At Grapplers Performance, we see this misdiagnosis constantly. Four athletes reached out to me this week alone, all self-diagnosed with "tennis elbow." Every single one actually had insertional bicep tendinopathy instead. Zero had true lateral epicondylitis (tennis elbow).

The distinction matters because these conditions require completely different treatment approaches. Treating bicep tendinopathy as tennis elbow means weeks of wasted time, continued pain, and mounting frustration.

Let's fix that.

The Misdiagnosis Problem

As soon as someone experiences elbow pain, the automatic assumption is tennis elbow. This happens for several reasons:

1. Tennis elbow is widely known It's the most recognizable elbow condition, so it becomes the default diagnosis—even when symptoms don't match.

2. Poor initial assessment Most people never get proper evaluation. They self-diagnose online, or worse, receive a cursory diagnosis from providers unfamiliar with grappling-specific injuries.

3. Similar pain locations Both conditions can cause pain on or near the lateral (outer) elbow, leading to confusion.

4. Generic advice compounds the problem "Rest and take ibuprofen for 6 weeks" might be the single worst advice for tendinopathies, yet it's what most people hear from their doctors.

The result? Athletes following incorrect treatment protocols, wondering why nothing improves after months of compliance.

What Actually Is Tennis Elbow?

Tennis elbow (lateral epicondylitis) involves the extensor tendons on the outside of your elbow—specifically the muscles that extend your wrist and fingers.

Anatomy:

• Multiple forearm extensor muscles merge into a common tendon

• This tendon attaches to the lateral epicondyle (bony bump on outside of elbow)

• These muscles control wrist extension and finger extension

Causes in BJJ:

• Excessive grip fighting (especially gi training)

• Posting with extended wrist during scrambles

• Overuse of wrist extensors during training

• Poor grip mechanics creating compensatory stress

Characteristic symptoms:

• Pain on the outer (lateral) elbow

• Worsens with wrist extension against resistance

• Hurts when gripping or shaking hands

• Pain when lifting objects with palm down

• Tenderness directly on the bony prominence

Diagnosis test: Resist wrist extension while applying pressure to lateral epicondyle. Significant pain = likely tennis elbow.

What Is Insertional Bicep Tendinopathy?

Insertional bicep tendinopathy involves the bicep tendon where it attaches to the radius bone in your forearm—about 1-2 inches below the elbow crease.

Anatomy:

• The bicep muscle has two heads at the shoulder but one insertion at the elbow

• This tendon attaches to the radial tuberosity (a bump on your radius bone)

• Controls elbow flexion and forearm supination (palm turning up)

Causes in BJJ:

• Defensive armbar grips (isometric bicep loading)

• Pulling movements (arm drags, collar grips)

• Kimura defense (eccentric bicep loading under rotation)

• Inadequate shoulder internal rotation forcing bicep compensation

Characteristic symptoms:

• Pain on the front of elbow or slightly inside

• Worsens with elbow flexion against resistance

• Painful when turning palm up (supination)

• Deep, achy sensation different from surface tennis elbow pain

• May extend into bicep belly or toward shoulder

Diagnosis test: Resist elbow flexion while palpating bicep tendon insertion. Significant pain = likely bicep tendinopathy.

The Critical Difference: Location and Movement

Here's your quick differential:

Pro tip: You can have BOTH simultaneously, especially if you've been compensating for one with the other. Always test both regions.

Self-Assessment: Which Do You Have?

Perform these tests to differentiate:

Test 1: Resisted Wrist Extension (Tennis Elbow Test)

Steps:

1. Straighten your affected arm completely

2. Make a fist with palm facing down

3. Have someone resist while you try to extend (lift) your wrist

4. Alternative: Press your fist down onto a table while lifting your wrist against the resistance

Positive test: Sharp pain on outer elbow = likely tennis elbow

Test 2: Resisted Elbow Flexion (Bicep Tendon Test)

Steps:

1. Bend your elbow to 90 degrees

2. Turn your palm up (supination)

3. Have someone resist while you try to bend your elbow more

4. Alternative: Hold a weight and curl it slowly

Positive test: Pain in front of elbow or deep in elbow crease = likely bicep tendinopathy

Test 3: Palpation Test

For Tennis Elbow: Press firmly on the bony bump on the outside of your elbow. Extreme tenderness = tennis elbow.

For Bicep Tendinopathy: Press firmly about 1-2 inches below your elbow crease, slightly toward the thumb side. You're feeling for the radial tuberosity. Deep tenderness = bicep tendinopathy.

Test 4: Supination Test (Bicep-Specific)

Steps:

1. Straighten your arm

2. Start with palm facing down

3. Turn your palm up (supination) against resistance

4. Note any pain location

Positive test: Pain in front of elbow during this motion = bicep tendinopathy (tennis elbow won't hurt with this movement)

Why Bicep Tendinopathy Is So Common in Grapplers

BJJ creates unique demands on the bicep tendon that most sports don't:

1. Defensive armbar positioning When defending armbars, your bicep works isometrically at near-maximal tension while your arm is extended—an extremely demanding position for the tendon.

2. Pulling mechanics Constant collar grips, arm drags, and pulling movements create repetitive loading of the bicep insertion.

3. Upstream shoulder restrictions This is the most overlooked cause: limited shoulder internal rotation forces excessive bicep compensation.

When your shoulder can't internally rotate properly (common in grapplers), your bicep has to work overtime during pulling and positioning movements. Over time, this creates chronic overload at the tendon insertion.

The fix? Address the shoulder restriction, and bicep tendon pain often resolves without directly treating the elbow.

The 3-Step Treatment Protocol for Bicep Tendinopathy

Unlike tennis elbow (which requires different interventions), bicep tendinopathy responds to this specific sequence:

Step 1: Address the Joint Restriction (Shoulder Internal Rotation)

Why this matters: Most bicep tendinopathies in grapplers stem from inadequate shoulder internal rotation. Fix the root cause first.

Assessment: Your shoulder should have 40+ degrees of internal rotation. Test by lying on your back, shoulder at 90 degrees, and rotating your forearm toward your body.

Treatment:

• Internal rotation mobilizations

• Sleeper stretches

• Joint capsule work

• Typically requires 2-3 weeks of daily work

Step 2: Soft Tissue Work (Bicep Smash)

Equipment: Barbell (or similar round object)

Technique:

1. Place barbell on the floor

2. Position the meat of your bicep (middle to lower third) on the barbell

3. Apply pressure by leaning your body weight onto the bar

4. Slowly move your arm through flexion and extension

5. Pause on tender spots for 15-30 seconds

6. Move the bar slightly up or down your bicep and repeat

7. Perform for 2-3 minutes per arm

What you should feel: Deep, uncomfortable pressure (5-7/10 intensity). The tissue should feel like it's releasing. You may feel referral into the elbow—this is normal.

Why it works: The bicep tendon doesn't exist in isolation. Tension in the muscle belly creates pulling forces on the tendon insertion. Releasing muscle tension reduces load on the tendon.

Timing: Pre-training and on rest days. Avoid aggressive smashing immediately post-training when tissues are inflamed.

Step 3: Progressive Loading (Eccentric Protocol)

Once acute inflammation settles (typically 1-2 weeks into treatment), begin loading the tendon:

Phase 1: Isometric Loading (Week 1-2)

• Hold dumbbell at 90 degrees elbow flexion

• Palm up position

• Hold for 30-45 seconds

• 3-4 sets

• Should be 3-4/10 discomfort maximum

Phase 2: Slow Eccentric Loading (Week 3-4)

• Bicep curls with 3-5 second lowering phase

• Light weight (30-40% of normal curl weight)

• 12-15 reps, 3 sets

• Focus on the lowering, not the lifting

Phase 3: Progressive Overload (Week 5+)

• Gradually increase weight

• Maintain slow eccentrics

• Add isometric holds at end-range

• Progress toward normal training loads

Critical rule: Never train through sharp pain (>5/10). Some discomfort (2-4/10) during rehab exercises is acceptable and even beneficial, but sharp pain indicates excessive loading.

What Most People Get Wrong

Mistake #1: Just resting Tendons need load to heal. Complete rest weakens them further. You need carefully dosed loading to stimulate tissue remodeling.

Mistake #2: Treating symptoms only If you never address the shoulder restriction causing compensatory bicep overload, the tendinopathy returns as soon as you resume training.

Mistake #3: Too much, too soon Jumping straight into heavy loading re-aggravates the injury. You must progress through isometric → eccentric → full loading phases.

Mistake #4: Ignoring the kinetic chain Bicep tendinopathy often connects to shoulder restrictions, thoracic mobility limitations, or even grip strength imbalances. Treat the whole system, not just the painful spot.

When to Seek Professional Help

Consult a professional if:

• No improvement after 3-4 weeks of proper self-treatment

• Pain getting progressively worse

• Significant weakness developing

• Visible swelling or deformity

• Pain at rest or at night

• Unable to perform daily activities

Our I3 Model Assessment determines whether your elbow pain stems from incomplete mechanics (like shoulder restrictions), an incident (specific injury), or actual structural injury requiring different intervention.

The Tennis Elbow Treatment (When You Actually Have It)

If testing confirms true tennis elbow, treatment differs significantly:

Key interventions:

• Wrist extensor eccentric exercises

• Forearm muscle release work

• Grip strength balancing

• Activity modification (reduce repetitive wrist extension)

• Consider counterforce bracing during training

Tennis elbow requires 6-12 weeks for full recovery—longer than bicep tendinopathy typically takes. The good news: it's less common in grapplers than you'd think.

Conclusion

Stop wasting time treating the wrong condition. Most grapplers with elbow pain have bicep tendinopathy, not tennis elbow.

The distinction matters because:

• Different anatomy involved

• Different movement patterns aggravate each

• Different root causes (shoulder restrictions vs. wrist overuse)

• Different treatment protocols required

Your action plan:

1. Perform the self-tests above to identify which you have

2. For bicep tendinopathy: Fix shoulder internal rotation, perform bicep smash, progressive loading

3. For tennis elbow: Focus on wrist extensors, forearm work, grip balancing

4. Give proper treatment 3-4 weeks before changing course

5. Schedule a discovery call if no improvement

The four athletes who reached out to me this week? All following the correct protocol now. All seeing improvement within 10-14 days. All avoiding months of wasted time on incorrect treatment.

Don't be another case of misdiagnosis. Test accurately, treat specifically, train pain-free.

Related Resources:

• BJJ Elbow Injuries Hub

• Bicep Smash Technique

• Shoulder Internal Rotation Test

• Free Elbow Injury Guide