Tennis elbow is pain over the bony point on the outside of the elbow, caused by a rise in load through the tendons that lift the wrist. Past the first few weeks it is no longer an inflammation but a weakened, disorganised tendon, and that changes the treatment completely: it responds to graded loading, not to rest.
Two words in the everyday name are wrong, and both of them cost people months. Fewer than one case in ten involves a racquet. And the “itis” ending describes a process that, in most of the elbows that reach a clinic, finished long ago.
What is actually hurting
On the outside of the elbow there is a bony ridge called the lateral epicondyle. It is the anchor point for the tendons of the muscles that lift the wrist and open the fingers. One of them, extensor carpi radialis brevis, is involved in the great majority of cases.
The pain is remarkably precise. It sits over an area about the size of a thumbnail and it lights up when you grip something: lifting a full mug, turning a key, opening a jar, shaking hands. It can travel down the forearm, but the centre of it does not move.
It is a common problem rather than an exotic one: between 1 and 3 per cent of adults get it in any given year, most often between the ages of 40 and 60, and usually in the dominant arm.
That precision is diagnostically useful. Diffuse pain across the whole joint, pain that wanders, or an elbow that is swollen, hot and red is not tennis elbow. Those are different conditions and they need looking at. A broad, burning ache spread over the forearm that eases once you have been moving for ten minutes belongs to the fascia rather than to this tendon.
Outside or inside? The thirty-second test
Hold the affected arm straight out in front of you, palm facing the floor. Ask someone to press down on the back of your hand while you lift your wrist against them. Pain on the outside of the elbow is tennis elbow, or lateral epicondylalgia if you want the term your physiotherapist will use.
Now do the reverse. Palm facing up, bend the wrist towards you against resistance. Pain on the inside of the elbow points to golfer’s elbow instead. It is seven to ten times less common, and the exercises for it are the mirror image, so getting this right at the start saves twelve weeks of the wrong programme.
What is mistaken for tennis elbow
The question comes up so often that Google puts it in the People Also Ask box. Three near neighbours are worth knowing about, because each one changes what you should do.
Radial tunnel syndrome. The radial nerve is squeezed a few centimetres below the elbow. The ache is duller, sits further down the forearm, and there is no single point that makes you flinch when pressed. Loading exercises do not help it.
Referred pain from the neck. An irritated nerve root in the lower neck can send pain into the outer forearm. The giveaway is that neck movements change it, and that pins and needles come with it.
Inflammatory joint disease. Swelling, warmth, redness, morning stiffness lasting more than half an hour, or the same trouble in several joints at once. That is a reason to see a GP rather than to start exercises.
Why the “itis” ending is the expensive part
When surgeons take tissue from an elbow that has hurt for months, they find almost no inflammatory cells. What they find is collagen laid down in the wrong directions, a thickened tendon, and new blood vessels and nerve endings that have grown into a structure that should have neither. A review in the British Medical Journal argued as far back as 2002 that the profession should drop the word tendinitis and say tendinopathy instead, and the elbow is the most studied example of that shift.
What the name promises against what the tissue shows
What “itis” suggests
- The suffix means inflammation.
- So an anti-inflammatory should settle it.
- So rest should let the inflammation burn out.
- So the sensible plan is to stop and wait.
What surgeons find under the microscope
- Past about six weeks, inflammatory cells are largely absent.
- Collagen fibres are disorganised and the tendon is thickened.
- New blood vessels and nerve endings have grown into it.
- The tendon is not inflamed. It is weakened.
The reference primer on tendinopathy, published in Nature Reviews Disease Primers in 2021, was led from the University of Glasgow by Neal Millar, with Iain McInnes among the authors. That matters for a British reader for a practical reason: the group that put the modern account of tendon disease together is working in Glasgow, and the message from that work is consistent. Past the early phase, you are dealing with a structural problem in the tissue and you fix it by loading it.
The practical consequence is blunt. After around six weeks your elbow is not inflamed, it is degraded, and anti-inflammatory tablets are muting a signal that was protecting you.
What really causes it, and it is rarely the racquet
The movements that cause tennis elbow combine three things: they are repeated a lot, they involve real force, and they hold the wrist out of its natural line, which is the same recipe behind arm tendon problems generally. Whether that happens on a court or at a workbench makes no difference to the tendon.
| Setting | The movement that does the damage | What to change |
|---|---|---|
| Desk work | Mouse used with the wrist cocked upwards, eight hours a day | Forearm supported, mouse close to the body, wrist in line with the forearm |
| Trades and building | Using a screwdriver or drill at arm’s length, carrying loads with the arm extended | Elbow bent, load close to the chest, swap hands on repetitive jobs |
| Kitchens and hairdressing | Hard, repeated gripping with the wrist rotating | Break the task into twenty-minute blocks, lighter tools where the choice exists |
| Garden and DIY | Secateurs, sanding, painting a ceiling, a weekend of hedge cutting | Wide-handled tools, a break every twenty minutes, spread the job over days |
| Gym | Pull-ups and rows with an overhand grip, heavy deadlift holds | Neutral or underhand grip while the elbow settles, straps for heavy holds |
| Tennis and racquet sports | Single-handed backhand, racquet strung too tight, grip too small | Drop the string tension, check the grip size, get the backhand looked at |
Four stages, and why catching it early matters
Tennis elbow does not arrive overnight. It moves through stages you can recognise, and the earlier you act the shorter the whole business is.
Stage one, pain after the activity. It turns up in the evening or the next morning after something unusual, then fades within a day. This is the ideal moment to change the movement, and almost nobody does.
Stage two, pain during the activity. It bothers the movement without stopping it, and settles with rest. Anything requiring force starts to feel awkward.
Stage three, pain that limits you. Shaking hands, lifting a pan, turning a key become difficult. Grip strength drops noticeably.
Stage four, constant pain. Present at rest and disturbing sleep. At this point expect several months of rehabilitation rather than several weeks.
A simple way to place yourself: squeeze a tennis ball hard in each hand and compare. A clear difference between the two sides means you are already at stage three or beyond.
The NHS pathway, and how long it really takes
Most people start with their GP, and that is still sensible if you are unsure of the diagnosis or if any of the warning signs below apply. But in England you no longer have to. Adults can refer themselves directly to community musculoskeletal services in most areas, and by 2024 every adult in England could see a first contact physiotherapist at their own GP practice without a GP appointment first. If your elbow has hurt for more than a few weeks, that is usually the faster route.
The British Elbow and Shoulder Society published a patient care pathway for tennis elbow that sets the expectation clearly: this is managed conservatively, over months, and referral for anything invasive comes late. Waiting times for routine MSK physiotherapy vary widely between trusts, which is one more reason to start the loading work yourself on day one rather than waiting for an appointment to give you permission.
Do book an appointment rather than self-managing if you have any of these: pins and needles, numbness or loss of strength in the hand, a hot swollen joint, pain that began after a fall or a blow, night pain with nothing resting on the elbow, or a grip that gives way without warning and makes you drop things.
The treatment that rebuilds the tendon
The principle was established by Hakan Alfredson in 1998 on the Achilles tendon, and it transferred to the elbow more or less intact: load the tendon progressively instead of protecting it. His fifteen athletes had all failed to improve over an average of eighteen months. All fifteen were back to their previous level after twelve weeks of daily exercises.
The reference exercise for tennis elbow is simple enough to do while the kettle boils. Forearm flat on a table, hand over the edge, palm down, a light weight in the hand. Lift the wrist using your other hand to help, then let it come down on its own, very slowly, over four seconds. It is the braked descent that rebuilds the tendon. Three sets of fifteen, every other day, starting at around 500 g.
For golfer’s elbow, the same exercise turned over: palm up, slow lowering into wrist extension.
The twelve-week loading programme, week by week
WEEKS 1 TO 2, FIND YOUR STARTING WEIGHT
Forearm resting on a table, hand over the edge, palm down, a small weight in the hand. Lift the wrist with your other hand, then lower it on its own over four slow seconds. Three sets of fifteen, every other day. Start at 500 g, or a tin of beans if you have no weights.
WEEKS 3 TO 6, THE PAIN HAS NOT MOVED YET
This is where most people stop, and it is exactly the wrong moment. Tendon tissue responds to load over months, not days. Keep the weight the same and keep the sessions.
WEEKS 6 TO 9, ADD LOAD, NOT REPS
As soon as three sets of fifteen feel comfortable the next morning, add 250 g rather than more repetitions. The tendon adapts to load, not to volume.
WEEKS 9 TO 12, PUT THE GRIP BACK IN
Add gripping work: squeeze a soft ball, carry a shopping bag on that side, wring out a cloth. Grip strength is the last thing to come back and the thing you actually use.
AFTER TWELVE WEEKS, KEEP TWO SESSIONS A WEEK
Stopping altogether is the commonest reason a settled elbow flares again six months later. Two short sessions a week hold the gain.
Give it twelve weeks before you judge it. Noticeable improvement often starts around week six. The people who abandon the programme almost always do so between weeks two and four, when nothing has changed yet, and that is precisely when nothing is supposed to have changed yet.
Steroid injections: excellent at six weeks, worse at one year
This is the section the British search results demand, because “steroid” and “injection” run through every page that ranks for tennis elbow, and because a corticosteroid injection is still frequently offered.
The short-term effect is genuine and large. A randomised trial of 198 patients aged 18 to 65, published in the BMJ in 2006, compared injection, physiotherapy and a wait-and-see approach. At 6 weeks the injection group was doing best by a wide margin: 78 per cent rated themselves improved, against 65 per cent with physiotherapy and 27 per cent left alone.
Then the picture inverts. By 52 weeks, 72 per cent of the injected group had relapsed, far more than either of the other two arms, and the physiotherapy group had overtaken them. A second randomised trial published in JAMA in 2013 found the same shape: 96 per cent of participants who had no injection had recovered at one year, against 83 per cent of those who had one, with recurrences roughly four times more frequent after injection.
None of that makes an injection wrong. It makes it a specific tool for a specific job: pain severe enough to stop you sleeping, or severe enough to prevent you starting the exercises at all. The mistake is having the injection instead of the loading programme, which is the combination that leads most reliably to a relapse.
What the other treatments are worth
A support strap. Worn a few centimetres below the sore point, it shifts the pull on the tendon and will ease the pain of gripping for as long as you wear it. Useful for getting through a shift. No effect on healing.
Shockwave therapy. Results are inconsistent for the elbow, better in long-standing cases than in recent ones. Rarely available on the NHS for this condition.
Platelet-rich plasma. Widely marketed privately, and the trial evidence remains weak once you compare it against a properly delivered exercise programme rather than against nothing.
Surgery. Genuinely useful, and genuinely rare. It is for the small proportion who are still limited after a year of conservative treatment carried out properly. “Carried out properly” is doing a lot of work in that sentence: most people who reach a surgeon have never completed twelve consecutive weeks of loading.
Is it a work-related injury?
In France, epicondylitis sits on an official schedule of occupational diseases and can be recognised as one. British readers reasonably assume the same applies here, and it does not, quite. Tennis elbow is not on the list of prescribed diseases for Industrial Injuries Disablement Benefit. Tenosynovitis of the hand or forearm is, as prescribed disease A8, and carpal tunnel syndrome is too, but lateral epicondylitis by itself is not.
That does not leave you without options. Your employer still has duties under health and safety law to assess and reduce repetitive strain at work, occupational health can be asked for a workstation assessment, and a documented pattern of symptoms linked to a specific task is worth putting in writing early rather than after a year. The point is simply not to wait for a benefit decision that is not coming.
Changing the movement, in practice
Correcting the cause beats treating the consequence. Three adjustments cover most desk situations.
Wrist in line. The hand should continue the forearm, neither cocked up nor dropped down. A badly placed wrist rest often makes things worse by lifting the hand.
Forearm supported. Elbow at about ninety degrees, forearm resting on the desk or the armrest. A forearm held in mid-air keeps the extensor muscles working continuously, even when you are not moving.
Mouse close in. Reaching for a distant mouse loads the whole chain. Bring it in, or switch to a vertical model that puts the forearm in a neutral position.
For manual work the principle is splitting the job. Two hours of sanding in one go does more harm than four separate half-hours across a day. A tendon recovers quickly when it is given the chance and very badly under continuous demand.
Where a supplement fits, and where it does not
Nothing you swallow rebuilds collagen. The exercises do that. What a well-formulated anti-inflammatory can reasonably do is make the first weeks tolerable enough that you actually start, and support the background terrain in someone dealing with several irritable tendons at once rather than one.
If that is your situation, the useful question is bioavailability rather than dose on the label: curcumin taken as plain powder is very poorly absorbed, and the difference between a formulation designed for absorption and a cheap capsule is the whole product. Our tendon support formulation was built around that constraint, and the general rationale sits on the bioavailable natural anti-inflammatory page. Neither replaces the twelve weeks.
Frequently asked questions
What is the best cure for tennis elbow?
Progressive loading of the forearm extensor tendons, not rest. The protocol with the best evidence is slow, controlled wrist exercises done every other day for at least twelve weeks. Rest eases the pain while it lasts and leaves the tendon exactly as weak as it was, which is why symptoms return the moment you go back to normal activities.
How do you know if it is tennis elbow?
Press the bony point on the outside of the elbow with your opposite thumb. Tennis elbow is exquisitely tender there, over an area about the size of a thumbnail. Then hold your arm straight out, palm down, and lift your wrist against resistance. Pain on the outside of the elbow during that movement is the classic sign.
What is the primary cause of tennis elbow?
A sudden increase in load on tendons that were not prepared for it. A house move, a weekend of hedge cutting, a new mouse, a heavier tool, a fortnight of decorating. The trigger is almost never the activity in itself, it is the jump in how much of it you did.
What is mistaken for tennis elbow?
Four conditions account for most of the confusion. Golfer’s elbow sits on the inside of the joint rather than the outside. Radial tunnel syndrome causes an aching pain three or four centimetres further down the forearm, with no single tender spot. Referred pain from the neck follows the whole arm rather than one point. And a joint that is swollen, hot and red is not a tendon problem at all.
How long does tennis elbow last?
Left alone, most episodes settle somewhere between six months and two years, and roughly eight or nine people in ten are better within a year. With a loading programme actually carried out, three to six months is the usual figure. The gap between those two numbers is the entire argument for doing the exercises.
Do steroid injections work for tennis elbow?
Very well at six weeks and worse than doing nothing at one year. In a randomised trial published in JAMA, 96 per cent of people who had no injection had recovered at twelve months, against 83 per cent of those who did, and recurrences were four times more common after injection. The short-term relief is real. It is borrowed against the following year.
Does a tennis elbow support strap help?
It helps you get through a working day and it does not speed healing. A strap worn a few centimetres below the painful point shifts where the tendon pulls and takes the edge off during gripping. Treat it as a way to keep working while the loading programme does the actual repair, not as the treatment itself.
What to take away
Do this today: rest your forearm on the table, pick up a small bottle of water, and lower the wrist slowly, three sets of fifteen. Then do it again tomorrow, and for the twelve weeks after that.
And hold on to the one idea that most information about tennis elbow leaves out. After six weeks you are not treating an inflammation, you are rebuilding a weakened tendon, and no anti-inflammatory rebuilds collagen. If you have already had a steroid injection, that is not a disaster. Just do not count on it to spare you the exercises, because that is exactly the combination that brings the pain back.
Sources
Khan K.M., Cook J.L., Kannus P. et al. (2002). Time to abandon the “tendinitis” myth. British Medical Journal, 324(7338), 626-627. DOI: 10.1136/bmj.324.7338.626
Millar N.L., Silbernagel K.G., Thorborg K. et al. (2021). Tendinopathy. Nature Reviews Disease Primers, 7, 1. DOI: 10.1038/s41572-020-00234-1
Alfredson H., Pietila T., Jonsson P., Lorentzon R. (1998). Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. American Journal of Sports Medicine, 26(3), 360-366. DOI: 10.1177/03635465980260030301
Coombes B.K., Bisset L., Brooks P., Khan A., Vicenzino B. (2013). Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA, 309(5), 461-469. DOI: 10.1001/jama.2013.129
Bisset L., Beller E., Jull G., Brooks P., Darnell R., Vicenzino B. (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. British Medical Journal, 333(7575), 939. DOI: 10.1136/bmj.38961.584653.AE
