Tennis Elbow: Which Treatments Work Best?

Tennis elbow, also called lateral elbow tendinopathy or lateral epicondylalgia, causes pain on the outside of the elbow. It usually develops when the wrist-extensor tendons are loaded, by gripping, lifting, twisting or repetitive work, faster than they can adapt. Despite the name, persistent tennis elbow isn't simply inflammation, it's better understood as a load-related tendon problem, so the treatments that work best over time modify the load and gradually rebuild the tendon's strength, rather than relying on injections. It affects racquet-sport players, but repetitive gripping, manual work and computer use are just as common triggers.

What is tennis elbow?

Tennis elbow affects the wrist-extensor tendons, where the muscles that straighten the wrist and fingers attach to the bony bump on the outside of the elbow (the lateral epicondyle). When these tendons are loaded repeatedly, faster than they can recover, the tendon's structure and capacity change and it becomes painful. Because the underlying problem is a loss of tendon capacity rather than active inflammation, the most effective long-term treatment is the one that steadily rebuilds the tendon's tolerance to load.

Symptoms and diagnosis

Symptoms may include:

• pain or tenderness on the outside of the elbow;
• pain when gripping, lifting or twisting;
• discomfort straightening the wrist against resistance;
• reduced grip strength;
• pain when pouring a kettle, opening a jar or carrying a bag.

The diagnosis is normally clinical. Ultrasound or other imaging isn't routinely needed, but can help when the diagnosis is uncertain, symptoms are persistent, or an image-guided procedure is being considered. It's also worth remembering that neck problems, radial-nerve irritation, elbow-joint disease and tendon tears can occasionally produce similar symptoms, which is why a careful assessment matters.

Best initial treatment

1. Activity modification

Complete rest is rarely necessary. The aim is to temporarily reduce the activities that repeatedly aggravate the tendon while keeping comfortable movement. Helpful adjustments include reducing forceful or repetitive gripping, lifting with the palm facing up where practical, using two hands for heavier objects, increasing the size of tool or racquet handles, reviewing racquet tension, technique or workplace ergonomics, and taking short breaks during repetitive tasks. Activities are then built back up gradually as pain and strength improve.

2. Progressive exercise

A graded strengthening programme is usually the foundation of rehabilitation, targeting wrist extension, forearm rotation, grip strength, elbow and shoulder strength, and control of the shoulder blade and upper limb. Isometric exercises can help when the elbow is particularly irritable, progressing to slow resistance work and then faster or activity-specific loading when appropriate. Exercise should be challenging but tolerable, mild discomfort during treatment can be acceptable if it settles reasonably quickly and doesn't cause a substantial flare the next day.

The evidence here is less certain than is sometimes suggested. A 2024 Cochrane review found that manual therapy and exercise may give small short-term improvements, but the evidence was low-certainty and the average benefit may not be clinically important. Even so, graded rehabilitation remains a practical, low-risk way to restore the tendon's ability to cope with work, sport and daily activity.

For a clear set of exercises you can start at home, the British Elbow and Shoulder Society (BESS) tennis elbow exercise guide is a useful, reputable starting point. It works best alongside an individual assessment, so the load and progression are matched to your stage.

Evidence: low-certainty benefit, but a sensible, low-risk foundation

3. Bracing

A counterforce strap worn just below the painful area, or a wrist-support splint, can reduce discomfort during selected activities. A brace doesn't heal the tendon and shouldn't replace rehabilitation, it's best used as a temporary aid when it makes essential activities more comfortable.

4. Pain medication

A topical anti-inflammatory gel may be appropriate. Oral anti-inflammatories can help some people for a short period, but need caution with kidney disease, stomach-ulcer risk, cardiovascular disease or certain other conditions. Medication is best used to support movement and rehabilitation, not as the only treatment.

Are corticosteroid injections helpful?

A corticosteroid injection can reduce pain quickly, but the improvement is often temporary, and there's an important catch. A high-quality randomised trial published in JAMA found worse outcomes at one year and more recurrence after corticosteroid injection than after a placebo injection (Coombes et al., 2013). For that reason, steroid injection is no longer the preferred routine treatment for persistent tennis elbow. It may occasionally be discussed when short-term pain relief is particularly important, but only alongside a clear explanation of the likelihood of recurrence and the local risks, which include temporary post-injection pain, skin thinning or loss of pigment, fat atrophy, uncommonly infection, and tendon weakening or injury (particularly with repeated exposure or injection into the tendon). Repeated steroid injections are generally avoided.

Evidence: quick relief but worse one-year outcomes and more recurrence, so not first-line

What about PRP?

Platelet-rich plasma (PRP) is prepared from a sample of your own blood and injected around the affected tendon. Recent reviews suggest a fairly consistent pattern: corticosteroid tends to do better in the first few weeks, while PRP may give better pain and disability scores by around six months, reported in a 2024 meta-analysis of 11 randomised trials and an earlier 2023 systematic review. However, these studies used different PRP products, injection techniques and rehabilitation programmes, many carried a substantial risk of bias, and doing better than corticosteroid doesn't prove PRP beats a placebo procedure. PRP can therefore be considered a specialist option for persistent symptoms, but not a guaranteed cure.

Autologous whole-blood injection is another blood-derived treatment, less processed than PRP and studied even less consistently. The current evidence doesn't establish a clear advantage over structured rehabilitation or other injections. I should also be clear that I don't currently offer PRP or autologous blood injection at Insight MSK; I've included them here so you have the full picture.

Evidence: PRP may help at 6 months, but heterogeneous and not a guaranteed cure

Does ultrasound guidance improve an injection?

Ultrasound lets me examine the tendon, identify a significant tear or an alternative diagnosis, and place a needle accurately while avoiding nearby structures. Being honest, though, greater accuracy doesn't automatically produce a better clinical result, a randomised trial comparing ultrasound-guided with palpation-guided corticosteroid injection found no significant difference in pain or function. Ultrasound guidance is most useful when the diagnosis is uncertain, a tear or another cause of pain is suspected, previous treatment has failed, a needle fenestration or other targeted procedure is planned, or it's especially important to avoid nearby nerves or blood vessels.

Needle fenestration and tenotomy

Needle fenestration involves repeatedly passing a needle through the abnormal part of the tendon; percutaneous tenotomy uses a needle or a specialised device to remove or disrupt abnormal tendon tissue. These are sometimes offered for persistent tendinopathy, but the studies are generally small and use different techniques, and it's uncertain how much improvement comes from the procedure itself, the accompanying injection, or the rehabilitation that follows. They're best regarded as specialist options rather than routine first-line treatment.

Evidence: limited, specialist options for selected cases

When is surgery considered?

Most people don't need surgery. A surgical opinion may be appropriate when substantial pain and functional limitation persist despite a well-delivered non-operative programme and the diagnosis has been carefully reviewed. Surgery may involve removing abnormal tendon tissue and repairing the tendon attachment. Recovery takes several months and needs rehabilitation, and the potential benefits should be weighed against stiffness, nerve injury, infection, persistent symptoms and the possibility that surgery may not fully restore strength.

Evidence: reserved for persistent, function-limiting symptoms after thorough conservative care

Recommended treatment pathway

A practical sequence looks like this:

1. Confirm the diagnosis and exclude nerve, neck or elbow-joint problems.
2. Modify aggravating activity without completely resting the arm.
3. Begin progressive wrist, grip, elbow and shoulder strengthening.
4. Consider a brace or topical pain medication for short-term symptom control.
5. Review the diagnosis and rehabilitation programme if improvement is limited.
6. Discuss the uncertainties and risks before considering PRP, fenestration or another procedure.
7. Reserve surgery for persistent, function-limiting symptoms after comprehensive non-operative care.

When should you seek further assessment?

Key message

Frequently asked questions

References