Tennis Elbow

Tennis elbow is one of those problems that sounds minor until you have it. Then you discover how much of your day involves gripping something.

Kettles. Door handles. A shopping bag. Shaking hands. Turning a screwdriver. Picking up a mug, which is the one that catches most people out, because a full mug weighs almost nothing and yet there it is.

Three things are worth knowing straight away.

The name is wrong twice over. It is usually nothing to do with tennis, and it is not the kind of problem the name suggests. Section 1 explains.

The outlook is good. Around 9 in 10 people improve within a year. That is true whether you have had it for a month or a year already.

And the most popular treatment for it is one the UK guidance now says should not be used. That is section 8, and if you are thinking about an injection, read that part before you book one.

This guide is not saying your pain is in your head. Your pain is completely real.

One thing before you start. This guide assumes I have examined you. If nobody has examined you, read section 14 first.

The short version

• It is not inflammation. When researchers looked at the tissue, they did not find an inflamed tendon. They found a poorly healed one. That changes what helps.
• It is a capacity problem. The tendon is being asked for more than it can currently give.
• About 9 in 10 people improve within a year, and that holds even if you have had it a while.
• It is slow. Months, not weeks. That is normal and it is not a sign of failure.
• Steroid injections make you feel better for a month and worse for a year. See section 8.
• Loading the tendon is the treatment with the best evidence. See section 10.
• Your neck is worth checking, and section 9 explains why.

1. Two things wrong with the name

First, it is usually nothing to do with tennis. Most people who get it have never picked up a racket. It is far more common in people who grip, twist and carry for a living or a hobby: trades, cooking, cleaning, gardening, lifting, DIY.

Second, and this one matters more, the medical name is misleading. You may have been told you have lateral epicondylitis. The ending, "itis", means inflammation.

When researchers took tissue samples from these tendons, they did not find inflammation. What they found was tendon that had become disorganised and had not healed properly. Not an angry tendon. A poorly repaired one.

So the better name, and the one now generally preferred, is lateral elbow tendinopathy. Tendinopathy just means a tendon that is not coping.

Why this matters practically: if you think the problem is inflammation, you reach for anti-inflammatories and rest, and you wait for it to calm down. Neither of those addresses a tendon that has not healed properly. What that needs is careful, progressive loading, which is section 10.

2. Pain is an alarm, not a damage meter

Your body has danger sensors. They fire when tissue is stretched, squashed or irritated. They send warning signals to your spinal cord, and then to your brain. None of that is pain yet. It is just information. Then your brain weighs it against everything else it knows: what you were doing, what happened last time, what you think it means, how stressed you are, whether you slept. Then it decides how much pain you need to feel in order to stay safe.

Pain is the answer to that question. Your brain produces it.

That is why damage and pain match up so badly. A paper cut is agony with almost no damage. Soldiers get badly hurt and feel very little until they are safe.

So how much your elbow hurts does not tell you how damaged the tendon is. It tells you how protective your body is being.

This is worth holding on to with tennis elbow, because it explains something that puzzles people: how a light mug can hurt more than a heavy toolbox. The mug is not doing more damage. It is catching the arm in a position the alarm is currently watching closely.

3. The pain gate

In 1965, two researchers called Ronald Melzack and Patrick Wall came up with an idea that changed pain medicine.

Picture a gate in your spinal cord. Warning signals from your arm have to pass through it to reach your brain. Open, and more gets through. Closed, and less does. Nothing in your elbow has to change for the pain to change. Only the gate setting.

What closes it: touch, rubbing, heat, hands-on treatment, movement, sleep, feeling calm, and understanding what is going on.

What opens it: broken sleep, stress, low mood, testing the elbow repeatedly to see if it still hurts, bracing before you grip something, and worrying that you are doing damage every time it twinges.

That last pair matters here. People with tennis elbow start gripping tentatively, testing before they commit, and flinching in advance. All of that keeps the gate open.

4. When the alarm gets too sensitive

If you have had this a while, the tendon is not the whole story.

When a pain system has been busy for months, it does not wear out. It gets better at its job. The sensors fire more easily and the brain concludes danger more quickly. Think of a car alarm. When it was fitted, it went off if someone forced the door. Years later it goes off when a cat walks past. The alarm is not broken. It is set too sensitive for the actual threat.

With long-standing tennis elbow, part of what you feel is a sensitive system rather than an angry tendon. That is good news, because sensitivity is a setting and settings change.

5. What actually causes it

The muscles that pull your wrist and fingers back run from the outside of your elbow down your forearm. They all share one attachment point, on the bony bump on the outside of your elbow.

Here is the bit that surprises people. Those muscles work hard every time you grip. To grip firmly, your wrist has to be held steady, and that steadying is their job. So every time you hold anything, you are loading that tendon. You do not have to be lifting weights above your head.

Tennis elbow happens when the demand on that tendon goes past what it can currently handle. Usually:

• A new or unaccustomed task. A weekend of decorating, a house move, a new job, a different tool, a fortnight of gardening.
• A step up in volume. Same job, more hours.
• A period of being generally run down, when your tolerance for everything is lower.
• Occasionally a single heavy or awkward effort.

It is usually not one dramatic injury. It is the total load creeping past the line.

And the load is grip. Which is why a job you have done for years can suddenly become a problem, and why the fix has to involve building the tendon up rather than simply avoiding things.

6. What to expect

This is the part people most want, so here it is plainly.

Around 9 in 10 people with tennis elbow improve within the first year. The UK care pathway puts it at 89 per cent.

Improvement builds steadily rather than arriving all at once. Across large groups, the symptoms roughly halve over about two and a half to three months. And here is the finding that matters most if you have had this a while: improvement happens regardless of how long you have had it when you start. Having put up with it for eight months does not mean you have missed your chance. People who have had it for a long time still get better.

Two honest cautions:

• It is slow. Months, not weeks. If you are six weeks in and frustrated, you are exactly where most people are at six weeks.
• It can be grumbly on the way. Better does not mean a clean line upwards. Good weeks and annoying weeks are normal.

7. What the evidence says helps

Exercise and progressive loading. This has the strongest evidence of the options available and it is the mainstay of treatment. Section 10 covers it properly.

Adjusting what you do, temporarily. Not stopping. Adjusting. Section 11.

Topical anti-inflammatory gel. The UK pathway supports this for short-term pain relief, up to about four weeks, and prefers gels to tablets. It will not fix the tendon, but making the first few weeks more bearable has value.

Understanding what is going on. Which is what you are doing now, and it genuinely counts.

Hands-on treatment, for what it does to pain and sensitivity rather than to the tendon itself. See section 13.

8. What the evidence says does not help

This section will surprise you, and the first item is the important one.

Steroid injections

This is the treatment most people have heard of, and often the one they ask for. The UK care pathway for tennis elbow now says it should not be used.

Here is why. A trial published in 2013 split people into four groups: a steroid injection, a dummy injection, steroid plus physiotherapy, and dummy injection plus physiotherapy. Then it followed them for a year.

• At one year:
• Steroid injection: 83 in 100 had recovered or much improved.
• Dummy injection: 96 in 100.
• Physiotherapy with a dummy injection: 100 in 100.

And recurrence during that year:

• Steroid injection: 54 in 100 had it come back.
• Dummy injection: 12 in 100.
• Physiotherapy: 5 in 100.

Read that again. The people who got the real steroid did worse than the people who got a fake injection, and were four to five times more likely to have it return.

The injection does work in the short term. People genuinely feel better for a few weeks. But by six months the position has reversed, and by a year it has cost them.

I am not telling you never to have one. There are occasional situations where short-term relief is worth it, and that is a conversation for you and your GP. But go in knowing the trade, because most people are not told it.

Other things with weaker evidence than their reputation

• Shockwave therapy. The UK pathway says it should not be used. No clinically meaningful improvement over placebo.
• PRP, or platelet-rich plasma injections. May have no benefit over a dummy injection. Often expensive.
• Dry needling. No evidence of benefit compared with placebo.
• Surgery. This one startles people: the UK pathway states there is no evidence of benefit compared with placebo surgery. It remains an option late on, but it is not the reliable fix people assume.
• Elbow braces and clasps. May be offered, and some people like them, but you should know they may not help. If one makes your day easier, use it. Do not expect it to be the treatment.

The pattern across that list is worth noticing. The things that get done to the elbow have a poor record. The thing that involves the tendon doing work has the best one.

9. Why I will look at your neck

This seems like a detour and it is not. The nerves that supply your elbow and forearm come from your neck. Problems there can send pain into the outside of the elbow, and can make the area more sensitive than it would otherwise be.

Not everyone with tennis elbow has a neck component. But enough people do that it is worth checking, particularly if:

• You also have neck or shoulder blade symptoms.
• The pain is more spread out than a single tender point.
• You have pins and needles or numbness anywhere in the arm or hand.
• The elbow has not responded to sensible loading.

If your neck is contributing, treating only the elbow is likely to disappoint. That is one of the more common reasons these get stuck.

10. Loading it: the part that works

Tendons adapt to load. That is how they get stronger, and it is the only thing on the list that changes the tendon itself rather than just how it feels.

The rule that governs everything:

Discomfort up to about 4 or 5 out of 10 while you exercise is acceptable, as long as it has settled back to your normal by the next morning, and is not creeping up week by week.

If it is worse the next day, you did too much. That is information, not damage. Repeat the previous week rather than progressing.

If it is very sore right now

Start with grip holds. Squeeze something firm, a rolled towel or a soft ball, at about half your maximum, hold for 30 to 45 seconds, rest, repeat 5 times. Twice a day. These often take the edge off for a while afterwards.

The main work

Two exercises, three days a week, never on consecutive days.

• Wrist extension. Forearm supported on your thigh or a table, palm down, a light weight in your hand. Raise the wrist slowly over 3 seconds, lower slowly over 3 seconds.
• Grip strengthening. A gripper, a squeeze ball, or simply holding a weight.

Slow is the point. Three seconds up, three seconds down. Build like this, adding weight as the repetitions come down:

• Weeks 1 to 2: 3 sets of 15, light enough to complete but hard by the end.
• Weeks 3 to 4: 3 sets of 12, heavier.
• Weeks 5 to 8: 4 sets of 10, heavier again.
• Weeks 9 to 12: 4 sets of 8.

Twelve weeks is the timeframe. Tendons are slow and there is no way to hurry them. Adding load faster does not speed it up, it just makes you sore.

And when it stops hurting, keep going for another couple of months. Stopping the week it settles is the single commonest reason it comes back.

11. Getting through the day

Practical things that reduce the load without stopping your life:

• Carry with your palm up, or hug things to your chest, rather than gripping palm down. Palm down loads the sore tendon most.
• Fatten up your grips. Thicker handles on tools, pens and kettles need less gripping force. Foam tubing or tape works.
• Use two hands for the kettle, the pan, the shopping bag.
• Break up long gripping tasks. Five minutes of something else every twenty is worth more than pushing to the end.
• Check the obvious offender. A new tool, a heavier laptop bag, a different mouse, a bike with the wrong bar position. There is often one thing.
• Do not stop using the arm. Protecting it completely makes it weaker and more sensitive, which is the opposite of the goal.

12. Flare-ups

You will have some. They do not mean you have undone your progress.

They are usually a pile-up: a heavy week, poor sleep, an unusual task, a stressful patch.

• Drop back to the previous week of your programme for a few days, then build again.
• Keep using the arm within comfort. Do not go into a sling or stop entirely.
• Grip holds from section 10 often settle things.
• Heat, topical gel, and reducing the aggravating task for a few days.
• Remind yourself that it has settled before and will again. That lowers the threat and closes the gate.

13. What treatment does, and what it does not

Hands-on treatment works on pain and sensitivity. It closes the gate, calms things down, relaxes forearm muscles that have been working overtime, and often gives you a spell where gripping is easier. That is a real effect and it is worth having, particularly early on when everything hurts.

What it does not do is repair the tendon. No treatment I can do to your elbow will rebuild it. Only loading does that.

So the useful way to think about a session is as a window: a stretch of time where the arm feels easier, which you use to do the work in section 10.

I will also check your neck and shoulder, for the reasons in section 9, and I will tell you honestly if I think the elbow is the whole story or not.

On measuring progress. Pain scores bounce around. Better questions: can I carry the shopping in that hand? Can I lift a full kettle? How long can I work before it starts? Those change before the pain score does.

14. When to get it checked properly

Tennis elbow is a clinical diagnosis. It does not usually need a scan, and the UK pathway says imaging is not routinely required.

But some things are not tennis elbow. See your GP, or tell me, if you have:

• Swelling around the elbow, or a hot, red joint.
• Pain in several joints, or morning stiffness lasting more than half an hour, which can point to an inflammatory arthritis.
• Locking, catching, or the elbow giving way, which can suggest something loose inside the joint.
• Pins and needles, numbness, or weakness in the hand or fingers. A nerve can be irritated in the forearm and mimic this.
• A history of a fracture or dislocation in that elbow.
• Pain that is much worse at night, unexplained weight loss, fever, or feeling generally unwell.
• Elbow pain in a child or teenager, which needs assessing differently.
• Pain that started with a significant fall or injury. If you are not improving at all after about three months of doing the right things, that is worth reviewing rather than pushing on. The UK pathway suggests considering onward referral somewhere between three and six months without improvement.

15. If you want to read or watch more

Start here

• NHS advice on tennis elbow. nhs.uk/conditions/tennis-elbow
• Tame the Beast. A five minute animation by Professor Lorimer Moseley on how pain works. tamethebeast.org
• Versus Arthritis, on elbow pain. versusarthritis.org

Practical help

• Recovery Strategies, by Greg Lehman. A free illustrated workbook, very good on load and pacing. greglehman.ca/recovery-strategies-pain-guidebook

The research behind this guide

• Singh HP et al. BESS patient care pathway: tennis elbow. Shoulder and Elbow, 2023. The UK care pathway. The source of the recovery figures in section 6 and the treatment positions in sections 7 and 8.
• Coombes BK et al. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA, 2013. The injection figures in section 8.
• Smidt N et al. Corticosteroid injections, physiotherapy, or a wait and see policy for lateral epicondylitis: a randomised controlled trial. The Lancet, 2002. An earlier trial showing the same pattern over 52 weeks.
• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.

Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar.

This guide is general information. It does not replace the advice I give you in clinic.