Tennis Elbow Today: What Really Works (and What Doesn’t)

Tennis elbow (lateral epicondylalgia/epicondylitis) is an overuse problem of the tendons on the outside of the elbow, most often the extensor carpi radialis brevis. Despite the “-itis” suffix, it behaves more like a degenerative tendinopathy than a pure inflammatory flare. Most people improve with sensible loading and time; surgery is rarely needed. HWE Clinical Guidance+1

Natural history and first steps

Symptoms typically ease over months with activity modification and progressive exercise. Early self-care usually includes relative rest, brief use of ice or heat for comfort, and avoiding the specific gripping or twisting loads that provoke pain. Off-the-shelf counterforce straps can be tried for short activities. NICE

Pain relief: short courses of simple analgesia or topical NSAIDs may help some people. The aim is comfort while you start rehabilitation, not to “switch off” the condition. (Discuss any medication with a clinician if you have other health conditions.)

Gold standard: progressive loading (physiotherapy)

The backbone of treatment is graded exercise to restore tendon load-tolerance—typically a mix of isometrics early on, then eccentric and concentric strengthening of the wrist extensors, plus shoulder and grip work. A structured programme improves function and helps you return to normal activity. In trials comparing common options, physiotherapy holds its value over the long term. ScienceDirect

Practical tips:

• Begin with pain-tolerable isometrics (e.g., wrist extension holds), progress to slow eccentrics, then heavier, faster work as pain allows.
• Load little and often; avoid sharp spikes (gardening weekends, sudden DIY binges).

Injections: what the evidence actually says

Corticosteroid injections can produce short-term relief (weeks), but repeatedly show worse outcomes later—including higher recurrence—than placebo or physiotherapy. For most people they’re not a good long-term solution and are best avoided as first-line care. PubMed+2JAMA Network+2

Platelet-rich plasma (PRP) and autologous blood injections have mixed evidence; some studies suggest benefit, others do not. Results vary by protocol and patient selection, so these are generally considered second-line options when good loading programmes have failed, and after discussion with a specialist. (Evidence is heterogeneous; no firm consensus superior to quality rehab.)

Shockwave therapy (ESWT)

Extracorporeal shockwave therapy is used in chronic cases. Meta-analyses are mixed: some report clinically meaningful improvement in pain and grip strength; others find little average benefit but a higher chance of 50% pain reduction in a subset. If chosen, it should sit alongside a loading programme rather than replace it. PMC+1

Bracing and taping

A counterforce strap (placed just below the elbow) can reduce peak tendon load during gripping; kinesiology or rigid taping may give short-term comfort. Treat these as adjuncts while you do the real work—progressive exercise. NICE

Manual therapy and modalities

Joint mobilisation, soft-tissue techniques, and certain modalities can help pain in the short term and may make it easier to train, but they are supporting actors, not the main treatment. The gains come from restoring load capacity with exercise. PMC

Vibration-based pain relief (where it fits)

Non-pharmacological vibration can provide short-term symptom relief through sensory gating (competing, non-painful input that blunts pain signalling). It can be useful before or after exercise to make loading more tolerable, or to settle symptoms during daily tasks. Think of it as a comfort aid that complements—not replaces—your rehab plan.

When to image or refer

If symptoms are atypical, there is trauma, neurological signs, or pain persists despite 3–6 months of good rehabilitation, consider further assessment. Ultrasound or MRI is generally reserved for refractory cases or when an alternative diagnosis is suspected. Surgical options (e.g., debridement, percutaneous tenotomy) are last-line after exhaustive non-operative care. HWE Clinical Guidance

What a sensible plan looks like (summary)

1. Calm pain: brief self-care (ice/heat), simple analgesia if appropriate, optional counterforce strap. NICE
2. Restore capacity: structured progressive loading (isometric → eccentric/concentric → power/grip). ScienceDirect
3. Consider add-ons if needed: ESWT, or (select cases) PRP/ABI after specialist advice. Avoid routine corticosteroid injections due to poorer long-term outcomes. PMC+1
4. Reassess at 6–12 weeks; escalate only if you’ve genuinely progressed loading and still can’t function. Most people improve without procedures. Cleveland Clinic

References (select)

• NICE Clinical Knowledge Summaries (CKS): Tennis elbow—management. Practical first-line advice and self-care. NICE+1
• Corticosteroid injections: short-term benefit, worse long-term vs placebo/physio (JAMA 2013; Lancet 2002). JAMA Network+2PubMed+2
• Shockwave therapy (ESWT): mixed evidence; some meta-analyses report benefit, others modest or none on averages. PMC+1
• Natural history/education: most improve without surgery over months.