There’s a pattern with tennis elbow that plays out often enough to be predictable.
The elbow has hurt for a few months. Gripping is the problem — a kettle, a door handle, a laptop bag. Eventually someone offers a steroid injection.
It works. Within a fortnight the elbow feels transformed. Relief, and a sense that the problem is solved.
Then, somewhere between two and six months later, it comes back. Often worse. And the second injection doesn’t do what the first one did.
For a long time this was treated as bad luck. In 2013 a trial published in JAMA offered a considerably less comfortable explanation, and it’s worth understanding properly — because it changed what good practice looks like, and a lot of people still haven’t been told.
The Trial
Coombes, Bisset, Vicenzino and colleagues at the University of Queensland recruited 165 adults with tennis elbow on one side, recruited between 2008 and 2010. These weren’t acute cases — the median duration of symptoms before treatment was around 16 weeks.
Participants were randomised into four groups:
Corticosteroid injection alone. Placebo injection alone. Corticosteroid injection plus physiotherapy. Placebo injection plus physiotherapy.
That design matters. The placebo injection arms mean the trial could separate the genuine effect of the steroid from the effect of simply having something done. And the combination arms tested a common clinical assumption — that adding physiotherapy would offset the known problem with injections.
Everyone was followed for a full year.
The Short Term
The steroid did what steroids do. Pain dropped, and it dropped early — meaningful relief within weeks.
If the trial had stopped at six or eight weeks, as many trials do, the conclusion would have been that corticosteroid injection is an effective treatment for tennis elbow. That’s roughly what earlier short-horizon studies had found, and it’s why the injection became a standard offering.
The One-Year Results
At twelve months, the picture inverted.
Complete recovery or much improved: 83% in the corticosteroid group, compared with 96% in the placebo injection group.
Recurrence: 54% in the corticosteroid group, compared with 12% in the placebo group.
Read that second line again. More than half the people who received a steroid injection had their problem return, against roughly one in eight of those who received salt water.
The people given a placebo injection did better at a year than the people given the active drug.
Why It Reverses
The explanation lies in the name, and specifically in the “-itis” that shouldn’t be there.
Tennis elbow was long assumed to be an inflammatory condition — lateral epicondylitis. When the tissue is actually examined, particularly in longer-standing cases, what’s found isn’t primarily inflammation. It’s a degenerative change in the tendon: disorganised collagen, altered structure, and a tissue that has lost its capacity to tolerate the load being placed on it. Many clinicians now use lateral epicondylalgia or lateral elbow tendinopathy for exactly this reason.
Corticosteroids are very effective at suppressing inflammatory signalling. If inflammation isn’t the underlying problem, that’s an intervention aimed at the wrong target.
Worse, there’s a cost. Corticosteroids have been shown to reduce the tensile strength of collagen fascicles. So the injection is thought to be dampening a process that wasn’t driving the problem, while further weakening a tendon whose collagen matrix was already disordered.
Short-term relief, purchased against the structure of the tendon.
The Part That Matters Most
Buried in the same trial is the finding that should get more attention than the headline.
In the group that received physiotherapy without the corticosteroid, outcomes at one year were 100% complete recovery or much improvement, with a recurrence rate of 4.9% — the lowest of any arm in the study.
Physiotherapy alone also produced short-term benefit across all outcomes.
The other half of that finding is worth reporting honestly, because it’s less flattering: adding physiotherapy to a corticosteroid injection did not rescue the poor long-term outcome. The researchers had hypothesised it would, and it didn’t. Combining the two doesn’t give you the best of both — the injection appears to undermine what follows.
What This Doesn’t Mean
It doesn’t mean injections are never appropriate. There are situations — severe pain preventing sleep or work, a specific short-term deadline, a case where nothing else has been tolerable — where a clinician and patient may reasonably decide the short-term relief is worth the trade-off. That’s a judgement to make with full information rather than a blanket rule.
It doesn’t mean you should refuse an injection you’ve been offered. It means the conversation is worth having: what does this do in the short term, what does the evidence say at a year, and what’s the plan for the period after it wears off?
And it doesn’t mean physiotherapy is a guaranteed fix. It means loading the tendon appropriately outperformed the alternative substantially over the timeframe that matters.
So What Does Work?
If the problem is a tendon that has lost load tolerance, the treatment is to rebuild that tolerance progressively.
Progressive loading of the wrist extensors and the grip. Programmes typically begin with isometric holds where symptoms are irritable, progress into controlled slow strengthening, and build towards the demands you actually need — gripping, lifting, rotating.
Load management alongside it. Loading raises the tendon’s ceiling; reducing provocative demand lowers what’s hitting it. Both together work considerably better than either alone. That means looking honestly at what changed in the weeks before it started — a DIY project, a new job task, a change in equipment, more time at a keyboard or on tools.
Looking beyond the elbow. Grip strength, shoulder and scapular control, and sometimes the neck all contribute. Symptoms that include tingling, numbness, or pain further down the forearm particularly warrant a wider assessment.
A brace or strap, which some people find genuinely useful for symptom control. Reasonable as a support during the rebuilding; not a treatment on its own.
Patience. Tendon tissue adapts slowly. Meaningful change is measured across months, not weeks, and the most common reason a loading programme fails is that it was abandoned at week five when symptoms first eased.
Most Cases Have Nothing to Do With Tennis
Worth saying, because the name misleads. The large majority of people with this condition don’t play racquet sports. It shows up in tradespeople, in office workers, in gardeners, in new parents lifting a growing baby, and in anyone who took on an unaccustomed amount of gripping over a few weeks.
That matters for treatment, because the aggravating load is usually something in daily life rather than a sport you could simply pause.
When It Isn’t Tennis Elbow
Not all lateral elbow pain is tendinopathy. Get it assessed rather than self-treating if you have:
Numbness, tingling or weakness in the hand or forearm. Pain further down the forearm than the elbow itself. Neck pain or symptoms radiating from the neck. An elbow that locks, catches or won’t fully straighten. Significant swelling, redness or warmth. Pain following a fall or direct injury. Night pain that’s severe and unrelenting. Elbow pain alongside fever or feeling generally unwell.
Several conditions mimic tennis elbow closely, and treating the wrong one is a common reason people stall for months.
The Practical Summary
An injection can make you feel considerably better within a fortnight and leave you more likely to be dealing with this a year from now. In the trial, salt water outperformed it at twelve months, and physiotherapy without any injection produced the best outcomes of all.
If that’s news to you, it’s worth a conversation before the needle rather than after.
Get a Proper Plan Instead
A loading programme only works if it’s the right diagnosis, the right starting point and the right progression — and if someone helps you keep going through the months where progress is quiet.
Body Zest offers a free discovery visit at no cost and no obligation. You’ll get a thorough assessment of your elbow, grip, shoulder and neck, confirmation of what you’re actually dealing with, and a realistic plan with an honest timeline.
If your presentation suggests something other than tendinopathy, or warrants a medical opinion, we’ll tell you plainly.