Tennis elbow: what works, what doesn’t and how long it takes

Despite the name, you do not need a racket to get tennis elbow. It is pain on the outside of the elbow, at the point where the forearm muscles that lift your wrist attach to the bone. About 1.3% of adults had it in a Finnish population study, most often between the ages of 45 and 54 [1]. In a US study of diagnosed cases, the people most often affected were office workers and health care workers [2], and the physical therapy guideline notes that many people with it do not play racket sports [3].

It has been linked to handling tools heavier than about 2 pounds (1 kg), and to repetitive arm movements for more than 2 hours a day [4]. And although it is often described as inflammation, the tendon usually shows degeneration or small tears by the time people seek care [3] [14].

How long does it last?

This is the good news: most people get better, but it takes time. A review of 24 trials looked at about 1,000 people who received no active treatment. Symptoms fell by about half every 3 to 4 months, and about 9 in 10 people had improved at one year [5].

“Improved” does not always mean symptom-free, though, and not everyone follows that pattern. The physical therapy guideline notes that many people seeking care still report symptoms after a year [3], and the NHS says it can sometimes last more than a year [15].

What the trials show

In a well-known Australian trial, people with tennis elbow were assigned to physical therapy (8 sessions of elbow manipulation and exercise), a steroid injection, or wait and see [6]:

Share who were “much improved” or “completely recovered”	Wait and see	Steroid injection	Physical therapy
6 weeks	27%	78%	65%
26 weeks	83%	45%	86%
52 weeks	90%	68%	94%

Source: Bisset et al., BMJ, 2006 [6].

The injection worked fast, but the benefit did not last, and symptoms came back far more often in the injection group:

• Steroid injection72%
• Wait and see9%
• Physical therapy8%

Source: Bisset et al., BMJ, 2006 [6].

A later placebo-controlled trial in JAMA confirmed it: at one year, a steroid injection led to worse outcomes than a placebo injection (83% vs. 96% recovered or much improved) and many more recurrences (54% vs. 12%) [7].

What about physical therapy? The honest answer is that it seems to speed up recovery rather than change where you end up. In the JAMA trial, physical therapy gave a clear early benefit, with 39% vs. 10% improved at 4 weeks among people who did not get a steroid injection, but there was no significant difference at one year [7]. A review of 30 trials found low-certainty evidence that exercise beats passive treatments, and the effect is small [8]. For many people, getting better weeks sooner is still well worth it, especially if the pain affects your work.

What the guidelines recommend

The physical therapy guideline’s main recommendations, rated moderate evidence, are [3]:

• Resistance exercises for the wrist extensors, in any form (isometric, concentric or eccentric), on their own or combined with other treatment such as hands-on therapy
• Elbow joint mobilization or manipulation for short-term pain relief and pain-free grip
• Rigid taping for immediate, short-term relief when the elbow is very irritable

A UK guideline agrees that people should be offered physical therapy, along with advice on self-management, and says steroid injections and shockwave therapy should not be used [9]. Guidelines do not always agree: the physical therapy guideline supports dry needling [3], while the UK guideline says there is no evidence it beats a placebo [9].

Braces, injections and surgery

• Forearm straps and braces: evidence for intermediate or long-term relief is conflicting. A strap worn during activity may help with immediate pain, based on expert opinion [3].
• PRP and blood injections: a Cochrane review of 32 studies found they probably provide little or no clinically important benefit over placebo. Success rates were 67% with injection and 65% with placebo at 3 months [10].
• Shockwave therapy: a Cochrane review found little or no benefit for pain and function [11].
• Surgery: a Cochrane review found insufficient evidence to support or refute it [12], and a later review of poor-quality studies found it was no more effective than non-surgical or sham treatment [13]. Surgery is usually considered only if symptoms do not respond to 6 to 12 months of non-surgical care [14].

What you can do now

• Reduce or change the activities that make it worse for a few weeks, rather than stopping everything [14] [15]
• Use a hot or cold pack wrapped in a towel for up to 20 minutes every 2 to 3 hours [15]
• Ask about an anti-inflammatory gel, which may help with pain for up to 4 weeks [9] [15]
• Look at your setup at work: guideline advice includes ergonomic changes and workstation adjustments [3]

See a clinician if you still have pain after at least 2 weeks of self-care [15]. Arm pain can also come from the neck or from nerve compression, which can feel similar, so a proper exam matters [14].

Get urgent care if you have pain or trouble moving your elbow after a fall or injury, a visibly deformed elbow, significant swelling, redness or heat around the elbow with a fever, or a sudden loss of strength or feeling in the arm [16].

The takeaway

• Tennis elbow is not just for tennis players, and it is linked to repetitive and forceful work.
• About 9 in 10 people improve within a year, though recovery can be slow and is not guaranteed.
• Steroid injections help at first but lead to worse results and more relapses over time.
• Physical therapy and resistance exercise help you improve sooner, even if the long-term difference is small.
• PRP, shockwave and surgery have not been shown to beat placebo or sham treatment.

You can start physical therapy in Utah without a referral. If elbow pain is getting in the way of your work, an evaluation can confirm the cause and build a plan that fits your job.