Paddler’s Elbow: Why Rest Fails & What Works

Around the sixth week of the season, at least one paddler will approach me on the dock or email me complaining of discomfort on the outside of their elbow. The pain typically manifests during the catch phase and intensifies throughout the press. I am usually told it is manageable on the water, but by evening it can become severe enough to prevent simple tasks like opening a jar. Despite rest and stretching, the discomfort and pain persist, which can really become mentally draining. For some, this nagging issue can lead to concerns about potentially having to give up paddling altogether.

In my twenty years of coaching, I have seen many paddlers face this challenge, and in my experience, most have been able to resolve it successfully. When extended rest fails, you can resolve it by addressing the underlying causes of your symptoms.

Why “just rest it” isn’t enough

The American Physical Therapy Association’s 2022 clinical practice guideline opens by noting that this condition is “often described as a self-limiting condition and likely to resolve on its own.” In the same breath, it flags “high recurrence rates and extended sick leave” (Lucado et al., 2022). That pairing is the pattern most paddlers know firsthand: the pain settles with rest, you return to training, and it comes back.

The standard exercise prescription doesn’t fare much better. After reviewing the evidence, the Canadian Shoulder and Elbow Society concluded that patients starting a standard eccentric strengthening program “should be counseled that pain and function are similar to no active treatment” (Lapner et al., 2022). In other words, the wrist-strengthening routine most people are given to resolve the issue generally performs as well as simply resting it and waiting it out.

So if you have rested your elbow, done the wrist exercises, and the pain keeps coming back, you are not dealing with an unusually stubborn case. You are running into the documented limits of elbow-focused treatment — and that is exactly why I stopped giving elbow-only advice to my paddlers.

The Chain Model

Your arm, from shoulder to hand, works as a chain in a specific pattern for stability and mobility. The shoulder provides mobility, the elbow provides stability, the wrist provides mobility, and the hand provides stability. The elbow sits in the middle of this chain as the stable link that transfers force. When one of the mobile joints on either side of the stable elbow stops doing its job, the surrounding muscles and joints have to compensate — and in this chain, it is commonly the tendon on the outside of your elbow where you feel it.

The chain model is a coaching framework that helps coaches and athletes understand what might be causing the discomfort. For instance, a 2025 systematic review of 55 studies and 33,228 athletes found reduced range of motion, reduced shoulder strength, and scapular dyskinesis as modifiable risk factors for upper-extremity injury (Heming et al., 2025). However, those associations with injury risk don’t guarantee that freeing your shoulder will address your elbow pain.

Paddling by nature asks a great deal of the shoulder. A survey of 583 paddling athletes — kayak, touring, ocean-ski and stand-up paddleboard racers — found elbow injury affecting 11.0% of them. More to the point, after controlling for on-water training hours, the relative risk of wrist injury ran 1.53 to 1.83 times higher in paddlers with decreased flexibility (Griffin et al., 2020). Less available motion, more injury one joint down the chain. The chain model is built around that pattern, especially in paddlers.

A second paddling study of thirty-one competitive flatwater kayakers measured shoulder rotation and asked about shoulder pain. Those with a history of pain had roughly 11 to 14 degrees less internal rotation than those without — 49.3 against 60.0 degrees on the right, 51.9 against 66.0 on the left. They were also far more likely to show scapular dyskinesis, meaning the shoulder blade not moving as it should, represented by 15 of the 17 painful shoulders, against a significantly lower rate in the pain-free group (Johansson et al., 2016).

The wrist on the other side of the elbow in this chain matters too. Across four marathon races, an average of 23% of the competitors in each race developed tenosynovitis of the wrist extensors — the same muscle group whose tendon becomes painful in tennis elbow, one joint further up (du Toit et al., 1999). In paddling, it is linked to wrist hyperextension during the pressing phase of the stroke and to conditions that can affect technique, such as choppy water or fast-flowing waters. Not surprisingly, paddlers training more than 100 km a week had a higher rate of this condition than those training less. This is not a volume story. It is a position-under-load story, and at 80 to 90 strokes a minute, a small positional technique problem can become a big problem very quickly.

When your elbow compensates for other joints that aren't functioning optimally, it causes real discomfort and pain. Resolving this issue requires redistributing the workload among all relevant joints, rather than simply resting the elbow. This also explains why isolated elbow treatments are often ineffective: they address the site of pain rather than the source of the excessive load.

Injuries and coaches’ wisdom

Paddlers with less flexibility and mobility get injured more often. Kayakers with shoulder pain have measurably less internal rotation, and more scapular dyskinesis, than those without. And in the best recent evidence on prevention, shoulder programs built from strength, stability, and sport-specific work cut shoulder injury rates by 51% in handball and volleyball players, with a confidence interval from 0.30 to 0.79 (Heming et al., 2025).

However, no trial has tested a mobility program in paddlers. And when mobility work has been tested head-to-head against strength work, strength did better than mobility. In high school baseball pitchers randomized to nightly sleeper stretching or nightly external-rotation strength training, the injury rate was 22.6% in the stretching group and 9.8% in the strength group, a hazard ratio of 0.489 (Shitara et al., 2022). Mobility training for paddle athletes is essential, but it does not replace your current on- and off-water training plans; it is an essential addition. Keep lifting. This sits alongside your current training, not in place of it.

How mobility work helps

Seven drills. Thirty to sixty seconds each. About ten minutes a day with a tennis ball, a towel, and a wall can provide real long-term relief.

I recommend that, to address and prevent issues, every session touch all four points: shoulder mobility, elbow stability, wrist mobility, and hand stability and grip strength. Repeat this 10-minute-per-day, seven-day flow for three weeks in a controlled manner. The program I complete with my clients does not require strenuous effort or forced movements; instead, it emphasizes relaxed shoulders, proper alignment from shoulder to hand, and comfortable ranges of motion. Most importantly, the exercises are designed to be accessible and easy to incorporate into daily routines, which has contributed to high completion rates for my paddlers. Finding a routine that fits easily into your day helps you stick with it.

When the program is effective, initial improvements often show up in performance first rather than in the elbow itself. Paddlers may notice a longer catch, sustained grip strength throughout extended sessions, and improved sleep quality without discomfort. Typically, the elbow symptoms diminish last, as the rest of the arm resumes its proper function.

Start with one number today.

Squeeze something until it first becomes uncomfortable and note how long it took. This simple exercise measures your pain-free grip. In a study of 100 people with tennis elbow, it was one of only two measures — alongside the pain subscale of a tennis elbow questionnaire — that actually responded to change over time (Sveinall et al., 2025). The sample was 68% women, with an average age of 48; most were symptomatic for more than three months.

Write the time and date, then take it again three weeks later after consistently performing full chain mobility work as suggested each day. That costs you nothing, and it will tell you more about your elbow than another month of waiting will.

And then, if you want my structured version

The 21-Day Elbow Pain Solution is live inside the Paddle Performance Framework: seven drills, ten minutes a day, 49 follow-along videos with a printable calendar, the Prevention & Approach Guide, and continued access — so it is there next season, and the one after that.

Ready to start? Enroll in The 21-Day Elbow Pain Solution here.

Looking for our latest deals? Current promotions on all of our mobility programs can be found on our Mobility page.

And if your elbow is fine but you recognize yourself in the shoulder description — start with the 21-Day Shoulder Mobility program instead. That is where I would send you first if your shoulder is causing you the most discomfort.

Better technique and power on the water, less next-day soreness in the gym.

Annely Thorstad is a Sport Performance Specialist with over 20 years of coaching experience, has coached paddle sport athletes across six countries, and is currently completing her doctorate in Sport Performance. She works out of Boundary Waters Paddlesports Coaching & Conditioning, LLC, in Georgetown, South Carolina.

Medical note

This is an educational exercise program — coaching, not medical care, and not a diagnosis or treatment. If you have severe pain, numbness, tingling, sudden weakness, loss of grip, or a recent injury, see a healthcare professional first, and again if you don't feel relief after completing or maintaining a mobility program.

References

du Toit, P., Sole, G., Bowerbank, P., & Noakes, T. D. (1999). Incidence and causes of tenosynovitis of the wrist extensors in long-distance paddle canoeists. British Journal of Sports Medicine, 33(2), 105–109. https://doi.org/10.1136/bjsm.33.2.105

Griffin, A. R., Perriman, D. M., Neeman, T. M., & Smith, P. N. (2020). Musculoskeletal injury in paddle sport athletes. Clinical Journal of Sport Medicine, 30(1), 67–75. https://doi.org/10.1097/JSM.0000000000000565

Heming, E. E., Gibson, E. S., Friesen, K. B., Martin, C. L., Martin, M., Asker, M., Blauwet, C., Bullock, G. S., Fredriksen, H., Galarneau, J.-M., Hayden, K. A., Lee, J. H., Mosler, A. B., Myklebust, G., Pluim, B. M., Thornton, J. S., Whittaker, J. L., Whiteley, R., Crossley, K. M., . . . Emery, C. A. (2025). Prevention strategies and modifiable risk factors for upper extremity injury: A systematic review and meta-analysis for the Female, woman and/or girl Athlete Injury Prevention (FAIR) consensus. British Journal of Sports Medicine, 59(22), 1587–1598. https://doi.org/10.1136/bjsports-2025-109907

Johansson, A., Svantesson, U., Tannerstedt, J., & Alricsson, M. (2016). Prevalence of shoulder pain in Swedish flatwater kayakers and its relation to range of motion and scapular stability of the shoulder joint. Journal of Sports Sciences, 34(10), 951–958. https://doi.org/10.1080/02640414.2015.1080852

Lapner, P., Alfonso, A., Herbert-Davies, J., Pollock, J. W., Marsh, J., King, G. J. W., & Canadian Shoulder and Elbow Society. (2022). Position statement: Nonoperative management of lateral epicondylitis in adults. Canadian Journal of Surgery, 65(5), E625–E629. https://doi.org/10.1503/cjs.019221

Lucado, A. M., Day, J. M., Vincent, J. I., MacDermid, J. C., Fedorczyk, J., Grewal, R., & Martin, R. L. (2022). Lateral elbow pain and muscle function impairments: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Academy of Hand and Upper Extremity Physical Therapy and the Academy of Orthopedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopedic & Sports Physical Therapy, 52(12), CPG1–CPG111. https://doi.org/10.2519/jospt.2022.0302

Shitara, H., Tajika, T., Kuboi, T., Ichinose, T., Sasaki, T., Hamano, N., Kamiyama, M., Miyamoto, R., Ino, F., Nakase, K., Yamamoto, A., Takagishi, K., & Chikuda, H. (2022). Shoulder stretching versus shoulder muscle strength training for the prevention of baseball-related arm injuries: A randomized, active-controlled, open-label, non-inferiority study. Scientific Reports, 12(1), Article 22118. https://doi.org/10.1038/s41598-022-26682-1

Sveinall, H., Brox, J. I., Engebretsen, K. B., Hoksrud, A. F., Røe, C., & Johnsen, M. B. (2026). Measurement properties of core outcomes in patients with tennis elbow. Shoulder & Elbow, 18(4), 835–848. https://doi.org/10.1177/17585732251344264