Jul 17, 20206 min read

Why isn’t my tennis elbow pain getting better?

Updated: Nov 12

So, you’ve read the advice, watched the YouTube videos and been doing all the exercises, but your tennis elbow STILL isn’t getting better. Before you sink into total despair, let me explain a few common reasons why this might be the case and what you can do about it. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.

Why isn't my tennis elbow getting better?

Quick recap on what tennis elbow is

Tennis elbow is that nagging ache on the outside of your elbow that tends to be more bothersome when trying to grip, lift or carry things. Most of the time, it has absolutely nothing to do with playing tennis, which makes the name ‘tennis elbow’ seem slightly daft.

Tennis elbow’ is also known as ‘Lateral elbow tendinopathy’ and this is the term we’ll stick with for now, as this is the up-to-date term for it in the most recent scientific literature – it basically means ‘a problem with the tendons on the outside of the elbow’. For some reason, medical people love to turn simple descriptions half into Latin, but ‘lateral elbow tendinopathy’ does fit the bill better than ‘tennis elbow’.

What do tendons do?

Tendons are there to attach muscles to bone. Many of the muscles in the back of the hand, wrist and forearm all attach via a common tendon to the outside of the elbow on the ‘lateral epicondyle’ – the source of pain in lateral elbow tendinopathy. When you grip, lift or carry things, these muscles are put to work and load the tendon attachment.

Picture showing the wrist extensor muscles and tendons attaching on the lateral elbow.

Why do tendons get irritated?

Like most of the tendon problems that start without any obvious trauma or accident, lateral elbow tendinopathy is usually caused by a mismatch between the load being placed on the tendon versus the load it can consistently cope with.

In real terms, the sudden increase in load might have been from chopping a stack of logs, completing a DIY job, starting a new regime at the gym, or completing a particularly nasty CrossFit WOD.

A sudden increase in any activity that requires gripping, pushing or pulling can lead to lateral elbow tendinopathy.

Sometimes it can be from resuming normal activities but following a period of relative deconditioning – like if you had been out of action for a period of time, and sometimes it can be a more gradual build-up such as a change in job or workstation set up over a period of several months.

Here's a more comprehensive article on the causes of tennis elbow.

How do tendons recover?

The earlier you deal with an irritated tendon the quicker it can recover. Generally speaking, the management of lateral elbow tendinopathy tends to follow the same stages as any other tendon problem:

OFFLOAD – temporarily modify activities so the tendon doesn’t get irritated and has a chance to settle down;
REHAB – address underlying individual biomechanical issues, work out what loads are tolerated without causing an increase in pain and start working on them (this is the bit a physio can be of most help after a thorough assessment);
STRENGTHEN – gradually add resistance to the exercises, strategically progressing the type and amount of loading, working towards your individual goal;
RECONDITION / GRADUAL RETURN TO LOAD – gradual return to the activity that may have caused the overload in the first place, but in much better condition so it doesn’t happen again!

So why isn’t my elbow pain getting better?

OK, so let’s say you know all that already. And it’s STILL HURTING. Here are the most common reasons, in my experience, why lateral elbow tendinopathy can fail to progress:

1. Inadequate offload

Most of the YouTube videos and existing advice for lateral elbow tendinopathy tends to include ‘eccentric’ exercises for the wrist, slowly lowering the hand using a weight or a hammer – if you do these while the tendon is still irritated, this just overloads the tendon even more.

It’s not the fault of the video makers or the leaflet writers, because some of the research on elbow pain suggests these are the exercises to do. BUT, that’s because elbows seem to be rather an unfashionable thing to research, so there really isn’t much good quality research out there. If there was, they would soon see the hammer exercises at the early stages are a bad idea and that giving it time to settle down first is more effective.

When it comes to rehab exercises, timing is important. If you do the wrong exercises at the wrong stage of injury, you usually just make it worse.

2. Over treating

Friction massage, heat balms, freeze rubs, anything that perpetually pokes at a painful tendon is likely to keep it irritated. If you were already angry, wouldn't it make you more irritated if someone kept poking at you? Leave it alone for a bit to let it settle down.

Yes, massage may help reduce pain in ongoing cases, but constantly poking or rubbing the painful part can actually cause it to become more irritated.

3. Forgetting other factors

It’s easy to think ‘elbow, elbow, elbow’ and concentrate only on the bit that hurts. But to get the elbow better, attention also needs to be paid to shoulder stability, core stability, ergonomics at work / in the gym, general fitness, diet, sleep, anxiety / stress, nerve irritation / sensitisation, or other medical conditions.

All of these can contribute to elbow pain and might need addressing in order to get things better.

4. It might just need more time

Unfortunately, a great deal of patience is often required for lateral elbow tendinopathy to get better. And we’re talking 3 to 6 months, if not more, most of the time.

Why does it take so long? Most likely because it is REALLY HARD to offload an elbow tendon that you use every day for simple things, like pouring a kettle, opening doors and having a drink. Tendons are also mainly made up of collagen, and producing and strengthening collagen fibres takes much longer than producing muscle fibres for instance.

So, if your symptoms are slooowly getting better and you find you can do more before it hurts (even though the pain is not gone yet), then it might just need more time.

Tennis elbow recovery takes a long time because it's difficult to rest your arms properly and repairing tendons take much longer than other tissues in the body.

And finally…

When things aren’t getting better, it is important to get a qualified healthcare professional to assess you, whether it is your GP, a physiotherapist or a sports medicine physician. Just in case it isn’t what you thought it was.

It is always worth trying simple treatment and rehab first, before seeking further interventions such as injections, shockwave therapy and surgery. Most of the time the basics, when done correctly, can not only solve the issue but address some of the underlying causes that went with it.

Injections with corticosteroid have more recently been shown to provide short-term benefit, but symptoms tend to be worse in the intermediate term and the long term effects are not yet known.

Research has also shown that Platelet Rich Plasma (PRP) injections have been ineffective in the treatment of persistent lateral elbow tendinopathy.

Another recent clinical trial compared the outcomes for surgery for chronic lateral elbow tendinopathy with ‘sham surgery’ and found that both groups improved and were no different to each other at follow up – suggesting it wasn’t what was done in surgery that helped, it was what they did afterwards during rehabilitation that mattered. Food for thought.

How we can help

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

Learn how online physio diagnosis and treatment works.

About the Author

Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can follow Steph on LinkedIn.

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