Tennis elbow: why it does not go away on its own

You lift a full mug in the kitchen and it stabs through the outside of your elbow. Or you turn a door handle. Tennis elbow rarely introduces itself during tennis: about five per cent of the cases seen in practice are tennis players. The rest of us hold tools, drag a mouse, lift children.

It affects one to three per cent of adults. The name misleads, and not merely as a matter of naming: someone who plays no sport often goes months without considering that this is what it is.

It is not inflammation — and that changes what helps

Its older name, epicondylitis, means inflammation. But when tissue removed in surgery was examined under a microscope, no sign of acute or chronic inflammation was found in it. What happens in the tendon is structural remodelling: at the shared attachment of the wrist and finger extensors, fibres take microscopic damage again and again, and the tissue cannot keep pace with repairing it.

That is why it is now more often called a tendinosis. And it is why ice and anti-inflammatories on their own resolve nothing: they are trying to stop something that is not happening. They do no harm — they simply do not treat the problem.

"How long until it goes away?"

There is no honest short answer, and anyone who offers one has not looked it up.

On one side: up to eighty per cent of cases improve within twelve months, and the literature generally describes it as self-limiting, running its course somewhere between six months and two years.

On the other: of the people who take this complaint to their GP, more than half do not consider themselves recovered a year later.

These do not contradict each other; they measure different people. If it twinges once and you look after it, it will probably settle on its own. If you have got as far as seeing a doctor about it, you are already in the group where it drags on. Waiting is not a strategy at that point, only a delay.

The corticosteroid injection question

This is where most people decide badly — because in the short term the injection works, visibly.

A randomised trial of a hundred and ninety-eight patients split them three ways: corticosteroid injection, physiotherapy, or wait and see. At six weeks the injection group was far ahead. At one year, seventy-two per cent of that same group had the pain back, and their recovery had been delayed.

A second, placebo-controlled trial found the same: worse outcomes at one year, more recurrence, and no improvement from combining it with physiotherapy.

None of this makes the injection forbidden. It means that what you buy with it is a few good weeks, and you pay for them a year later. If someone offers you one, it is worth discussing this — not to argue, but so you know what you are taking on.

What actually helps: load, built up gradually

In that same trial the physiotherapy group did better from six weeks on — and, perhaps more telling, they asked for the least additional treatment. They did not need to reach for painkillers.

The best-documented kind of exercise is eccentric loading: the muscle working while it lengthens. The slow lowering is the point, not the lift. One protocol measured an eighty-one per cent reduction in pain over seven weeks.

Newer reviews temper that, though. What decides the outcome is not whether the exercise is eccentric, concentric or isometric, but whether it is tolerable. A perfect protocol you abandon because it hurts is worse than a simpler one you finish.

Alongside it comes everything that takes load off while the tendon strengthens: a counterforce brace, taping, hands-on work on the overloaded forearm muscles. None of these cure it on their own — they buy time for the loading work.

When it is not tennis elbow

A few things hurt in roughly the same place and need handling differently.

Radial tunnel syndrome is a nerve compression in the forearm. The pain sits a few centimetres lower than tennis elbow does, and tends to be duller and burning.

Referred pain from the neck starts in the spine and shows up in the elbow. Moving the neck changes it.

With wear in the elbow joint itself, bending and straightening, or rotating the forearm, becomes restricted. Tennis elbow does not do that: it hurts, but the elbow still moves fully.

That last one is the easiest difference to check — and it is exactly why every treatment here starts with an assessment. The first question is not what to treat it with, but what it is.

When not to wait

See a doctor first if the pain started after an injury and the arm will not take weight; if the elbow is swollen, hot, or comes with a fever; if there is numbness or weakness in the hand; if the pain wakes you at night; or if nothing has changed after six weeks.

None of these means something is wrong. They mean the question of what it is has to be settled before treatment starts.