Musculoskeletal Conditions
Tennis elbow (lateral epicondylitis) is a common condition affecting 1–3% of the UK population, predominantly adults aged 35–54, and the most effective treatment is progressive exercise-based physiotherapy. According to CK Physio's clinical experience and the 2023 British Elbow and Shoulder Society (BESS) guidelines, structured rehabilitation exercises are strongly recommended as first-line treatment, whilst corticosteroid injections are now advised against due to evidence of poorer long-term outcomes compared to placebo.
Tennis Elbow Treatment: Your Complete Evidence-Based Recovery Guide
Expert physiotherapy guidance backed by the latest UK clinical research and BESS guidelines
If you're experiencing persistent outer elbow pain that worsens with gripping, lifting, or twisting movements, you're not alone. Tennis elbow is one of the most common conditions we treat at CK Physio's West London clinic, and the good news is that most people make a full recovery with the right approach.
What Is Tennis Elbow? Understanding Your Condition
Tennis elbow, clinically known as lateral elbow tendinopathy, is a degenerative condition affecting the tendons that attach your forearm muscles to the bony prominence on the outside of your elbow. Despite its name, only around 5% of cases are actually related to playing tennis—it's far more commonly caused by repetitive workplace activities, computer use, or manual tasks like decorating and gardening.
Modern research has shifted our understanding of this condition significantly. What was once thought to be an inflammatory condition (hence the outdated term "tendinitis") is now understood to be a problem of tendon degeneration. Microscopic examination reveals disorganised collagen fibres and increased blood vessel formation rather than traditional inflammatory cells. This distinction matters because it explains why anti-inflammatory treatments like steroid injections don't work long-term—they don't address the underlying structural problem.
Common Symptoms of Tennis Elbow
- Pain and tenderness on the outside of your elbow
- Pain that radiates down the forearm towards the wrist
- Discomfort that worsens with gripping, lifting, or twisting movements
- Difficulty performing everyday tasks like opening jars, turning door handles, or using a computer mouse
- Weakness in grip strength
- Stiffness in the elbow, particularly first thing in the morning
At CK Physio, we understand how frustrating and debilitating tennis elbow can be when it interferes with your daily activities. The encouraging news is that with proper understanding and treatment, you can take control of your recovery journey.
What Causes Tennis Elbow?
Tennis elbow typically develops from repetitive overuse of the forearm muscles, particularly the extensor carpi radialis brevis (ECRB) muscle that helps stabilise your wrist during gripping. When these muscles are repeatedly stressed beyond their capacity to recover, microscopic damage accumulates in the tendon attachment.
A significant UK study at Royal Derby Hospital examining nearly 5,000 patients identified several key risk factors for developing tennis elbow. Understanding these can help you identify why you may have developed the condition and what changes might prevent recurrence.
| Risk Factor | Increased Risk |
|---|---|
| Rotator cuff problems | 5× more likely |
| Dominant arm involvement | 3× more likely |
| De Quervain's disease (thumb tendinopathy) | 2.5× more likely |
| Manual labour occupation | 2× more likely |
| Carpal tunnel syndrome | 1.5× more likely |
Additional factors include repetitive computer mouse use, increased body mass index, diabetes, and activities involving sustained gripping or twisting movements. If you work in painting and decorating, plumbing, or spend long hours at a computer, you may be at increased risk.
Evidence-Based Treatment: What the Research Shows
The 2023 BESS Patient Care Pathway represents the most current UK evidence-based recommendations for tennis elbow treatment. Using the GRADE methodology to assess evidence quality, these guidelines provide clear direction on which treatments are supported by research and which should be avoided.
Physiotherapy: The Gold Standard Treatment
CK Physio's approach to tennis elbow treatment aligns with the BESS guidelines' strong recommendation for physiotherapy. A comprehensive meta-analysis of over 2,000 patients found that structured exercise therapy outperforms a "wait-and-see" approach for pain reduction and improved function. Crucially, exercise shows clinically significant advantages in pain-free grip strength at short, medium, and long-term follow-up.
Exercise therapy works by stimulating proper collagen remodelling in the damaged tendon. Unlike passive treatments, progressive loading tells your body to build new, stronger, and more organised tendon fibres. This is why physiotherapy treatment remains the cornerstone of effective tennis elbow rehabilitation.
Why Steroid Injections Are No Longer Recommended
One of the most significant shifts in tennis elbow treatment has been the move away from corticosteroid injections. The 2023 BESS guidelines provide a strong recommendation against their use, based on compelling evidence that whilst they may provide short-term relief (4–6 weeks), outcomes become worse than placebo at 6 weeks to 6 months, with high recurrence rates and no long-term benefit.
This represents an important change from historical practice. If you've been considering or have been offered a steroid injection, it's worth discussing the current evidence with your healthcare provider.
What About PRP Injections?
Platelet-rich plasma (PRP) therapy has received considerable media attention as a potential treatment for tendon problems. However, a comprehensive 2021 Cochrane review examining 32 studies and over 2,300 participants found no clinically important benefit for pain or function at 3, 6, or 12 months compared to placebo. Pain improved by only 2% (0.16 points on a 0–10 scale), leading researchers to conclude that current data do not support the use of PRP injection for tennis elbow.
Treatment Summary Based on 2023 BESS Guidelines
- ✓ Strongly recommended: Physiotherapy and exercise-based rehabilitation
- ◯ May be used short-term (up to 4 weeks): Topical or oral anti-inflammatory medications
- ◯ Uncertain benefit: Bracing and orthotics
- ✗ Strongly not recommended: Corticosteroid injections
- ✗ Strongly not recommended: Extracorporeal shockwave therapy (for routine use)
Tennis Elbow Exercises: A Phased Approach to Recovery
CK Physio's rehabilitation programmes follow a progressive loading approach, carefully tailored to each patient's stage of recovery. Understanding that every person's tennis elbow is different, we adapt these evidence-based protocols to your specific needs, pain levels, and goals.
Phase 1: Isometric Exercises (For Highly Irritable Tendons)
When your tennis elbow is particularly painful, isometric exercises—where you contract the muscle without moving the joint—provide a safe starting point. Research has shown that isometric loading at moderate intensity can reduce tendon pain immediately and for 45 minutes or more after exercise.
Basic Isometric Exercise
- Make a fist with your affected hand
- Use your other hand to apply gentle pressure downward whilst pushing upward with your fist
- Neither hand should move—you're creating resistance without movement
- Hold for 10–20 seconds initially, progressing to 40–60 seconds
- Repeat 5 times, 2–3 times per day
Progress intensity from 40% to 70% of maximum effort as tolerated
Phase 2: The Tyler Twist Protocol (Eccentric Loading)
Once isometric exercises are comfortable, the Tyler Twist using a FlexBar has become a cornerstone of tennis elbow rehabilitation. A landmark 2010 study found this eccentric exercise programme achieved 81% pain improvement compared to just 22% with standard treatment, alongside a 79% improvement in strength. Average treatment duration was only 7 weeks.
Tyler Twist Technique
- Hold the FlexBar in your affected hand with your wrist bent back (extended)
- Grab the other end with your unaffected hand
- Twist the FlexBar using your unaffected wrist whilst keeping your affected wrist extended
- Bring your arms out in front with elbows straight, maintaining the twist
- Slowly allow the FlexBar to untwist—this is the eccentric contraction that works your affected wrist extensors
Dosage: 3 sets of 15 repetitions, once daily, 4 seconds per repetition
Phase 3: Heavy Slow Resistance Training
For those progressing well, heavy slow resistance (HSR) training shows evidence equal to eccentric training at 12-month follow-up, with potentially better collagen turnover due to the high load with minimal shock loading. This phase typically involves loading at around 6-repetition maximum intensity, performed 3 times per week for a minimum of 12 weeks to allow sufficient time for tendon adaptation.
Pain Monitoring During Exercise
Understanding how to monitor pain during rehabilitation is crucial for successful recovery. At CK Physio, we use a traffic light system to help patients gauge their exercise intensity:
- Green zone (0–3/10 pain): Safe to continue
- Amber zone (4–5/10 pain): Proceed with caution
- Red zone (above 6/10 pain): Reduce intensity
Importantly, exercise discomfort should settle within 20–30 minutes after finishing. If soreness persists beyond 48 hours, reduce the load at your next session. This guidance helps ensure you're challenging the tendon sufficiently to promote healing without causing further damage.
Shockwave Therapy for Chronic Tennis Elbow
Whilst the 2023 BESS guidelines recommend against routine use of extracorporeal shockwave therapy (ESWT), the picture is more nuanced for chronic, treatment-resistant cases. A November 2024 meta-analysis comparing ESWT to corticosteroid injections found that whilst shockwave therapy showed slower initial response at one month, it demonstrated superior outcomes at 3 and 6 months.
The National Institute for Health and Care Excellence (NICE) guidance states that evidence on ESWT for refractory tennis elbow raises no major safety concerns, though current evidence on efficacy is inconsistent. At CK Physio, we offer focused shockwave therapy for appropriate cases—typically those where symptoms have persisted despite 3–6 months of exercise-based treatment.
It's worth noting that focused shockwave therapy (which CK Physio uses) delivers energy more precisely to deeper tissue layers compared to radial shockwave therapy, making it potentially more effective for stubborn tendon problems. A typical treatment course involves 3–6 sessions at weekly intervals.
Learn more about whether shockwave therapy might be right for your condition.
Tennis Elbow Recovery Time: What to Expect
One of the most common questions we hear at CK Physio is "How long will this take to heal?" Whilst every person's recovery is different, research provides helpful guidance on typical timelines.
| Timeframe | Expected Progress |
|---|---|
| 6–8 weeks | Begin noticing improvement with consistent exercise |
| 3–4 months | 50% probability of significant improvement |
| 6 months | Most people show marked improvement |
| 12 months | 80–90% achieve complete or near-complete recovery |
| Up to 24 months | Full resolution in remaining cases |
A key research finding from a 2022 meta-analysis is particularly encouraging: pain and disability tend to halve approximately every 3–4 months, and symptom duration before treatment does not negatively affect prognosis. This means that even if you've had tennis elbow for a long time, you're just as likely to recover as someone with a recent onset.
The recurrence rate is approximately 8.5% within 2 years, which underscores the importance of completing your rehabilitation programme and making any necessary lifestyle modifications to prevent the problem returning.
Self-Management: What You Can Do at Home
Whilst professional physiotherapy guidance ensures you're on the right track, there's much you can do at home to support your recovery.
✓ Do
- Keep your elbow moving—avoid complete rest beyond a few days
- Lift objects with palms facing upward to reduce strain
- Use larger handles on tools and utensils
- Take regular short breaks from repetitive activities
- Pace activities—break tasks into smaller portions with rest periods
✗ Avoid
- Repetitive twisting movements where possible
- Sustained gripping activities
- Palm-down lifting (this puts more stress on the affected tendons)
- Pushing through severe pain
Workplace Ergonomics for Computer Users
If your tennis elbow is related to desk work, these adjustments can make a significant difference:
- Position your keyboard and mouse at elbow height (90-degree angle at the elbow)
- Keep your mouse close to your keyboard to maintain a neutral arm position
- Consider an ergonomic or vertical mouse for a more neutral wrist position
- Use armrests that slightly support your arms
- Take breaks every 30–60 minutes to move and stretch
When to Seek Professional Help
Whilst many cases of tennis elbow improve with self-management, certain situations warrant professional assessment. Consider booking an appointment at CK Physio if:
- Pain persists despite 6–12 weeks of self-management
- Your symptoms are progressively worsening
- The condition is significantly affecting your work or daily activities
- You're unable to move your elbow normally
- Over-the-counter medications aren't providing relief
Seek Urgent Medical Attention If You Experience:
- Hot, red, or swollen skin over your elbow
- Fever, unusual tiredness, or unexplained weight loss
- Pins and needles or numbness in your arm
- Inability to move your arm following an injury
- Multiple joints becoming painful (possible inflammatory arthritis)
Frequently Asked Questions
How long does tennis elbow take to heal?
Most people with tennis elbow recover within 6 to 24 months, with 80–90% achieving complete or near-complete recovery by 12 months. With consistent exercise-based rehabilitation guided by a physiotherapist, many patients notice improvement within 6–8 weeks. The key is maintaining your exercise programme even after symptoms begin to improve.
Should I rest my arm completely with tennis elbow?
Complete rest is not recommended beyond the first few days. Current evidence strongly supports continued movement and progressive loading through targeted exercises. Rest alone doesn't address the underlying tendon degeneration—controlled loading is what stimulates the tendon to repair and strengthen. However, you should modify or temporarily avoid activities that significantly aggravate your symptoms.
Is tennis elbow serious?
Tennis elbow is not a dangerous condition and won't cause lasting damage to your arm. However, it can be quite debilitating when it interferes with daily activities and work. The condition is self-limiting, meaning it will eventually resolve, but active treatment with physiotherapy can significantly speed up recovery and reduce the impact on your quality of life.
Can I still play tennis or golf with tennis elbow?
This depends on your pain levels. If playing causes significant pain during or after the activity, you may need to take a break or modify your technique. CK Physio can help assess your readiness to return to sport and provide specific advice on grip technique, equipment modifications, and graduated return-to-play programmes. Many patients find that adjusting racquet grip size, string tension, or technique allows them to continue playing with modifications.
Does NHS physiotherapy cover tennis elbow treatment?
Yes, NHS physiotherapy services can treat tennis elbow, and you may be able to self-refer to local NHS musculoskeletal services without needing a GP referral. However, waiting times can be lengthy. Private physiotherapy at CK Physio offers quicker access to treatment, typically with appointments available within a few days, allowing you to start your rehabilitation sooner.
Ready to Start Your Recovery?
CK Physio's Chartered Physiotherapists are here to help you overcome tennis elbow and get back to the activities you love. Our Hanwell clinic offers convenient appointments and evidence-based treatment.
Book Your AppointmentReferences and Further Reading
- Singh HP, et al. (2023) BESS patient care pathway: Tennis elbow. Shoulder & Elbow, 15(4), 348-359. Read the full guideline
- NHS UK (2024) Tennis Elbow – NHS. www.nhs.uk/conditions/tennis-elbow
- British Elbow and Shoulder Society (2023) Tennis Elbow Information and Exercise Videos. bess.ac.uk/tennis-elbow
- NICE (2009) IPG313: Extracorporeal shockwave therapy for refractory tennis elbow. www.nice.org.uk/guidance/ipg313
- Chartered Society of Physiotherapy (2024) Elbow Pain Treatment. www.csp.org.uk/conditions/elbow-pain
- Tyler TF, et al. (2010) Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis. Journal of Shoulder and Elbow Surgery, 19(6), 917-922. Read the study
- Cochrane (2024) Manual therapy and exercise for lateral elbow pain. Cochrane review
- NHS Lanarkshire (2024) Tennis Elbow – Physiotherapy MSK. nhslanarkshire.scot.nhs.uk
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