Tennis Elbow: Why Is It Not Getting Better and What Actually Helps?
Tennis elbow can be surprisingly persistent.
You may have rested it, tried exercises, changed how you work or even had an injection, only for the pain to return as soon as you start gripping, lifting or playing sport again.
Despite the name, you do not need to play tennis to develop tennis elbow. It commonly affects people who use their hands repeatedly for work, exercise, gardening, racket sports or other activities involving gripping and loading through the wrist and forearm.
The medical term is lateral elbow tendinopathy, referring to pain arising from the tendons around the outside of the elbow.
For most people it can be managed conservatively. When tennis elbow is not getting better, however, the important question is not simply which treatment to try next.
It is worth considering whether the diagnosis is correct, what continues to aggravate the problem and whether rehabilitation has genuinely restored enough capacity for the activities you need to perform.
Table of Contents
What is tennis elbow?
Tennis elbow usually causes pain around the bony prominence on the outside of the elbow, known as the lateral epicondyle.
The tendons attaching around this area help the muscles responsible for extending the wrist and fingers and are exposed to load during gripping and lifting.
Symptoms can include:
Pain on the outside of the elbow
Pain when gripping
Difficulty lifting objects
Pain when using tools
Discomfort with racket sports or gym exercises
Pain with repetitive hand or wrist movements
Reduced grip strength because of pain
Some people notice relatively little discomfort at rest but find that everyday activities such as lifting a kettle, carrying shopping or picking something up with the palm facing down become painful.
What causes tennis elbow?
There is rarely one single cause.
Symptoms often develop when the demands being placed on the tendon exceed its current capacity.
That might follow a sudden increase in activity, but the change does not have to involve sport.
DIY, gardening, manual work, increased computer or mouse use, gym training and racket sports can all increase demand around the elbow.
Sometimes there is an obvious change.
Someone may have spent a weekend gardening or started playing considerably more tennis.
In other cases, symptoms develop gradually without a clear trigger.
This is why simply identifying the activity that hurts does not necessarily explain the whole problem.
We need to understand what the elbow has been exposed to over time, what it currently tolerates and what capacity it ultimately needs.
How do you know if you actually have tennis elbow?
Tennis elbow is usually diagnosed clinically.
The location and behaviour of the symptoms provide useful information, alongside tests that load the muscles and tendons around the outside of the elbow.
However, not every pain on the outside of the elbow is tennis elbow.
Symptoms can sometimes be referred from the neck. Problems involving nerves around the elbow and forearm can produce overlapping symptoms, while other structures within the elbow can also cause lateral elbow pain.
This becomes particularly important when somebody has had months of treatment for tennis elbow without meaningful improvement.
At that point, simply prescribing another variation of the same exercise may not be the most useful next step.
The diagnosis deserves reconsideration.
Are the symptoms genuinely arising from the tendon?
Is there neck pain or altered movement?
Are there neurological symptoms?
Does the pattern of pain behave as we would expect?
Are there features suggesting another source within the elbow?
Good treatment starts with being reasonably confident that we are treating the right problem.
Why is tennis elbow sometimes so difficult to get rid of?
Tendons adapt relatively slowly.
Rest can reduce symptoms, but reducing pain and restoring capacity are not the same thing.
Imagine someone whose elbow hurts whenever they play tennis.
They stop playing for six weeks.
The elbow settles.
They then return to exactly the same amount of tennis that previously aggravated it.
The pain returns.
It is tempting to conclude that the tendon has become damaged again.
Another possibility is that the period of rest reduced symptoms without adequately preparing the tendon and surrounding muscles for the demands of tennis.
A similar pattern occurs with work.
Someone may feel better during a holiday and immediately become painful when they return to a job involving repeated gripping or lifting.
The longer term solution therefore usually involves more than simply avoiding whatever hurts.
Should you rest tennis elbow?
Complete rest is rarely the long term answer.
Temporarily reducing or modifying particularly provocative activities can be useful, especially when symptoms are highly irritable.
But eventually the elbow needs to tolerate load again.
The aim is therefore to find a manageable level of activity while progressively improving strength and capacity.
For someone who works at a computer, that may involve modifying certain tasks temporarily.
For a tradesperson, it may involve managing repetitive gripping or tool use.
For somebody playing tennis, it might mean adjusting frequency, duration or intensity while rehabilitation progresses.
This is load management rather than simply stopping everything until the pain disappears.
What exercises actually help tennis elbow?
Exercise is commonly used to improve the capacity of the wrist and forearm muscles.
That may include different forms of wrist extension strengthening, gripping and eventually more demanding exercises depending on the person's needs.
The precise exercise is less important than some of the principles behind the programme.
Rehabilitation should consider:
How much load is currently tolerated
How painful or irritable the elbow is
Strength
Dosage
Frequency
Progression
Work demands
Sporting demands
Response following exercise
A relatively irritable elbow might initially need quite modest loading.
As capacity improves, the exercises should generally become more demanding.
Someone returning to heavy manual work or competitive racket sport eventually needs considerably more capacity than someone whose main aggravating activity is using a computer mouse.
The rehabilitation programme should reflect that.
Why do tennis elbow exercises sometimes not work?
This is where things become more interesting.
Patients will often tell me:
“I've already done physio for it.”
That is useful information, but it does not necessarily tell us whether rehabilitation has been optimised.
What exercises were prescribed?
How difficult were they?
How frequently were they performed?
Was resistance progressively increased?
Did strength improve?
Were work or sporting loads considered?
Did the programme ever progress beyond a few light wrist exercises?
Was the diagnosis correct in the first place?
A generic exercise sheet can contain perfectly sensible exercises.
But an exercise that was appropriately challenging in week one may provide very little stimulus several weeks later.
If the ultimate goal is to return to tennis, heavy lifting or demanding manual work, rehabilitation eventually needs to prepare the arm for those demands.
Simply repeating the same exercises indefinitely is not necessarily rehabilitation.
Do braces and straps help tennis elbow?
Forearm straps and braces are commonly used for tennis elbow.
Some people find that they reduce symptoms during particular activities, particularly gripping or sport.
That can make them useful as a short term symptom management option.
But a brace does not address every factor contributing to the problem and should not usually replace progressive rehabilitation.
If somebody can perform an important activity more comfortably while wearing one, that may be useful.
The question is whether it helps that individual rather than whether everybody with tennis elbow should wear one.
Do steroid injections help tennis elbow?
This is an interesting example of why short term improvement does not necessarily mean better treatment.
Corticosteroid injections can provide impressive short term pain relief for tennis elbow.
That understandably makes them attractive when somebody has been struggling for weeks or months.
However, longer term outcomes tell a different story.
A placebo controlled randomised trial published in JAMA compared corticosteroid injection with placebo in people with lateral epicondylalgia.
At one year, 83% of people receiving corticosteroid reported complete recovery or much improvement compared with 96% receiving placebo.
More strikingly, recurrence occurred in 54% of the corticosteroid group compared with 12% of the placebo group.
This does not mean a corticosteroid injection can never reduce tennis elbow pain.
It clearly can.
The issue is that rapid pain relief and good longer term outcome are not necessarily the same thing.
That distinction matters when deciding whether an injection is worthwhile.
What about PRP and other injections?
Platelet rich plasma, or PRP, is increasingly offered for persistent tendon problems.
PRP uses a preparation derived from the patient's own blood and is intended to expose the affected area to a higher concentration of platelets and associated growth factors.
Some more recent systematic reviews comparing PRP with corticosteroid injection have found that corticosteroid tends to perform better in the short term, while PRP may produce better outcomes at later follow up.
However, this needs careful interpretation.
Comparing PRP with corticosteroid is not the same as demonstrating that PRP provides a clinically important benefit over placebo or good rehabilitation.
The injection literature for tennis elbow remains heterogeneous, with different preparations, protocols and comparators. Some analyses have found insufficient evidence that PRP or autologous blood provides superior outcomes to placebo.
Other injectable treatments are also being investigated, including dextrose prolotherapy and autologous blood, but the evidence is still evolving. A recent network meta analysis found that outcomes varied considerably according to both the intervention and the point at which it was measured.
So I would be cautious about presenting any injection as the obvious solution to persistent tennis elbow.
The useful question is:
Why are we considering an injection, and what evidence is there that it will improve the outcome we actually care about?
For someone whose rehabilitation has never been properly progressed, an expensive injection may not be the most logical next step.
For somebody with persistent symptoms despite well structured conservative management, discussing additional options may be more reasonable.
Do you need a scan for tennis elbow?
Usually not.
Tennis elbow can generally be diagnosed from the history and clinical examination.
Ultrasound or MRI can identify changes within the tendon, but finding an abnormal tendon on a scan does not automatically tell us why somebody is experiencing pain or what treatment they require.
Imaging becomes more useful when the diagnosis is uncertain, symptoms are atypical, there is concern about another pathology or the result is genuinely likely to influence management.
This is particularly relevant when symptoms have persisted despite appropriate treatment.
But again, persistent pain alone does not automatically mean that an MRI is required.
The first step should usually be reassessment.
How long does tennis elbow take to recover?
There is no reliable deadline.
Some cases settle relatively quickly, particularly when the provoking load is identified early and symptoms are manageable.
Others can persist for many months.
Longer standing symptoms, substantial reductions in strength or capacity, repeated aggravation and demanding occupational or sporting requirements can all make rehabilitation more challenging.
This is why promising that tennis elbow will disappear after a particular number of sessions is unrealistic.
Progress is better judged by whether pain is becoming more manageable, strength is improving and the person is progressively tolerating more of the activities they need to perform.
The aim is not simply to make the elbow comfortable while it is being protected.
It is to restore enough capacity that normal life no longer repeatedly aggravates it.
What if your tennis elbow is not getting better?
If tennis elbow is not improving, simply continuing the same treatment indefinitely is unlikely to be the best approach.
The clinical picture should be reassessed.
Is it definitely tennis elbow?
Could symptoms be referred from the neck?
Could a nerve be contributing?
What loads are continuing to aggravate it?
Has strength objectively improved?
Has rehabilitation actually progressed?
Does the programme resemble the demands of the person's work or sport?
Has conservative management genuinely been optimised?
Would imaging change management?
Is there a good reason to consider an injection or orthopaedic opinion?
These are the questions that become important when a seemingly straightforward tendon problem becomes persistent.
This is also where the reasoning involved in an Advanced Physiotherapy assessment can be particularly useful.
The aim is not simply to provide a different set of tennis elbow exercises.
It is to establish why the problem has persisted and what needs to happen next.
At Genuine Physio in Tadworth, near Kingswood, that might mean modifying and progressing rehabilitation.
It might mean reconsidering the diagnosis.
Occasionally imaging may add useful information.
And in selected cases, an injection or orthopaedic opinion may be worth considering.
The treatment should follow the clinical reasoning rather than the other way around.
Frequently Asked Questions
What is the best treatment for tennis elbow?
There is no single treatment that works for everybody. Management usually involves appropriate modification of provocative activity alongside progressively restoring strength and capacity. The programme should reflect the individual's symptoms and what they need to return to.
Should I rest tennis elbow completely?
Usually not. Temporarily reducing aggravating activity can help settle symptoms, but complete rest does not rebuild the capacity required for work, exercise or sport.
What exercises help tennis elbow?
Exercises that progressively load the wrist and forearm muscles are commonly used. The exact exercise, resistance, dosage and progression should depend on the individual's current capacity and goals.
Why is my tennis elbow not getting better?
There are several possibilities. The diagnosis may need reconsidering, aggravating loads may still be too high, rehabilitation may not have progressed sufficiently or the programme may not be preparing the elbow for the demands of work or sport.
Does a steroid injection cure tennis elbow?
No. Corticosteroid can provide substantial short term pain relief, but research has demonstrated higher recurrence and worse longer term recovery compared with placebo in a major randomised trial.
Is PRP better than steroid for tennis elbow?
Some studies suggest PRP may produce better longer term outcomes than corticosteroid injection, while steroid tends to provide greater short term relief. However, the overall injection evidence remains mixed and comparison with steroid does not establish that PRP is superior to placebo or appropriately delivered rehabilitation.
Do I need an MRI for tennis elbow?
Usually not. Tennis elbow is generally a clinical diagnosis. Imaging may become useful when the diagnosis is uncertain, symptoms are atypical or the result would genuinely influence management.
Can neck problems cause pain around the elbow?
Yes. Symptoms arising from the cervical spine can sometimes be experienced around the arm or elbow. This is one reason persistent or atypical lateral elbow pain deserves proper clinical assessment rather than automatically being labelled tennis elbow.
Tennis elbow not getting better?
If you have persistent tennis elbow despite rest, exercises or previous treatment, get in touch with Genuine Physio.
A detailed assessment can help establish whether the diagnosis is correct, identify what may be preventing recovery and determine whether rehabilitation has genuinely been optimised.
If imaging, an injection or another opinion is appropriate, that can be considered too.
The aim is not simply to temporarily settle the pain.
It is to understand why it keeps returning and build enough capacity for you to get back to the activities that matter.
Comments