Doctor’s Tips: Tennis Elbow

Hello USTA Mid-Atlantic Section members, Dr. Brad Carofino here from Atlantic Orthopaedic Specialists in Virginia Beach, VA! Today I wanted to take the opportunity to discuss something that could be all too common for some of you…Tennis Elbow! However, I also want to review treatment options for it that could speed up your recovery and return to play.

Tennis elbow, or Lateral Epicondylitis, in general terms, is a chronic degenerative overuse pathology that causes pain on the outside portion of the elbow. The muscles that extend the wrist, such as in hitting a backhand volley in tennis, can lead to a degenerative weakening or micro-tearing process of the tendon. The tendon becomes necrotic (dying) over extended periods of overuse…just like during long tournament weekends.

This overuse injury can snow-ball if athletes and patients don’t take proper
measures to stop the process and continue to overuse these wrist extensor muscles leading to further tendon injury.

A research article looked at a 13-year period of patient data and determined that the highest incidence of Tennis Elbow was among individuals aged 40 to 49 years, with 7.8 per 1,000 in male patients and 10.2 per 1,000 in female patients. The second highest incidence was from ages 50 to 59 years, with 7.0 per 1,000 in male patients and 6.7 per 1,000 in female patients.¹

Another interesting article noted that in regards to playing tennis, level of play, hours per day, and weight of racquets were directly related to ones’ possibility of acquiring tennis elbow. Also, athletes who were 40+ years of age and older who used a grip size of 4 3/8” or greater had a significantly greater chance of acquiring tennis elbow.²

When athletes or patients come to see me regarding tennis elbow I typically advise them of a few treatment options.

Above most, appropriate rest and recovery is the best thing someone can do as Tennis Elbow is an overuse injury. During a rest and recovery phase it is wise to perform Tennis Elbow stretches, wear a Tennis Elbow strap, and take oral over-the-counter anti-inflammatories for a brief stint.

If things still aren’t improving, I typically suggest seeing a Physical Therapist or Athletic Trainer to perform soft tissue therapies like massage, tool assisted soft tissue mobilization, ultrasound therapy, and even dry-needling.

If things still don’t turn around you could consider a cortisone injection. This option overall is a treatment that will eliminate pain, but is not shown to actually heal what is causing you pain.

If your elbow is still not responding to those treatment options, then some could consider performing surgery to debride the tendon of the necrotic tissue. As you can see, Tennis Elbow can linger for some time without resolution. The treatment algorithm is vast and sometimes cyclical. If you are having trouble with managing acute or chronic overuse Tennis Elbow, please call my Athletic Trainer, Brice Snyder, MSAT, ATC, OTC at 757-679-3407 to schedule an appointment.

Dr. Brad Carofino is an orthopaedic surgeon who specializes in shoulder, elbow and hand injuries. He is a physician with the Atlantic Orthopaedic Specialists in Virginia Beach, Va. AOS provides Athletic Trainers for several USTA Mid-Atlantic Regional, Sectional and other tennis events.

1. Sanders, T., Maradit Kremers, H., Bryan , A., Ransom, J., Smith, J., & Morrey , B. (2015, July). The Epidemiology and Health Care Burden of Tennis Elbow: A Population-Based Study. Am J Sports Med, 43(5), 1066-1071.

2. H. William Gruchow, P. D. (1979, July 1). An epidemiologic study of tennis elbow: Incidence, recurrence, and effectiveness of prevention strategies . The American Journal of Sports Medicine, 7(4), 234-238

Year-end Ratings: What You Need to Know

As the 2017 USTA Adult League season winds down, we gear up for the most highly anticipated time of the year – the moment year-end ratings are published! Think about it like this: you know on TV shows when the teacher posts test scores outside the classroom and everyone rushes to check their grade, this is that for league tennis players – except the teacher is a computer and you can’t fail!

This year, the year-end NTRP Ratings are expected to be published on Dec. 1, and we want to share with you some helpful information to get you ready for when you will know if your NTRP rating stayed the same or is adjusted.

Adult NTRP ratings are used in leagues and tournaments to group players of similar skill levels; for general information on the rating system, click here.

How are dynamic ratings calculated?

A player’s dynamic ratings, calculated after each match, are not solely contingent on record. They are calculated by an algorithm which considers your rating, your opponent’s rating, the expected outcome of the match, and the actual outcome of the match.

What is the difference between a dynamic rating and year-end rating?

  • Dynamic ratings are not disclosed to players, whereas year-end ratings are published annually at NTRP levels.
  • Dynamic ratings are expressed to the one-hundredth of a point, whereas year-end ratings are expressed only to the one-half point.
  • Dynamic ratings are calculated regularly and based on an average of the current match plus the previous three dynamic ratings, whereas year-end ratings are based on a combination of a player’s cumulative dynamic rating during the season and a comparison to an appropriate benchmark player.

Why did [insert USTA employee] decide to change my rating?

All NTRP ratings are generated by a very smart computer using a very advanced algorithm. Whether your NTRP level increases, decreases or stays the same, no humans are involved in creating that year-end rating.

My NTRP has changed. How do I find a team at my new level?

We can help! USTA Mid-Atlantic offers Tennis Connect, a service that can match up players and captains.  Just fill out the form here. We’ll help you find the right match for a team in your area!

How do I appeal my rating?

As a Computer (C) rated player, the way to appeal your rating is online through TennisLink. When you do, TennisLink checks to see if you are within appeal range.  This is a scale based on your dynamic ratings and the number of matches you’ve played in the most recent Championship year.  You will receive an immediate response (Granted or Denied).  If your appeal is granted, TennisLink will automatically adjust your rating level.

Here is how to appeal:

  • Log in to Tennislink and click the USTA League tab (across the top and to the left)
  • To the right of “Welcome!”, look for your NTRP Level
  • Under that, click “Appeal Rating Level”
  • Select Appeal rating level “Up or Down”
  • You will receive an immediate response at the top of the page

Things to know:

  • There is no appeal committee, thus no written letter of explanation. It’s all based on match data and numbers.
  • Appealing will NOT reveal your rating in the 100th of a point.
  • When an appeal has been granted, that player is eligible for dynamic disqualification

I see my ratings on other websites.  Are they the same as USTA?

The USTA posts the official NTRP ratings TennisLink, located at This is the only public website where official NTRP ratings authorized by the USTA are posted and can be obtained.

The USTA is aware of other sites that suggest they provide NTRP ratings or player statistics and skill analysis. Any alleged NTRP related information available on these other sites is not endorsed by the USTA, is not accurate, and cannot be relied upon.

I just really want to talk to someone about my NTRP. Who do I call?

Adult league tennis players in the Mid-Atlantic Section can call or email Adult Programs Coordinator Cassie Nocera. She is your go-to on all things year-end ratings and NTRP. She is totally cool with you reaching out!

Hmmm, alright you’ve answered my questions. Got any fun facts to share?

Funny you should ask, we really do have fun facts about NTRP and year-end ratings!

  • You need three valid matches to generate a year-end rating
  • Your Computer rating does not change during the year. It stays the same until the next year end.
  • Last year, when year-end ratings were published, TennisLink received 2,283,066 visits
  • The highest rating on the NTRP scale is 7.0. Note: This does not mean two 3.5 players could go toe-to-toe with Rafael Nadal, but it sure would be entertaining to watch.

A Coach’s Secret to Keeping New Players in the Game

By: Jeremy Carl

What is the easiest way to get any player new to tennis to keep playing?  Whether it’s beginner adults or 10 and under junior players, the ROGY Progression is without a doubt the best way.

For those unfamiliar, ROGY stands for Red, Orange, Green, Yellow – the color of the balls that can be used to teach kids and adult beginners in a more effective way. Red balls are the lowest compression and larger than the traditional yellow ball, meaning they don’t bounce as high and are easier to control. Orange balls have slightly higher compression than red balls and are the same size as yellow balls. The last step before traditional yellow balls is the green ball, which is similar to playing with a yellow ball but slows down the game and helps lengthen rallies through its lower compression.

I have really seen and experienced the benefits of using this progression in two ways:

Jeremy Carl

Jeremy Carl with his daughter accepting his USPTA Mid-Atlantic Pro of the Year Award in 2016. Photo: Mount Vernon Athletic Club

  1. My own seven-year-old daughter grew up using red balls since age three and half and is now loving playing orange ball level USTA tournaments
  2. Adults in beginner group classes learn how to
    rally from their first-ever tennis class by using red or orange balls from the get go

Here are the top reasons I’ve seen that make the USTA’s ROGY progression is so effective:

  • Helps Incorporate Fun Right Away – More than anything, my daughter loves playing the sport. A big reason for that is by using the ROGY progression throughout her learning process, she learned the sport through a game-based approach. She is not a fan of “drills.” (What kid is?) The only time she does like them is if she comes up with one herself.  Using red and orange balls have allowed her to rally and play games from an early age.
  • Helps Players Learn Situations in Tennis – Tennis is an open sport, and points develop in unexpected ways. However, sometimes lessons are too dependent on hitting in a closed environment, repeatedly hitting a forehand down the line for example.  Every world-class tennis player has learned how to play tennis as a game of situations, not as a game of perfection. Repetition is important but learning how to navigate points is also an extremely important skill to nurture. For example, you can coach players on ball recognition and making contact in the strike zone.

One game to develop these skills can be done by having an orange ball player at one baseline and a partner standing at the other baseline with a ball. The player with the ball tosses it to the other side of the court. Once the ball crosses the net, the player receiving the ball immediately calls out either “Defend,” “Hold,” or “Attack” and catches the ball between their waist and shoulder, slightly out in front of their body. If a player calls out the correct ball recognition and catches it in the strike zone, they get two points.  If a player just does one of the two, they get one point.  You can do this yourself when you go on court with a friend or if you are a coach, have teams compete against each other in class. Once they understand those two principles, you have the basis for learning about offensive, defensive and neutral court positioning.

  • Allows them to Practice Playing Front Court at an Early Age – One of the biggest coaching benefits of using the ROGY progression is that kids feel confident playing in the front court from an early age. They know the ball doesn’t hurt them even if it hits them, and it’s much easier to learn the correct footwork and volley form with the appropriate ball and court size. In the first TennisBASH my daughter played in, one of the first winning shots she hit in her doubles match was a volley winner at the net as the server’s partner. She did it with all the confidence in the world and with a split step before hitting the volley.
  • Helps Adults Enjoy Rallying Right Away – One of biggest themes I learned from completing the Adult Development PTR certification was that using orange or red balls are critical for early success of adults who are learning the game. It allows them to play a variety of rally games, learn footwork, contact point, ball recognition and other items through playing the game from the beginning, which they actually enjoy!

If you’re just starting out, ask about learning on red or orange balls. You won’t be disappointed.

  • Allows players to practice hitting shots with a purpose – Whether it be live ball drill, racket fed or hand toss drill, the balls allow kids to hit to a certain part of the court. Since the ball bounces at the appropriate height for their age, the ball can come to their optimal strike zone more easily, and therefore they can practice hitting down the line or crosscourt with correct swing path. This was one of the key principles I learned from being involved in the USTA Player Development National Early Development Camps.
  • Makes it Easier to Develop Proper Service Motion Early – One of the most important fundamentals on serve is swinging the racquet up toward the ball with full extension and rotating, regardless of a flat serve or spin serve.  When juniors use the appropriate color ball for their age, it gives them the confidence to hit through the ball since the balls actually weigh less.  This has made huge difference in my daughter learning the building blocks of the serve that allow her to play in USTA tournaments with confidence on her serve motion.
  • Helps Players Learn Proper Footwork – Studies have shown that players learning with this ball progression develop similar court footwork fundamentals to the pros. The appropriate size court helps build a foundation of footwork movement that they can develop as they grow bigger and taller.  It also helps them enjoy the movement of tennis because they’ll be able to reach more balls during a rally.

You want to get more people in the game of tennis? The answer is start off juniors or adults in the ROGY ball progression. Whether you’re a longtime coach or introducing the game to friends, or even getting yourself or your child in the game, using the proper ball can make a big difference in how much others enjoy playing tennis.

Look for red, orange and green balls in most places that sell tennis equipment. For more information on court sizes and ROGY progression in youth players, click here.

Jeremy Carl is a USPTA Elite Professional, PTR Professional and Safe Play-certified USTA High Performance Coach with Net Generation. He was named the 2016 USPTA Mid-Atlantic Pro of the Year and is currently coaching at Belle Haven Country Club after coaching at Mount Vernon Athletic Club in recent years.

Doctor Tips: Keeping Your Feet and Ankles Healthy

Hello USTA Mid-Atlantic! I’m Dr. Blake Moore at Atlantic Orthopaedic Specialists. I specialize in foot and ankle surgery for both acute injuries and chronic care. I work in Virginia Beach and see patients at both our Princess Anne and Camelot offices. My Athletic Trainer, Riley Fontaine, MSAT, ATC, OTC will be available at USTA MAS events across the greater Hampton Roads area for consultation and appointment scheduling if you experience an injury and need further care.

I wish to offer some advice to keep you in the game not only today, but for many years to come. There are a number of different structures in the foot and ankle that can lead to daily discomfort and even debilitating pain. For anyone who has experienced this type of pain you know that it can affect your daily life and extend to your game play as well. Among the various conditions that can affect one’s foot and ankle, tennis players are at an increased risk to sustain an ankle sprain due to the constant demands of the sport including lateral movement, cutting and twisting.

Recent sports literature suggests that ankle sprains are the most common injury suffered during sports participation. With appropriate treatment the vast majority of these injuries go on to heal themselves. If left untreated, and repeat incidents occur, some athletes go on to develop chronic ankle instability, where the ankle is no longer able to support the body as its virgin status once could. If you’ve experienced one of these injuries, here is what you should know.

Prevention of a primary incident or rehabilitation to prevent a secondary event is thought to be the key to decrease the rate of recurrence in most cases. Ankle sprain prevention programs that include proprioceptive exercises, isolated single leg strengthening and balance activities have been shown to decrease the risk of sustaining a repeat ankle sprain. An ankle sprain, regardless of severity, affects the ligaments that stabilize your ankle. Proper treatment and gradual/monitored return to sport, increase the chances of a long, healthy and successful career.

Click here to watch Dr. Moore demonstrate what severe ligament ankle damage looks like. 

With those tips in mind we hope you have a healthy and successful career. If you sustain an injury to the foot or ankle we would be happy to treat you and team up to safely return you to play. Please feel free to schedule an appointment by contacting Ceil Scarano at (757) 321-3307, or visit for more information.

Keeping your Knees Healthy

Hello USTA Mid-Atlantic! I’m Dr. Bradley Butkovich at Atlantic Orthopaedic Specialists. I specialize in Sports Medicine and Arthroscopy and see patients at our Kempsville and Depaul offices. I am the Team Physician for Old Dominion University and work with all athletes including ODU’s Men’s and Women’s Tennis Teams. My Athletic Trainer, Jonathan Hartman, MSAT, ATC will be available at USTA MAS events in the Virginia Beach area for consultation and appointment scheduling if you experience an injury on the court.

Today I wanted to discuss “knee health” and give you some tips to help keep you on the court! Tennis requires you to be quick on your feet to keep the ball in play. All of the constant back-and-forth, quick turns, and other moves mean that your knees are constantly being twisted, turned and pounded on.

As a tennis player it is very important to protect your knees and prevent knee pain and problems. Always warm up before a match, and cool down afterward. It is crucial to have a good stretching program to be performed before and after activity. Play within your limits, and ease back into play if you haven’t played in while. Strengthen the muscles around your knee and in your legs to offer better support and protection for your knees. Exercises that focus on quadriceps, hamstrings and core are all very important in injury prevention.

If you have an injury, take a break from tennis and allow the knee to heal. Ice the knee regularly to ease pain and inflammation, and keep the knee elevated to manage swelling. The use of a knee sleeve can help keep the knee warm and has proprioceptive properties that can help to support the knee. Anti-inflammatory medications such as Aleve, Advil or Ibuprofen, can help to manage your pain and swelling. If you are having persistent swelling, pain, locking, clicking or catching then you may have a more serious knee joint problem and you should come see us in the office. Please feel free to schedule an appointment by contacting Renee Hart at (757) 321-3311, or visit for more information.