Why Tennis Elbow Won’t Go Away
- Jonathan Hall
- 9 hours ago
- 16 min read
If your elbow settles with rest but hurts again when you grip, lift or train, the problem may not be that it has “failed to heal”. It may be that the tendon has never regained the capacity you keep asking from it.
There is a particular kind of frustration that comes with tennis elbow. It is rarely dramatic enough to stop life completely. Instead, it quietly interferes with it.
You pick up the kettle and feel the outside of the elbow.
You squeeze a handshake and instinctively reduce your grip.
You return to the gym after giving it a few weeks off, only for the same pain to come back during rows, pull-ups or curls.
The frustrating part is that you may have done exactly what you were told.
You rested it.
You stretched it.
You wore a brace.
You took anti-inflammatory medication.
You may even have had an injection or completed a set of exercises.
And yet the elbow still does not feel like it belongs to you.
So why does tennis elbow sometimes refuse to go away?
The answer is rarely that the body is simply bad at healing.
More often, the problem lies in the relationship between what the tendon can currently tolerate and what life keeps asking it to do.
The Answer in About 30 Seconds
Persistent tennis elbow is usually not explained by inflammation alone.
Longer-standing lateral elbow pain can involve changes within the common extensor tendon, reduced grip capacity, sensitivity of the local tissues, altered motor control and sometimes changes in pain processing. Symptoms can also persist because the tendon repeatedly moves between rest and overload without being progressively rebuilt for the demands of work, training or everyday life.
Progressive resistance exercise remains a central part of rehabilitation. Manual therapy can be used where it helps pain or movement, while shockwave therapy and high-intensity laser therapy are evidence-informed adjuncts that may be considered for selected persistent presentations.
A corticosteroid injection may produce faster short-term relief, but the longer-term picture is less favourable, which is one reason persistent cases are increasingly managed with strategies aimed at restoring capacity rather than repeatedly suppressing symptoms.
That is the short version.
The interesting part is why.
Tennis Elbow Is a Terrible Name for a Useful Diagnosis
Most people with tennis elbow do not play tennis. The condition is more accurately described as lateral elbow tendinopathy or lateral epicondylalgia.
The painful region usually involves the common extensor tendon where the wrist extensor muscles attach to the lateral epicondyle on the outside of the elbow. The extensor carpi radialis brevis is frequently implicated.
These muscles do far more than extend the wrist. They help stabilise the wrist every time you grip something. That means the common extensor tendon is being loaded when you:
lift a frying pan,
hold a drill,
carry shopping,
use gym equipment,
pick up a child,
play racquet sport,
garden,
or simply grip something firmly.
Population research found definite lateral epicondylitis in around 1.3% of adults aged 30 to 64, with the highest prevalence in the 45 to 54 age group. PubMed
It is common.
It is also frequently misunderstood.
It Is Not Simply an Inflamed Tendon
The word epicondylitis implies inflammation.
That description is increasingly recognised as incomplete.
Persistent lateral elbow tendinopathy can involve changes in collagen organisation, tendon structure, local vascularity, motor control and nociceptive processing. The 2022 clinical practice guideline specifically describes an interaction between tendon structural changes, motor-control impairment and altered pain processing rather than reducing the condition to local inflammation alone.
This matters because the treatment strategy changes when the model changes.
If we assume the entire problem is inflammation, the obvious solution is to rest the elbow, take anti-inflammatory medication or inject corticosteroid around the painful region.
Sometimes that reduces pain.
But reduced pain does not necessarily mean the tendon is better prepared for the next heavy day at work or the next pull session in the gym. And that is often where the cycle starts again.
Why Does Tennis Elbow Hurt So Much When You Grip?
This is one of the most common questions patients ask.
The answer lies partly in wrist stability.
When you grip firmly, your finger flexor muscles generate considerable force. The wrist extensors have to stabilise the wrist so that force can be transmitted efficiently through the hand.
That loads the common extensor tendon.
If the tendon and surrounding tissues have become sensitive, a task that appears to involve only the hand can reproduce pain directly at the outside of the elbow.
This is why tennis elbow can make surprisingly ordinary tasks feel disproportionately difficult.
It is also why grip strength is commonly used as part of the clinical assessment and as an outcome measure in research.
The goal is not merely to stop the elbow hurting when somebody presses on it.
It is to restore its ability to help you grip, lift and load again.
Why Rest Often Works, Until It Doesn’t
Rest is seductive because it frequently helps.
Stop gripping.
Stop lifting.
Stop playing.
Give the elbow a few weeks.
Pain decreases.
That can feel like healing. Then normal activity returns and so does the pain.
The problem is that rest can reduce the demand on the tendon without necessarily increasing its capacity.
If the tendon was struggling with the load required for six hours of tool use, three gym sessions a week or repeated lifting at work, a period of complete unloading does not automatically make it better prepared for that same workload.
Sometimes it makes the gap larger.
The clinical challenge is therefore not simply to remove load.
It is to temporarily reduce the load that is aggravating the tendon while progressively rebuilding its ability to tolerate meaningful force.
That distinction is central to modern tendinopathy rehabilitation.
Rehabilitation Can Fail Even When the Exercises Are “Right”
Many people arrive having already performed wrist exercises. That does not necessarily mean rehabilitation has failed. Sometimes the programme never progressed far enough.
A light resistance-band exercise may be appropriate early in recovery. But if your goal is to lift heavy weights, swing a hammer for eight hours or return to competitive sport, that exercise is not the final destination.
Clinical guidelines recommend isometric, concentric and eccentric resisted wrist-extensor exercise for subacute and chronic lateral elbow tendinopathy. They also support a phased return to stress, strength, endurance and task-specific demand.
That progression matters.
Rehabilitation should eventually begin to resemble the life you are returning to.
If work requires sustained grip, you need grip endurance.
If the gym requires heavy pulling, you need progressive pulling capacity.
If tennis is the goal, the tendon ultimately needs to tolerate speed, repeated force and racquet loading.
There is no magic exercise.
There is an appropriate progression.
Sometimes the Problem Is Not Tennis Elbow at All
This is one of the reasons a persistent elbow deserves a proper assessment.
Pain on the outside of the elbow can be produced by more than the common extensor tendon.
Radial tunnel or posterior interosseous nerve irritation
Nerve-related pain can sometimes mimic tennis elbow, particularly when symptoms sit slightly further down the forearm or are accompanied by unusual weakness or sensitivity.
Referred pain from the neck
The cervical spine and peripheral nervous system can occasionally refer symptoms towards the elbow and forearm.
Neck pain, numbness, tingling, altered reflexes or more widespread arm weakness change the clinical picture considerably.
Elbow joint pathology
Joint-related pain becomes more relevant when there is significant stiffness, locking, catching, swelling or loss of normal elbow range.
Significant tendon tearing
A gradual tendinopathy and an acute or substantial tendon tear are not the same condition.
A sudden injury, bruising or marked loss of strength may warrant imaging or further investigation.
This is where an osteopathic assessment has value beyond simply locating the tender spot.
At Movement Mechanics, we examine the elbow within the wider upper-limb system, including the wrist and forearm, shoulder and scapula, cervical region and neurological findings when relevant.
Not because every elbow problem comes from somewhere else.
Because occasionally it does.
What Does Osteopathy Add?
The osteopathic role is not to “put the elbow back in place”.
Nor do we believe every tennis elbow is caused by a spinal misalignment.
The value is in assessing the mechanical environment around the painful tendon and treating clinically relevant findings when they may be limiting movement or rehabilitation.
For example, someone may have:
a painful loss of elbow or wrist movement,
significant forearm muscle guarding,
a shoulder or scapular impairment that affects the task they are trying to return to,
neck-related symptoms requiring differentiation,
or simply enough pain that they cannot tolerate the loading programme they need.
Manual therapy can sometimes provide short-term improvements in pain, movement or grip that make progressive exercise easier to perform. Current guidelines support local and regional joint mobilisation as part of multimodal care when appropriate, while keeping therapeutic exercise central to recovery.
For us, that is where osteopathy fits.
Not instead of tendon rehabilitation.
Alongside it.
When Does Shockwave Therapy Make Sense?
Shockwave therapy becomes particularly relevant when the diagnosis appears sound, symptoms have become persistent and a sensible conservative plan has not moved the problem far enough.
Lateral epicondylopathy is listed by the International Society for Medical Shockwave Treatment as a standard indication for extracorporeal shockwave therapy.
The treatment introduces mechanical energy into the target tissue.
That mechanical input can influence biological signalling through mechanotransduction, with laboratory and experimental research describing effects involving cellular activity, vascular signalling, collagen turnover and pain-related mediators.
The clinical evidence matters more than the mechanism alone.
A randomised study using EMS Swiss DolorClast® radial shockwave treated patients with three weekly sessions alongside physiotherapy. Those receiving real rESWT achieved greater improvements in pain, grip strength and function than the sham-shockwave group over follow-up.
The EMS scientific library continues to list lateral epicondylosis among the conditions supported by Swiss DolorClast® clinical trials.
More recent evidence remains encouraging but nuanced.
A 2024 meta-analysis comparing ESWT with corticosteroid injection found that corticosteroid performed better at one month, but ESWT showed better pain, grip and functional outcomes at three months and better pain and grip outcomes at six months.
A 2026 network meta-analysis involving 938 patients found benefits across several radial and focused ESWT protocols, although the authors also emphasised limitations in the quality and quantity of existing studies.
So is shockwave a miracle cure for tennis elbow?
No.
Is it a reasonable evidence-informed option for selected persistent cases?
Yes.
Radial or Focused Shockwave for Tennis Elbow?
This question gets more attention than it deserves.
The common extensor tendon origin is usually accessible.
That means radial shockwave can deliver an appropriate therapeutic stimulus in many cases and has direct EMS DolorClast® clinical evidence behind it.
Focused shockwave can also be used when the target tissue can be reached and appropriately dosed, we do not consider one technology inherently “better” simply because it is focused.
The choice can instead come down to:
the precise treatment target,
tissue irritability,
patient tolerance,
anatomy,
and the energy-delivery strategy we want to use.
Current comparative evidence does not support a simplistic radial-bad, focused-good hierarchy. The latest network meta-analysis actually found different advantages across different radial and focused protocols depending on outcome and follow-up period.
At Movement Mechanics, we have access to both EMS DolorClast® Radial and Focused Shockwave Therapy.
That means we do not need to force every elbow into the one device we happen to own.
Where High-Power Laser Therapy Fits
Laser therapy acts very differently from shockwave.
Shockwave provides a mechanical stimulus.
Laser provides light energy.
The EMS DolorClast® High-Power Laser used at Movement Mechanics delivers superpulsed 905 nm light. EMS designed the device around high peak power with very short pulse duration, allowing high-energy delivery while limiting thermal accumulation.
For a patient with a highly sensitive elbow, laser can be useful because the immediate goal may not yet be to add more mechanical loading.
It may be to reduce pain sufficiently to make movement, gripping or rehabilitation easier to tolerate.
Clinical research specifically in lateral elbow tendinopathy is increasingly supportive.
A 2025 systematic review of seven randomised trials involving 323 patients found laser therapy and ESWT produced broadly comparable outcomes for pain, grip strength and patient-reported function.
A 2026 meta-analysis comparing high-intensity laser therapy with ESWT found that both treatments improved outcomes and reported some functional advantages for HILT at short- and medium-term follow-up.
There is an important limitation.
Those studies used different laser systems, wavelengths and protocols.
They should not be presented as direct proof that every 905 nm EMS protocol will produce the same outcome.
That is why we treat laser as an evidence-informed clinical tool rather than a marketing promise.
Should Shockwave and Laser Be Used Together?
Sometimes.
Not automatically.
The two modalities provide different physical stimuli.
High-power laser may help reduce pain or tissue irritability and create a better window for loading or treatment tolerance.
Shockwave can then provide mechanical stimulation when that is appropriate for the tendon.
That creates a sensible biological rationale for combination care.
What we do not currently have is strong evidence showing that every patient with tennis elbow does better with a standardised combined laser-plus-shockwave protocol than with either treatment used appropriately on its own.
At Movement Mechanics, combination treatment therefore needs a reason.
If laser has a job, we use it.
If shockwave has a job, we use it.
If the elbow needs neither, we do not add them because they are available.
More technology is not automatically better care.
Better selection is.
Why Did My Cortisone Injection Work, Then Wear Off?
Because pain relief and tendon recovery are not the same outcome.
Corticosteroid injection can provide impressive short-term symptom relief for lateral elbow pain.
That is real.
The difficulty appears later.
A major randomised trial found corticosteroid injection was associated with worse one-year outcomes and substantially greater recurrence than placebo injection.
More recently, the 2024 ESWT-versus-corticosteroid meta-analysis showed the same broad pattern: injections performed better in the early period, while ESWT produced better outcomes later in follow-up.
This does not mean corticosteroid has no place in medicine.
It means the decision should be made with an understanding of the trade-off between rapid symptom relief and the longer-term outcome.
For a persistent tendon problem, getting the pain down quickly is not necessarily the same as rebuilding the arm you need six months from now.
What About PRP?
Platelet-rich plasma is frequently offered for persistent tennis elbow.
The concept is appealing: take autologous blood, concentrate platelet-derived factors and inject them into the affected region.
The research has been less tidy.
Different preparation systems produce materially different PRP products, trials vary in technique and comparator, and evidence has remained inconsistent across reviews.
That does not make PRP invalid.
It does mean “regenerative injection” should not automatically be interpreted as a more advanced or more evidence-based treatment than non-invasive options.
For many patients, it is reasonable to ensure that diagnosis, progressive rehabilitation and appropriate non-invasive adjuncts have been properly explored before moving to an injection.
Does Tennis Elbow Ever Need Surgery?
Yes.
But far fewer patients need surgery than the length of their symptoms sometimes makes them fear.
Surgery is generally reserved for genuinely refractory cases where a prolonged, well-designed conservative pathway has failed and the diagnosis remains clear.
Persistent pain alone does not prove that surgery is necessary.
Before that decision, we would want to know:
Was the diagnosis correct?
Was the tendon progressively loaded?
Was rehabilitation progressed far enough?
Were significant nerve or joint causes excluded?
Was there a meaningful structural tear?
Have appropriate non-invasive treatment options been considered?
Conservative care should never become an excuse to delay surgery when surgery is genuinely indicated.
Equally, surgery should not become the default simply because a painful tendon has existed for a long time.
Do You Need an Ultrasound or MRI?
Usually, straightforward tennis elbow can be diagnosed clinically.
Imaging becomes more useful when the presentation is atypical.
For example:
a significant traumatic onset,
unexpected loss of strength,
persistent swelling,
locking or joint restriction,
neurological symptoms,
concern about a substantial tendon tear,
or symptoms that have not responded as expected despite a well-constructed treatment plan.
Ultrasound can provide useful information about the common extensor tendon, including thickening, structural change, tearing or calcification.
MRI can be appropriate when deeper structural or joint pathology needs to be clarified.
The scan should answer a clinical question.
It should not simply be ordered because pain has existed for a certain number of weeks.
How Do You Know Whether You Are Actually Getting Better?
Pain matters.
But it is not the only outcome worth measuring.
With tennis elbow, useful markers of recovery can include:
grip strength,
pain-free grip,
ability to carry weight,
tolerance to work tasks,
ability to train,
PRTEE or other patient-reported measures,
and how the elbow responds the following day after loading.
The goal is not necessarily zero sensation during every stage of rehabilitation.
The goal is progressively greater capacity with an acceptable response.
A patient who can lift twice as much, work longer and recover normally the following day may be progressing even if the tendon still occasionally reminds them it is there.
Recovery is rarely binary.
When Should You Get Persistent Tennis Elbow Assessed?
If your elbow has been painful for a few days after a one-off increase in activity, it may simply need sensible short-term modification.
If the same problem has been returning for weeks or months, the calculation changes.
Assessment becomes particularly useful when:
the pain repeatedly returns as soon as you increase load,
grip strength is declining,
you have already completed rehabilitation without meaningful progress,
an injection helped briefly but the symptoms returned,
pain is spreading further into the forearm,
you have numbness, tingling or neck symptoms,
or you are beginning to modify work, training or daily life around the elbow.
The earlier objective is not necessarily to start more treatment.
It is to understand what you are actually treating.
What We Do Differently at Movement Mechanics
We are an osteopathic clinic first.
That matters because our starting point is not:
Which machine should we use?
It is:
What appears to be driving this person’s problem, and what does the elbow need next?
Jonathan combines osteopathic assessment with access to the complete EMS DolorClast® clinical range:
alongside progressive rehabilitation and medical acupuncture where appropriate.
For a straightforward persistent common extensor tendinopathy, radial shockwave may be the most logical adjunct.
For another patient, focused treatment may be preferable because of sensitivity or treatment strategy.
A highly reactive elbow may benefit from laser therapy before it is ready for stronger mechanical input.
Another patient may need none of those things and simply require a better loading programme.
The equipment gives us options.
Clinical reasoning decides whether those options matter.
That sits at the centre of our philosophy of Biological Optimisation.
The aim is not to chase symptoms indefinitely.
It is to improve the environment in which the tissue is being asked to adapt, then restore the movement and capacity required for life outside the clinic.
Because Movement Matters™.
Looking for Tennis Elbow Treatment in Auckland?
If your elbow has stopped progressing despite rest, exercise or previous treatment, the next step does not need to be another guess.
Movement Mechanics is based inside Bays Health in Browns Bay on Auckland’s North Shore.
We assess persistent lateral elbow pain, determine whether the presentation is genuinely consistent with tennis elbow and build treatment around the diagnosis rather than the device.
Where clinically appropriate, that may include osteopathic care, EMS DolorClast® Radial or Focused Shockwave Therapy, High-Power Laser Therapy and progressive rehabilitation.
You do not need to decide which treatment you require before booking.
No GP referral required.
Frequently Asked Questions
Is tennis elbow actually inflammation?
Not usually in the simple sense implied by the term “epicondylitis”. Persistent lateral elbow tendinopathy can involve structural tendon change, impaired loading capacity, motor-control changes and altered pain processing. Inflammatory signalling may still be present, but the condition should not be understood as nothing more than an inflamed tendon.
Why does tennis elbow keep coming back?
A common reason is that pain settles when load is reduced, but the tendon has not regained enough strength or endurance for the activity that originally provoked it. When normal gripping, lifting or training resumes, demand again exceeds capacity.
How long does tennis elbow take to recover?
There is no single timetable. Some presentations improve over weeks, while persistent lateral elbow tendinopathy can take several months to fully restore strength and load tolerance. Duration alone does not tell us whether the tendon is damaged or whether recovery has failed.
Should I stop exercising with tennis elbow?
Usually not completely. Load often needs to be modified rather than removed altogether. Progressive wrist-extensor strengthening is recommended in clinical practice guidelines for subacute and chronic lateral elbow tendinopathy.
Does shockwave therapy work for tennis elbow?
It can. Lateral epicondylopathy is an internationally recognised shockwave indication, and clinical trials and systematic reviews support ESWT as an option for selected persistent cases. Outcomes vary according to protocol, patient selection and comparison treatment.
Is radial or focused shockwave better for tennis elbow?
Neither is universally better. The common extensor tendon is usually accessible, so EMS radial shockwave can be highly appropriate and has direct clinical trial evidence. Focused shockwave may also be selected according to tissue sensitivity, anatomy and treatment strategy. Current evidence suggests both approaches can be clinically useful.
Can laser therapy help tennis elbow?
High-intensity laser therapy has evidence supporting improvements in pain and function in lateral elbow tendinopathy. Recent systematic reviews suggest broadly comparable outcomes between laser and ESWT, although protocols and devices vary substantially.
Is laser better than shockwave?
Current evidence does not establish one as universally superior. They work through different physical mechanisms and may be useful at different stages or in different presentations.
Is cortisone good for tennis elbow?
Corticosteroid injection can provide strong short-term pain relief, but research has shown higher recurrence and less favourable longer-term outcomes in some studies.
Can osteopathy help tennis elbow?
Osteopathic care can form part of a wider management plan by assessing the elbow, wrist, shoulder, cervical region and relevant movement or neurological findings. Manual treatment may help symptoms or movement in selected patients, but progressive tendon loading remains important for restoring long-term capacity.
When should I get a scan?
Imaging may be useful if there has been significant trauma, marked weakness, locking, neurological symptoms, concern about a substantial tear or failure to progress despite an appropriate treatment plan. Straightforward tennis elbow does not always require imaging.
Your Elbow Probably Does Not Need More Guesswork
A persistent tendon is not necessarily a permanently damaged tendon.
And an elbow that hurts when you grip is not necessarily destined for an injection or operation.
Sometimes the missing piece is a clearer diagnosis.
Sometimes it is better loading.
Sometimes pain needs to be brought under enough control for rehabilitation to progress.
And sometimes an evidence-informed intervention such as EMS radial shockwave, focused shockwave or high-power laser therapy can help move a stalled recovery forward.
The treatment should follow the problem.
Not the other way around.
Movement Mechanics. Movement Matters™.
Written and clinically reviewed by Jonathan Hall
M.Ost, BAppSci (Human Biology), PGCertHSc, GradDipHealFIFA Diploma in Football Medicine
Jonathan is the founder and Clinical Director of Movement Mechanics, an ACC-registered osteopath, New Zealand Key Opinion Leader for EMS DolorClast® and an ISMST certified practitioner. He has more than a decade of clinical experience and a particular interest in persistent tendon disorders, shockwave therapy and high-power laser therapy.
References
Alharran, A. M., Alotaibi, M. N., Alasmari, O. Y., Alfailakawi, A. K., Alahmad, A. A., Aldeligan, B., Alahmadi, M. M., Alshammari, M., & Marwan, Y. (2025). Laser therapy versus extracorporeal shock wave therapy for the treatment of lateral epicondylitis: A systematic review and meta-analysis of randomized controlled trials. Lasers in Medical Science, 41(1), 3. https://doi.org/10.1007/s10103-025-04779-z PubMed
Coombes, B. K., Bisset, L., Brooks, P., Khan, A., & Vicenzino, B. (2013). Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: A randomized controlled trial. JAMA, 309(5), 461–469. https://doi.org/10.1001/jama.2013.129 PubMed
Jin, R., Wang, H., Lv, W., Cheng, H., Li, Y., & Yuan, Q. (2026). Comparison of the efficacy of different types and intensities of extracorporeal shock wave therapy for lateral epicondylitis: A systematic review and network meta-analysis. Journal of Orthopaedic Surgery and Research, 21(1), 435. https://doi.org/10.1186/s13018-026-06984-0 PubMed
Lucado, A. M., Day, J. M., Vincent, J. I., MacDermid, J. C., Fedorczyk, J., Grewal, R., & Martin, R. L. (2022). Lateral elbow pain and muscle function impairments: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Academy of Hand and Upper Extremity Physical Therapy and the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 52(12), CPG1–CPG111. https://doi.org/10.2519/jospt.2022.0302 Orthoptics UK
Shiri, R., Viikari-Juntura, E., Varonen, H., & Heliövaara, M. (2006). Prevalence and determinants of lateral and medial epicondylitis: A population study. American Journal of Epidemiology, 164(11), 1065–1074. https://doi.org/10.1093/aje/kwj325 PubMed
Wu, P.-C., Liu, D.-H., Cheng, Y.-S., Lin, C.-S., & Yang, F.-A. (2026). High-intensity laser therapy versus extracorporeal shockwave therapy for lateral elbow tendinopathy: A systematic review and meta-analysis. Bioengineering, 13(2), 155. https://doi.org/10.3390/bioengineering13020155 DOI
Yang, T.-H., Huang, Y.-C., Lau, Y.-C., & Wang, L.-Y. (2017). Efficacy of radial extracorporeal shock wave therapy on lateral epicondylosis, and changes in the common extensor tendon stiffness with pretherapy and posttherapy in real-time sonoelastography: A randomized controlled study. American Journal of Physical Medicine & Rehabilitation, 96(2), 93–100. https://doi.org/10.1097/PHM.0000000000000547 PubMed
Zhang, L., Zhang, X., Pang, L., Wang, Z., & Jiang, J. (2024). Extracorporeal shock wave therapy versus local corticosteroid injection for chronic lateral epicondylitis: A systematic review with meta-analysis of randomized controlled trials. Orthopaedic Surgery, 16(11), 2598–2607. https://doi.org/10.1111/os.14212
Last clinically reviewed: September 2026
This article is general information, not individual clinical advice. Treatment recommendations require assessment.
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