Physiotherapy Treatment for Elbow Pain and Injuries

30. June 2020

physiotherapy treatment for elbow pain and injuries

Physiotherapy is a highly effective, science-based profession that helps restore movement and function for individuals affected by elbow pain and injury.¹ Elbow pain is a uniquely frustrating and disruptive condition. It can manifest as a mild discomfort that only appears during specific activities or, for many, it can escalate into a constant, severe pain that affects sleep.² This pain can make the simplest daily tasks, such as lifting a kettle, gripping a pen, opening a jar, or turning a door handle, feel agonising.² Whether the pain is stopping you from working, enjoying your sport, or simply getting through the day, it is a significant barrier to a normal life.

Introduction: Your First Step to Overcoming Elbow Pain

This report provides an authoritative, in-depth guide to understanding the common causes of elbow pain, navigating the recommended treatment pathways in the UK, and understanding the crucial role of professional physiotherapy treatment in achieving a full, long-term recovery.⁵ This guidance is grounded in the recommendations of leading UK health bodies, including the NHS, the Chartered Society of Physiotherapy (CSP), and the National Institute for Health and Care Excellence (NICE).

As a degree-based healthcare profession, physiotherapy takes a 'whole person' approach to health and well-being.¹ It is not a passive treatment. At its core is the patient's involvement in their own care, achieved through education, awareness, and empowerment to participate in their physiotherapy treatment.¹ A physiotherapist will use their expert knowledge of movement, manual therapy, and exercise prescription to help manage pain, facilitate recovery, and prevent future disease or injury.¹

Understanding Your Elbow Pain: Common Conditions, Causes, and Symptoms

common elbow pain locations Successful treatment of elbow pain always depends on an accurate diagnosis.⁷ A physiotherapist is an expert in diagnosing and treating these joint and muscle problems.⁸ While a wide range of issues can cause elbow pain, including arthritis, trapped nerves, or referred pain from the neck or shoulder ⁹, the vast majority of cases seen in UK clinics fall into three main categories.

The "Outside" Pain: Lateral Epicondylitis (Tennis Elbow)

What it is: Tennis elbow is the most common condition, causing pain and tenderness on the outside of the elbow.² This is where the extensor tendons of the forearm (which pull the wrist backwards) attach to the bone. It is a very common condition, affecting an estimated 1-3% of the population, and is most prevalent in individuals between the ages of 35 and 54.¹¹
Symptoms: The primary symptom is pain on the outside of the elbow, which may be tender to the touch.² The pain can range from mild discomfort to a severe, constant ache that can disrupt sleep.² It is typically made worse by activities that involve gripping, lifting, or twisting the wrist, such as unscrewing a jar lid, lifting a bag, or using a mouse.² You may also experience pain in the forearm, stiffness in the elbow (especially in the morning), or difficulty fully straightening your arm.²
Causes: Despite its name, tennis elbow is not just a sports injury; in fact, most cases are unrelated to tennis.¹¹ It is an overuse or repetitive strain injury (RSI).¹⁴ In the UK, the most common causes are repetitive work-related activities, such as using a mouse and keyboard, decorating, or using manual tools like a screwdriver.² Clinically, it is now understood to be a tendinopathy (a problem of tendon degeneration) rather than a simple "itis" (inflammation).¹⁸ This distinction is critical as it explains why chronic cases do not respond to simple anti-inflammatory medication or rest.

The "Inside" Pain: Medial Epicondylitis (Golfer's Elbow)

What it is: Golfer's elbow is a similar condition to tennis elbow, but it causes pain on the inside bony part of the elbow.³ It is also known as medial epicondyle tendinopathy.³
Symptoms: The condition causes pain and tenderness on the inner elbow, which can spread down the forearm towards the wrist.³ It typically results in difficulty with gripping and twisting movements, particularly those that involve bending the wrist forward.³
Causes: This is also an overuse injury, but it affects the flexor tendons, which are responsible for bending the wrist and fingers.³ It is caused by repetitive or strenuous gripping, lifting, and pulling.³ Like tennis elbow, it is often not related to its namesake sport. Common causes in the UK include D.I.Y., gardening, spring cleaning, or repetitive manual work, as well as prolonged typing.³

The "Point of Elbow" Pain: Olecranon Bursitis

What it is: This condition, sometimes called "student's elbow," is an inflammation of the olecranon bursa, a small, fluid-filled sac that sits over the bony tip of the elbow to act as a cushion.²³
Symptoms: The most obvious symptom is a visible, localised swelling at the very point of the elbow.²³ This swelling is often described as looking like a small, soft golf ball. The area may feel warm, tender, and painful, usually as a dull ache.²³ The pain is often worse when leaning directly on the elbow.
Causes: Olecranon bursitis is typically caused by two main things: a single, hard trauma (like banging the elbow) or, more commonly, "repeated minor trauma".²⁵ This repetitive pressure can come from leaning on a hard desk for long periods, or from professions like gardening or mechanics that involve pressure on the elbows.²⁴
Important Warning: In some cases, the bursa can become infected (septic bursitis). This is a serious medical condition. Signs of infection include the swelling becoming progressively hot, red, and very painful, or if you develop a fever or feel unwell.²⁴ If you suspect an infection, you must seek medical help immediately.

Table: Common Elbow Conditions at a Glance

For a quick reference, this table summarises the key differences to help you identify the likely source of your pain.

Condition (Medical Name)	Common Name	Primary Pain Location	Key Symptoms & Aggravating Activities
Lateral Epicondylitis	Tennis Elbow	Outside of elbow	Pain with gripping, lifting, twisting (e.g., using a mouse, opening a jar) [2, 12, 13]
Medial Epicondylitis	Golfer's Elbow	Inside of elbow	Pain with gripping, lifting, bending wrist forward (e.g., carrying a bag, D.I.Y.) ³
Olecranon Bursitis	Student's Elbow	Point/Tip of the elbow	Visible swelling, warmth, tenderness; pain from direct pressure (e.g., leaning on it) ²³

Initial Management: What You Can Do at Home (NHS & CSP Advice)

For new or mild elbow pain, UK health guidelines from the NHS and CSP recommend a period of self-management before seeking professional physiotherapy treatment.²⁸

Activity Modification (The New "Rest")

A common mistake is to either rest the arm completely or to "push through" the pain. Both can make the problem worse.

Total rest is not recommended. While it may provide temporary relief, it can cause the joint to become stiff and the muscles to become weak, making the problem harder to solve when you return to activity.¹²
The modern advice is "relative rest" or "optimal loading".¹⁶ This means you should aim to "keep active" ¹² but "avoid or reduce activities that make your symptoms worse".² The goal is to find a balance between rest and activity that allows the tissues to settle without deconditioning.

Practical examples of activity modification include:

For Office Workers: Take regular short breaks from typing, ensure your workstation is set up ergonomically, or use an ergonomic mouse instead of a laptop trackpad.⁷
For Athletes/Manual Workers: Try putting a thicker grip on your racquet ⁷, consciously relaxing your grip when lifting or driving ²⁰, or temporarily changing how you lift objects.³

Pain and Inflammation Control

In the early stages, you can manage the discomfort using simple, at-home measures:

Ice or Heat: Applying a hot or cold pack (or a bag of frozen peas) wrapped in a towel to the painful area for 10-20 minutes every few hours can help ease pain.²
Painkillers: Simple pain relief, such as paracetamol or an anti-inflammatory gel (like ibuprofen) rubbed onto the area, can help reduce pain in the short term.² A pharmacist can provide advice on the most appropriate medication.²²
Braces and Straps: Many people find relief by using a forearm strap or an elbow/wrist brace, which can be bought from most pharmacies.² These devices work by "offloading" the affected tendon, reducing the strain on it during daily activities.³¹

Gentle Movement and Exercise

Even in the early stages, it is important to "keep moving".²⁹ Gentle exercises, such as slowly bending and straightening your arm or performing simple wrist stretches, are encouraged to prevent stiffness.²

A key piece of expert advice for any exercise is to manage the pain response. NHS Inform suggests aiming to keep your pain "within a rating of 0 to 5" on a 10-point scale.³² If your pain goes above this level, you are likely doing too much, too soon. You should modify the exercise by "reducing the number of times you do a movement," "reducing the speed," or "increasing rest time".³²

When to See a Physiotherapist

If you have tried these self-management strategies for a period of two to six weeks and your symptoms have not improved, or if the pain is severe from the start, UK guidelines recommend you see a GP or a physiotherapist.² In many areas of the UK, you can self-refer directly to an NHS or private physiotherapy service without needing a GP referral.²⁰

The Core of Recovery: Your Professional Physiotherapy Treatment Plan

Seeking professional physiotherapy is the most important step for persistent or severe elbow pain. The Chartered Society of Physiotherapy (CSP) identifies physiotherapists as the "experts in diagnosing and treating joint and muscle problems".⁸ Your physiotherapy treatment plan will be an active, collaborative process designed to get you back to full function.

The Critical First Step: Diagnosis and Education

Your first appointment will be a thorough assessment. This will involve a detailed discussion about your symptoms, your medical history, and the demands of your work and hobbies, followed by a physical examination.⁸ This allows the physiotherapist to make an accurate diagnosis and identify the specific factors contributing to your problem.

For complex or stubborn cases, an expert physiotherapy clinic may use diagnostic ultrasound.¹¹ This is an advanced application of electro therapy technology. It is important to note this is different from therapeutic ultrasound. Diagnostic ultrasound provides a "real-time view" of the muscles and tendons.³⁵ This allows your clinician to:

Confirm the diagnosis with visual evidence.¹¹
Assess the severity of the tendinopathy.¹¹
Check for underlying tears in the tendon.36

This high-level diagnostic step ensures your physiotherapy treatment plan is perfectly tailored to your specific injury from day one.

The Pillar of Treatment: Therapeutic Exercise

This is the most crucial, evidence-based component of your recovery. A 2017 UK survey found that 81% of consultant surgeons and experienced physiotherapists recommended exercise-based physiotherapy as the first-line intervention for tennis elbow.³⁷ Furthermore, recent UK research, backed by the NHS, has worked to develop an "optimised" physiotherapy package for tennis elbow, which is centred on two key components: detailed patient education and a "structured progressive exercise programme".³⁸

The reason exercise is so central is that tendinopathy is a problem with the tendon's structure.¹⁸ Passive treatments alone cannot fix this. Specific, progressive loading through exercise is the primary stimulus that "supports tissue healing" ³² and tells the body to build new, stronger, and more organised collagen fibres.

Your physiotherapy plan will be graded and will likely progress through three stages ¹⁶:

Isometric Exercises: These involve tensing the forearm muscles without moving the joint. They are often used in the early stages as they can provide significant pain relief.⁴¹
Eccentric Exercises: This is a clinically vital stage. Eccentric exercise involves strengthening the muscle as it lengthens—for example, slowly lowering a small weight or water bottle.²² This type of exercise has been shown to be highly effective for remodelling and strengthening damaged tendons.
Concentric Exercises: This is traditional strengthening, where the muscle shortens as it works—for example, lifting the weight up.³⁰

Hands-On Treatment: Manual Therapy and Soft Tissue Techniques

Manual therapy is not a cure in-itself, but it is a powerful enabler. These hands-on techniques are used to reduce your pain and improve your movement, allowing you to perform your crucial rehabilitation exercises more effectively and comfortably.

High-level clinical practice guidelines recommend the use of "local elbow joint manipulation or mobilization techniques" to "reduce pain and increase pain-free grip strength" in the short term.⁴¹ Your physiotherapist may also work on adjacent areas, as impairments in the neck (cervical spine), mid-back (thoracic spine), or wrist can all contribute to elbow pain.⁴¹

Other hands-on physiotherapy treatment techniques may include soft tissue massage ² or myofascial release. These help to reduce muscle tension in the forearm, promote blood flow, and alleviate discomfort, making the entire rehabilitation process more comfortable.⁴²

The Debate on Injections

This is a critical point of expert, evidence-based care. Many patients who are frustrated with pain ask for a corticosteroid (steroid) injection, hoping for a "quick fix."

However, the evidence from recent clinical trials and the advice from the Chartered Society of Physiotherapy (CSP) is now clear: steroid injections should generally be avoided for tennis or golfer's elbow.⁷

Here is the rationale:

While steroid injections can offer good short-term pain relief (sometimes mentioned on older patient leaflets ²), multiple high-quality studies have shown a significant downside.
In the long term, "it is more likely that the pain will come back and last longer overall" than if no injection was given.⁷
Comparative studies have concluded that physiotherapy, while it may take longer to show results initially, is "superior to corticosteroid injection" in the long term.³⁷

An expert physiotherapist will explain this to you, prioritising the long-term health and resilience of your tendon over a temporary solution that can lead to higher recurrence rates.

Advanced Physiotherapy Treatment for Stubborn, Chronic Elbow Pain

What happens if your pain has been there for six months, a year, or even longer? For those who have tried rest, basic exercises, and other treatments without success, advanced physiotherapy treatment options are available. This is often where specialist private clinics provide significant value for chronic, "refractory" cases.

Focus: Shockwave Therapy (ESWT) for Chronic Tendinopathy

If you are a "chronic sufferer," Extracorporeal Shockwave Therapy (ESWT) is one of the most effective tools available.

What is it? Shockwave therapy is a non-invasive treatment where your physiotherapist uses a special device to pass high-energy acoustic sound waves through the skin to the damaged tendon.⁴⁶
The UK Evidence (NICE): This treatment is supported by the National Institute for Health and Care Excellence (NICE). NICE has issued specific guidance (IPG313) for the use of shockwave therapy for "refractory" tennis elbow.⁴⁶ The word "refractory" is key—it means the condition has failed to respond to conventional conservative management (like rest and basic physiotherapy).⁴⁷ It is an advanced, second-line treatment for pain that just won't go away.³⁷
How it Works: The "shockwaves" are not electrical. They are acoustic pressure waves that are thought to "stimulate healing" ⁴⁶ in tendons that are "stuck" in a chronic, non-healing state. Shockwave therapy can help break down disorganised, scar-like tissue and stimulate the formation of new blood vessels, effectively kick-starting a new healing response.¹¹
The Clinical Picture: While some large-scale academic reviews have shown mixed results ⁴⁸, many clinical trials have found that shockwave therapy can "effectively relieve the pain and functional impairment (loss of grip strength)" caused by tennis elbow.⁴⁹ Patient-reported outcomes are often excellent, with one study showing 93% of patients reporting at least a 50% improvement in pain at one-year follow-up.⁵⁰

A Positive Effect: Case Study

The positive impact of shockwave therapy is best illustrated by a typical patient story, synthesised from UK clinic reports.

The Patient: "Steve," a 48-year-old keen golfer ¹¹, or "David," a 57-year-old who loved playing tennis.⁴
The Problem: He had been suffering from "agonising" elbow pain for over 8 months.¹¹ It started as a "niggle" after changing his equipment (a heavier racket) but slowly became a "constant dull ache".⁴ He was unable to play his sport, and even simple daily tasks like lifting a mug or turning a key were painful.⁴
The Frustration: He was frustrated. He had "tried all the right things"—rest, stretching, and wearing a brace, but nothing helped at all.¹¹ He had even tried exercises from another practitioner, but they "just seem[ed] to make it worse".⁴
The Solution: He sought help from a specialist physiotherapy clinic. After a clear diagnosis of chronic lateral epicondylitis, he was offered a combined physiotherapy treatment plan. Due to the chronic nature of the injury, this plan included three to six sessions of shockwave therapy to kick-start the healing, alongside a new, comprehensive, and progressive exercise programme.⁴
The Outcome: The results were transformative. "Steve" was "pain-free and back on the golf course in under 6 weeks".¹¹ "David" reported his elbow was "ninety percent better" by his sixth session, and a month after his final treatment, "the pain was completely gone".⁴

The Evidence on Electro Therapy: A Modern, Expert Perspective

Patients often ask about "electro therapy," a broad term that usually covers older, more passive treatments.¹⁹ An expert and trustworthy clinic will be transparent about the evidence for these treatments.

The CSP Stance: The Chartered Society of Physiotherapy (CSP), the UK's professional body, is very clear on this. Their guidance states: "Some physiotherapy treatments such as massage, electrotherapy and acupuncture have very little value in treating elbow pain and are not recommended".⁷ The clinical focus in modern physiotherapy has shifted decisively from passive treatments to active rehabilitation (i.e., exercise).
TENS (Transcutaneous Electrical Nerve Stimulation): This involves a small, battery-powered machine that uses sticky pads on the skin to send a mild, tingling electrical current.⁵¹ The theory is that it blocks pain messages from reaching the brain. However, a large UK-based trial published in the BMJ investigated TENS for tennis elbow in primary care and found that adding it to standard advice and exercise "does not provide additional clinical benefits".⁴³
Therapeutic Ultrasound: This must not be confused with shockwave therapy or diagnostic ultrasound. This modality uses sound waves to create "deep heat" in the tissues.⁵³ Older NHS leaflets sometimes listed it as a treatment ², but its "effect remains uncertain" ⁵⁴, and "many therapeutists refuse to use it".⁵⁴ Evidence for its general efficacy is lacking, and it is seldom used in modern, evidence-based UK practice.⁴³

The final word on electro therapy is that while some of these passive modalities might provide very short-term pain relief, they do not fix the underlying tendon problem. Your long-term recovery will be built on the active physiotherapy programme of graded exercise prescribed by your clinician.

Conclusion: Your Long-Term Path Back to Full Function

Elbow pain, whether it stems from a repetitive strain at work, a new D.I.Y. project, or a beloved sport, is a frustrating condition that can severely impact your quality of life. However, it is highly treatable. The path to recovery begins with a clear understanding of your specific condition, followed by initial self-management strategies recommended by the NHS.

If the pain persists, a formal diagnosis from an expert physiotherapist is the most important step you can take. Your recovery will not be based on passive treatments or temporary fixes. Instead, it will be built on a solid, evidence-based foundation of patient education and a progressive, exercise-based physiotherapy treatment programme.³² This active approach is the only proven way to remodel the tendon and build long-term strength.

For those who have endured chronic, stubborn pain for months or even years, there is still hope. Modern physiotherapy offers advanced, evidence-based options like shockwave therapy to finally break the pain cycle and stimulate a new healing response, getting you back to the activities you love.⁴ The ultimate goal of your physiotherapy treatment is not just to make you pain-free; it is to restore full strength, function, and resilience, so you can return to your work, your sport, and your daily life without fear of re-injury.⁴² Empowering you to understand your condition, engage in your recovery, and return to the life you love is the central goal of modern, evidence-based physiotherapy.

Frequently Asked Questions (FAQs)

Q: How much does private physiotherapy treatment for elbow pain cost in the UK?

Private physiotherapy sessions typically cost between £40-80 per appointment, with most elbow pain conditions requiring 4-8 sessions for effective treatment. Some clinics offer package deals or discounted initial assessments.

Q: How long does it take to recover from tennis elbow or golfer's elbow?

Acute cases can improve within 6-12 weeks with proper physiotherapy treatment, while chronic tendinopathy that has persisted for months may take 3-6 months of consistent rehabilitation. Recovery time depends on the severity of the condition and adherence to your exercise programme.

Q: Can I continue working if I have elbow pain?

Yes, most people can continue working with activity modification and ergonomic adjustments, such as taking regular breaks, using supportive equipment, or temporarily adapting how you perform tasks. Your physiotherapist can provide specific workplace advice tailored to your job.

Q: Will I need surgery for my tennis elbow or golfer's elbow?

Surgery is rarely needed, with over 90% of cases successfully treated with conservative physiotherapy treatment and exercise. Surgical intervention is only considered if symptoms persist after 6-12 months of comprehensive non-surgical management.

Q: Do I need a GP referral to see a physiotherapist for elbow pain?

No, many NHS physiotherapy services and all private clinics accept self-referrals, allowing you to book directly without seeing your GP first. However, check your local NHS service or private insurance policy for specific requirements.

Q: How can I prevent elbow pain from coming back after recovery?

Continue with a maintenance exercise programme 2-3 times per week, use proper technique during activities, and gradually progress any increases in training load or work demands. Regular strengthening and ergonomic awareness are key to preventing recurrence.

Q: What should I expect during my first physiotherapy appointment for elbow pain?

Your initial assessment typically lasts 45-60 minutes and includes a detailed discussion of your symptoms, medical history, physical examination, diagnosis, and development of your personalized treatment plan. You'll usually receive your first exercises and hands-on treatment during this session.

Q: Can elbow pain be a sign of something more serious?

While most elbow pain is musculoskeletal and benign, severe pain with numbness, tingling down the arm, sudden swelling with fever, or inability to move the elbow should be assessed urgently as these may indicate nerve compression, infection, or fracture. Your physiotherapist is trained to screen for these red flags.

Q: Is tennis elbow more common in certain age groups or occupations?

Tennis elbow is most prevalent in people aged 35-54 and commonly affects office workers, manual labourers, decorators, and those performing repetitive gripping or computer work. Despite its name, only 5-10% of cases actually occur in tennis players.

Q: What's the difference between a physiotherapist and a sports massage therapist for elbow pain?

Physiotherapists are regulated healthcare professionals with university degrees who can diagnose conditions and prescribe rehabilitation programmes, while sports massage therapists focus on soft tissue treatment but cannot diagnose or provide comprehensive exercise-based treatment. For elbow tendinopathy, a physiotherapist offers the most evidence-based, complete approach.

Q: Does acupuncture work for tennis elbow or golfer's elbow?

Current evidence shows limited benefit for acupuncture in treating elbow tendinopathy, and it is not recommended as a primary treatment by the Chartered Society of Physiotherapy. Exercise-based physiotherapy remains the gold standard first-line treatment.

Q: How should I sleep with elbow pain at night?

Avoid sleeping with your arm bent tightly or under excessive pressure; instead, try supporting your arm on a pillow in a comfortable, slightly bent position. Some people find relief using a soft elbow support or brace at night to prevent unconscious over-flexion.

Q: Can I use a TENS machine at home for elbow pain?

While TENS machines are safe to use and may provide short-term pain relief, research shows they don't provide additional clinical benefits for tennis elbow beyond standard treatment and exercise. Focus your efforts on the active rehabilitation exercises prescribed by your physiotherapist.

Q: What's the difference between diagnostic ultrasound and therapeutic ultrasound for elbow pain?

Diagnostic ultrasound is an imaging tool used to visualize tendons and confirm diagnosis, while therapeutic ultrasound is a treatment modality that uses sound waves to create deep heat (though evidence for its effectiveness is limited). These are completely different applications of ultrasound technology.

Q: Are there any exercises I should avoid with tennis elbow or golfer's elbow?

Avoid heavy lifting, forceful gripping, and activities that cause sharp pain (rated above 5/10) until cleared by your physiotherapist. Your rehabilitation programme will gradually reintroduce these movements under controlled, progressive loading.