Tennis Elbow: What the Research Actually Says (And Why Your Cortisone Plan Might Be Wrong)

Tennis Elbow Is Less About Tennis Than You Think

Most people we see for tennis elbow at our Burlington clinic have never picked up a racquet. They are painters, contractors, hairdressers, pickleball players, gardeners, parents lifting car seats. Tennis elbow (clinicians call it lateral elbow tendinopathy) is a repetitive-load problem at the outside of the elbow, not a sport-specific injury. With pickleball booming across Burlington and racquet sports starting up at outdoor courts in Millcroft and Aldershot, May and June are when we see the spike.

Here is the part that surprises a lot of patients: the research on tennis elbow has shifted significantly over the last decade. A lot of what people are still told (rest, brace it, get a cortisone shot, get an MRI) either does not match the evidence or actually slows recovery down. At Pursuit Physiotherapy, we want to walk you through what current research actually says and how we treat tennis elbow differently because of it.

What Tennis Elbow Actually Is

Tennis elbow is pain at the outside of the elbow, specifically at the bony bump called the lateral epicondyle. This is where the tendons of your wrist extensor muscles attach. The most commonly involved tendon is the extensor carpi radialis brevis, which is one of the muscles that lifts your wrist back.

It is a tendinopathy, not a tendinitis. That distinction matters. The older term "lateral epicondylitis" implied an inflammatory problem, but biopsies of these tendons show very little classic inflammation. What you find instead is a failed healing response: disorganized collagen, increased ground substance, and new blood vessel growth. The tendon has been loaded more than it could adapt to, and the repair did not keep up.

This matters because if it is not inflammation, then anti-inflammatory strategies (ice it, rest it, take a steroid) are not solving the actual problem. Loading the tendon properly is.

What Causes It

Tennis elbow shows up between ages 35 and 65, with the peak around 40 to 50. It often happens to people who:

• Suddenly increase a gripping or wrist activity. Picking up pickleball this spring after a winter of nothing. Starting a renovation project. New job that involves more typing or tool use.

• Have a job that loads the wrist extensors all day. Trades, hairstyling, dental work, manual labour, heavy keyboard and mouse use.

• Play racquet sports with poor technique or equipment. A racquet that is too heavy, strings strung too tight, or hitting the ball off-centre repeatedly all transmit more force into the elbow.

• Have underlying neck or shoulder issues that change how their arm loads through the day.

If you are in Burlington and your tennis elbow started in the last few weeks, ask yourself what changed. The answer is usually a load you were not ready for.

What the Research Actually Says (And Why It Should Change Your Plan)

In one well-known study, 90% of patients who received no active treatment for lateral elbow tendinopathy had either fully recovered or were much improved by 1 year. The condition has a high rate of natural resolution, which means past studies of injections and surgery have likely overestimated their benefit. (Smidt et al., as summarized in Physio Network reviews)

A few key findings from recent literature:

• Heavy slow resistance training works. A randomized controlled trial compared heavy slow resistance exercise alone, heavy slow resistance plus corticosteroid injection, and heavy slow resistance plus tendon needling. All groups improved in the short and long term. The injection and needling added nothing on top of the exercise.

• Cortisone may actually make you worse. In that same trial, the corticosteroid injection group ended up with greater disability than the placebo injection group at long-term follow-up. The short-term pain relief comes with a long-term cost.

• MRI findings are not reliable. A 2024 study found that 37% of completely asymptomatic people had MRI changes consistent with tennis elbow. Imaging can lead to unnecessary procedures because the findings do not always correlate with what is actually causing your pain.

• Manual therapy plus exercise beats exercise alone in the short term. Mobilization with movement combined with eccentric exercise produced significantly bigger improvements in pain and function than eccentric exercise alone over 4 weeks.

[ADD IMAGE HERE — suggested: exercise/treatment shot, e.g. physiotherapist-wrist-hand-assess or a forearm strengthening photo. Alt text: "Heavy slow resistance forearm exercise for tennis elbow at Pursuit Physiotherapy Burlington"]

The takeaway: the strongest evidence supports loading the tendon progressively, supported by hands-on therapy when appropriate, and being patient with the timeline. Quick-fix injections often trade short-term relief for worse outcomes later.

Signs You Have Tennis Elbow (and Signs You Might Not)

Typical tennis elbow looks like:

• Pain at the outside of the elbow, sometimes radiating down the forearm

• Pain or weakness when gripping (coffee cup, doorknob, kettlebell, racquet)

• Pain when lifting an object with the palm down

• Tenderness when you press on the bony bump at the outside of the elbow

• Pain when you resist lifting your wrist back against pressure

When It Might Be Something Else

Not every elbow pain is tennis elbow. Watch for these:

• Numbness or tingling in the fingers can suggest a nerve issue, like radial tunnel syndrome or referred pain from the neck

• Pain on the inside of the elbow is golfer's elbow, not tennis elbow (different tendons)

• Locking, catching, or true loss of motion suggests a joint problem rather than a tendon

• Pain after a fall or trauma needs a different workup to rule out fracture or ligament injury

A proper one-on-one assessment can sort this out quickly. Self-diagnosing through Google can leave you on the wrong treatment path for months.

How We Treat Tennis Elbow at Pursuit Physiotherapy in Burlington

When a patient walks into our Burlington clinic with elbow pain, our approach is built around what the research actually supports:

1. A real assessment first. One-on-one, 60 minutes. We look at the elbow, the wrist, the shoulder, the neck, your grip strength, and your day-to-day loads. Tennis elbow often co-exists with neck or shoulder issues, and treating only the elbow can leave you spinning your wheels.

2. Progressive tendon loading through exercise prescription. Heavy slow resistance, eccentric work, and isometric holds, dosed appropriately for where you are in the recovery. This is the part that actually drives long-term healing.

3. Manual therapy as an adjunct. Mobilization with movement and soft tissue work can help reduce pain in the short term so you can tolerate more loading. The research is clear that this works best when paired with exercise, not as a standalone.

4. Medical acupuncture when appropriate. For some patients, dry needling or acupuncture can help reduce pain and muscle guarding around the elbow and forearm, especially when the symptoms are stubborn.

5. Activity modification, not activity elimination. Telling a pickleball player to just stop playing is rarely the answer. We adjust load, grip, technique, and recovery so you can stay active while the tendon adapts.

Javier Diaz, our physiotherapist and a medical acupuncture instructor at McMaster University, treats a steady stream of tennis elbow cases across Burlington, Waterdown, Hamilton, and Oakville. Many of them have already tried cortisone, bracing, and rest without success. The fix is usually unsexy: a structured loading plan, six to twelve weeks of consistency, and a few adjustments to how the elbow is being used day to day.

What You Can Do Right Now

If you suspect tennis elbow and want to start helping yourself before your appointment, a few reasonable first steps:

• Identify the load that triggered it and dial that back, but do not stop using the arm entirely. Total rest does not rebuild a tendon.

• Try isometric holds: with your elbow bent at 90 degrees, press the back of your hand into the underside of a table and hold for 30 to 45 seconds. Repeat 4 to 5 times. This often gives short-term pain relief and is safe to do regularly.

• If you grip a tool, racquet, or steering wheel for hours, look at how hard you are gripping. A softer grip transmits less force to the tendon.

• Skip the daily ice routine. Cold may feel good, but it does not move the needle on tendon recovery.

• Avoid the urge to chase an MRI or an injection in the first few weeks. The evidence does not support rushing to those for most cases.

When to See a Physiotherapist

Tennis elbow can resolve on its own, but the timeline is often 12 to 24 months without proper management. With a good loading program, most patients see meaningful improvement in 6 to 12 weeks. Worth getting it looked at if:

• The pain has been there more than 4 to 6 weeks and is not improving

• It is affecting your work or your ability to do activities you care about

• You have tried bracing, rest, or over-the-counter anti-inflammatories without progress

• You are being offered a cortisone injection and want to understand your options first

• You have numbness, tingling, or symptoms that do not fit a straightforward tennis elbow picture

If you are dealing with stubborn outer elbow pain and want to do this right the first time, book a one-on-one assessment at Pursuit Physiotherapy. We are located at #201-4125 Upper Middle Road in Burlington. Call us at (905) 331-8993 or book online.

References: Paluch A, et al. (2024) Defining tennis elbow characteristics: the assessment of MRI defined tendon pathology in an asymptomatic population. Shoulder & Elbow. / Stasinopoulos D, et al. Comparison of mobilization with movement and eccentric exercise in lateral elbow tendinopathy. / Heavy slow resistance training plus injection trials for lateral elbow tendinopathy, as reviewed in Physio Network.