Has Modern Tennis Changed the Mechanical Environment of the Elbow? A Narrative Review and the Cumulative Elbow Load Model

Upper-extremity injuries are common in tennis and are predominantly associated with repetitive mechanical loading. Modern professional tennis has evolved substantially, with greater topspin production, higher racquet-head speeds, prolonged baseline exchanges, increased physical demands, and dense competitive schedules. These changes may influence the cumulative mechanical environment experienced by the upper extremity. This narrative review synthesizes current evidence regarding elbow injury risk in tennis, with particular attention to workload, stroke biomechanics, fatigue, kinetic-chain function, recovery capacity, and tennis ball characteristics. The available literature supports a multifactorial perspective in which stroke volume, stroke intensity, topspin demand, fatigue accumulation, and equipment-related factors may interact to influence cumulative mechanical exposure, while recovery capacity and kinetic-chain efficiency may modify the athlete’s ability to tolerate and adapt to repeated loading. Based on these concepts, the authors propose the Cumulative Elbow Load Model (CELM), a conceptual framework in which elbow symptoms and injury may occur when cumulative mechanical exposure persistently exceeds tissue adaptation capacity. The CELM integrates primary loading factors with protective and modifying factors, emphasizing the interaction between exposure, recovery, load distribution, and biological adaptation rather than a single causative mechanism. Direct evidence linking tennis ball characteristics to elbow injury remains limited, and the CELM should therefore be considered hypothesis-generating rather than predictive. This framework may provide a basis for clinical reasoning and future research examining the complex interaction among workload, biomechanics, fatigue, recovery, and tissue adaptation in tennis-related elbow disorders.