.70885/hmsj.2026.10.001

Abstract

Background: Medial elbow microinstability in tennis remains insufficiently characterized, and current understanding is largely derived from throwing athletes. The biomechanical evolution of modern tennis and cumulative tennis-specific loading may require a broader framework for understanding medial elbow dysfunction.Purpose: To synthesize the available evidence regarding medial elbow overload and microinstability in tennis players and propose a hypothesis-generating, tennis-specific load–adaptation continuum to guide future clinical and biomechanical research.Methods: A focused narrative review was conducted using PubMed, Scopus, and Web of Science. Studies addressing tennis biomechanics, medial collateral ligament pathology, medial elbow instability, diagnostic evaluation, rehabilitation, and surgical management were considered. Tennis-specific evidence was prioritized, whereas evidence from throwing and other overhead athletes was included when relevant to medial elbow anatomy, biomechanics, diagnosis, or treatment. Findings were synthesized qualitatively because of the heterogeneity and limited tennis-specific literature. No formal risk-of-bias assessment was performed.Results: Thirty-two studies were included in the qualitative synthesis. The literature describes the biomechanical evolution of modern tennis, including greater topspin production, increased trunk rotational contribution, widespread use of semi-Western and Western grips, and demanding serving mechanics. However, direct evidence linking these technical characteristics to increased medial elbow loading or ulnar collateral ligament injury in tennis players remains limited. Available evidence suggests that medial elbow symptoms may reflect interactions among repetitive valgus-torsional loading, kinetic-chain function, dynamic stabilizer capacity, and capsuloligamentous adaptation. Based on this synthesis, we developed a five-stage conceptual load–adaptation continuum. This framework represents an expert interpretation of heterogeneous evidence and has not been prospectively or biomechanically validated.Conclusion: This review adds an integrated, tennis-specific conceptual framework connecting biomechanics, clinical assessment, rehabilitation, and surgical considerations, rather than treating these domains independently.What this study adds: The proposed continuum may support earlier recognition of functional medial elbow dysfunction, inform individualized clinical assessment and rehabilitation strategies, and guide future tennis-specific research, while clarifying the distinction between direct tennis evidence and extrapolated findings from overhead athletes.Potential impacts on research, practice, or policy: This may improve transparency in future clinical reasoning. Prospective biomechanical and clinical studies are required to validate its stages, diagnostic relevance, and potential management implications.Study Design: Narrative review and conceptual frameworkLevel of Evidence: Level VKeywords: Tennis; Medial elbow microinstability; Ulnar collateral ligament; Tennis biomechanics; Rehabilitation.https://doi.org/10.70885/hmsj.2026.10.001

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