Body Area
Elbow PainTennis Elbow, Golfer's Elbow & Tendinopathy
Tennis elbow, golfer's elbow, and elbow tendinopathy in racquet sport players, golfers, desk workers, and anyone whose work loads the forearm repeatedly.
Book Your First VisitElbow tendinopathy typically responds to progressive loading, not rest alone, and not passive approaches as the primary intervention. The cervical spine (C6, C7) can refer symptoms that mimic or contribute to elbow pain, worth assessing when symptoms are resistant to local treatment. Equipment modifications and ergonomic changes matter while the tendon heals.
What's happening in the elbow
Elbow pain is most commonly tendinopathy at one of two sites: the lateral epicondyle (tennis elbow, or lateral epicondylitis) or the medial epicondyle (golfer's elbow, or medial epicondylitis). Both are tendon overload injuries from repetitive wrist and forearm loading, not acute tears or inflammation in the traditional sense. The underlying process is tendon degeneration from load that exceeds the tendon's capacity to repair, which is why passive rest doesn't resolve them and cortisone injections produce short-term relief but poorer long-term outcomes than physiotherapy or a supervised wait-and-see approach.
Lateral epicondylitis is far more common and affects the extensor carpi radialis brevis at its origin on the lateral elbow. It is strongly associated with racquet sports (grip and wrist extension on impact), prolonged mouse use with the wrist extended, and repetitive gripping work. Medial epicondylitis affects the common flexor origin and is more common in golfers, throwing athletes, and manual workers who do sustained forearm flexion and gripping.
A distinction worth considering: C6 and C7 nerve root irritation from cervical spine pathology can mimic or contribute to elbow symptoms, and may not be identified without neurological assessment. If you've been treating tennis elbow for months without improvement, the cervical spine is worth assessing. Symptoms that reproduce or shift with neck movement, or arm ache that doesn't map neatly to the elbow, can point to cervical involvement. I assess both areas together, which is where chiropractic training is particularly relevant for elbow presentations.
Common causes
- Lateral epicondylitis (tennis elbow): pain at the outer elbow, worse with gripping, lifting, and resisted wrist extension. Common in tennis and racquet sport players (particularly with high string tension or oversized grip), desk workers with sustained mouse use, and trades workers. The most common elbow presentation.
- Medial epicondylitis (golfer's elbow): pain at the inner elbow, worse with wrist flexion and grip. Common in golfers, throwing athletes, and anyone doing sustained grip and forearm flexion work. Less common than lateral epicondylitis.
- Cervical nerve root referral: C6 and C7 nerve root irritation from a cervical disc or facet problem: C6 referral can closely mimic lateral elbow pain; C7 tends to produce posterior elbow and triceps symptoms. Both can coexist with local tendinopathy.
- Olecranon bursitis: swelling and pain at the tip of the elbow from bursa irritation. Usually from direct trauma or sustained pressure. Visually distinctive (fluid-filled swelling at the elbow point). Needs to be differentiated from septic bursitis when warm or red.
- Cubital tunnel syndrome: ulnar nerve compression at the elbow producing inner elbow pain, forearm ache, and numbness in the ring and little fingers. Often confused with golfer's elbow because of the similar location.
What helps
Progressive tendon loading is the primary evidence-supported treatment for both lateral and medial epicondylitis, recommended in current clinical practice guidelines and supported by systematic review evidence for eccentric exercise specifically. Eccentric loading has the strongest evidence base for lateral epicondylalgia; isometric loading is a useful adjunct, particularly in more acute or irritable presentations where heavy loading introduced too soon would worsen rather than help. The exercise programme needs to be specific to the tendon involved, dosed appropriately, and adjusted as the tendon responds. In my experience, most people with lateral epicondylitis see meaningful improvement within the first 6–12 weeks of appropriate progressive loading, though this also reflects the condition's natural tendency to improve over time. Full resolution often takes longer and depends on how severe the tendinopathy is and how long symptoms have been present.
Manual therapy to the elbow, wrist, and cervical spine addresses contributing restrictions. When a cervical component is identified, cervical manipulative therapy has been shown to produce an immediate hypoalgesic effect at the elbow, and addressing cervical involvement alongside local treatment may support recovery. Soft tissue work to the forearm extensors and manual therapy to the wrist and elbow joints are useful adjuncts to the loading program.
On cortisone injections for tennis elbow
Cortisone produces reliable short-term pain reduction in lateral epicondylitis, typically 4–6 weeks. However, two high-quality randomised trials found that patients who received cortisone had worse outcomes at one year compared with those who received physiotherapy or a supervised wait-and-see approach. One proposed explanation is that cortisone reduces the short-term pain that might otherwise drive adherence to the loading programme, though this mechanism is not definitively established. If you've already had an injection that provided temporary relief and symptoms have since returned, that pattern is consistent with what the evidence shows: the underlying tendon issue hasn't been resolved, and the loading programme is typically the next step. It's a common situation and a workable one. If an injection has been offered and you want to understand the evidence first, that's a reasonable question to raise with your doctor.
Equipment modifications are an important part of management during recovery. For racquet sports: reducing string tension, using a lighter racquet, and ensuring the grip size is appropriate reduce lateral epicondyle load. For desk workers: mouse position and wrist angle during prolonged computer use can be adjusted to reduce the provocative load.
Elbow tendinopathy typically responds to the right loading programme, but the approach depends on which tendon is involved and what's driving the load on it. If you'd like to talk through your situation before booking, get in touch.
When to seek care promptly
See a doctor if you have:
- Acute elbow swelling after a fall or direct impact (possible fracture)
- A warm, red, swollen elbow tip without a clear traumatic cause (possible septic bursitis)
- Elbow pain with significant weakness in grip or wrist extension
- Numbness and tingling in the ring and little fingers alongside elbow pain (possible cubital tunnel syndrome)
- Elbow pain that is worsening despite 3 months of structured conservative management including a supervised loading programme
Most elbow tendinopathy is appropriate for conservative management. Structural injuries, nerve entrapment, and infected bursitis need medical assessment first.
Related reading
Common questions
Most elbow pain is tendinopathy, not acute injury or inflammation in the traditional sense. Tennis elbow (lateral epicondylitis) is degeneration at the tendon origin on the outer elbow, typically from repetitive gripping and wrist extension. Think racquet sports, mouse use, or trades work. Golfer's elbow (medial epicondylitis) is the same process on the inner elbow, more common in golfers, throwers, and anyone doing sustained forearm flexion work. Both are overload injuries where load on the tendon exceeds its capacity to repair.
What gets missed is that the cervical spine can refer symptoms into the elbow. C6 and C7 nerve root irritation from a disc or facet problem in the neck can produce arm and elbow pain that closely mimics local tendinopathy. If someone has been treating tennis elbow for months without improving, a cervical source is worth checking. I routinely assess the neck in elbow presentations because the two can coexist and the cervical component won't respond to local elbow treatment alone.
Less common causes include cubital tunnel syndrome (ulnar nerve compression at the inner elbow, producing forearm ache and numbness in the ring and little fingers) and olecranon bursitis (fluid-filled swelling at the elbow tip, usually from direct trauma or sustained pressure).
Yes, with some caveats about what the primary treatment actually is. Elbow tendinopathy responds best to progressive tendon loading, meaning a structured exercise program that gradually increases load on the affected tendon. That's not passive treatment. What I do is combine manual therapy to the elbow, wrist, and cervical spine with a loading program and guidance on what's provoking the tendon and how to modify it.
The cervical assessment is where my approach differs most from a physio-led loading programme: I assess and treat the cervical component alongside local treatment, which matters for presentations where the neck is contributing. When cervical involvement is identified and addressed, some people notice improvement that local treatment alone had not produced, though the evidence base for this is still developing.
Where I'm less useful: if you have a structural injury like a fracture, significant nerve entrapment, or infected bursitis, those need medical assessment first. Chiropractic is appropriate for the musculoskeletal presentations, not for everything that causes elbow pain.
Elbow tendinopathy is one of the slower musculoskeletal conditions to resolve fully, and I prefer to be upfront about that. Most people with lateral epicondylitis notice meaningful improvement within the first 6 to 12 weeks of a structured loading programme. Full resolution often takes longer, sometimes 3 to 6 months, and depends on how severe the tendinopathy is, how long it's been present, and whether the provoking load has been modified.
In terms of hands-on sessions with me, in my experience that's typically 4 to 8 visits for most elbow presentations, front-loaded in the early weeks. The goal is to get you to a point where you're managing the loading programme independently and returning to your sport or activity without provoking things. I'm not aiming to keep you coming back once you're on track.
If there's a cervical component that responds quickly, some people feel noticeably better within the first few visits. If the tendon is severely degenerated or there's been years of on-and-off symptoms, realistic expectations need to account for that.
If you've already had a cortisone injection and symptoms have returned, you're not starting over, but the loading programme is generally the next step from this point, and the recovery timeline is similar to a first presentation.
Most elbow tendinopathy does not need imaging. The diagnosis is clinical, meaning the history and physical examination tell the story. X-rays won't show tendon pathology and are mainly useful when a fracture or calcification is suspected. MRI can visualise the degree of tendon degeneration and confirm the diagnosis when it's genuinely unclear, but it rarely changes the initial management for a straightforward lateral or medial epicondylitis presentation.
Imaging is worth pursuing if: your symptoms are severe and worsening despite appropriate conservative treatment over several months, there was a significant traumatic mechanism (fall on outstretched hand, direct impact), there's significant grip weakness suggesting a possible tendon rupture, or there are neurological signs pointing to nerve entrapment that may need surgical assessment. If I think imaging would change what we do, I'll say so and refer you to your GP or a sports medicine doctor to arrange it.
References
- Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. PubMed
- Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461–469. PubMed
- Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain. 1996;68(1):69–74. PubMed
- Lucado AM, Day JM, Vincent JI, MacDermid JC, Fedorczyk J, Grewal R, Martin RL. Lateral Elbow Pain and Muscle Function Impairments: Clinical Practice Guidelines. J Orthop Sports Phys Ther. 2022;52(12):CPG1–CPG111. PubMed
- Yoon SY, Kim YW, Shin IS, Kang S, Moon HI, Lee SC. The Beneficial Effects of Eccentric Exercise in the Management of Lateral Elbow Tendinopathy: A Systematic Review and Meta-Analysis. J Clin Med. 2021;10(17):3968. MDPI
Disclaimer
This page is for general information only and does not constitute medical advice. Every person's situation is different. Nothing here should be used as a substitute for assessment and advice from a qualified health professional who can evaluate your specific circumstances.
If you are experiencing severe or rapidly worsening symptoms, loss of bladder or bowel control, progressive weakness, or any symptom that concerns you, seek medical care promptly rather than reading websites.
This page was written with AI assistance and reviewed by Erik Anderson for accuracy. If you find an error, please contact us and we will endeavour to correct it.
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