Updated: Mar 22
First, let’s recap on the basics, which you can see by visiting my previous blog ‘Part 1: What is tennis elbow’. If you haven’t read this yet, take a look at it first because the rest of this will make far more sense if you do.
Perhaps you’ve read the advice, watched the YouTube videos and been doing all the exercises, but your lateral elbow tendinopathy STILL isn’t getting better. Perhaps you feel like screaming with frustration or knocking at the door of the first surgeon to open their doors to routine cases after the end of the lockdown. Before you sink into total despair, let me explain a few common reasons why this might be the case and what you can do about it.
So why isn’t my elbow pain getting better?
OK, so let’s say you know all that already. And it’s STILL HURTING. Here are the most common reasons, in my experience, that lateral elbow tendinopathy can fail to progress:
I've also explained all of this in more detail in this video:
1. Inadequate offload
Most of the YouTube videos and existing advice for lateral elbow tendinopathy tends to include ‘eccentric’ exercises for the wrist, slowly lowering the hand using a weight or a hammer – if you do these while the tendon is still irritated, this just overloads the tendon even more. And it’s not the fault of the video makers or the leaflet writers, because some of the research on elbow pain suggests these are the exercises to do. BUT, that’s because elbows seem to be rather an unfashionable thing to research, so there really isn’t much good quality research out there. If there was, they would soon see the hammer exercises at the early stages are a bad idea and that giving it time to settle down first is more effective.
2. Over treating
Friction massage, heat balms, freeze rubs, anything that perpetually pokes at a painful tendon is likely to keep it irritated. If you were already angry, would you be irritated if someone kept poking at you? Leave it alone for a bit to let it settle down.
3. Forgetting other factors
It’s easy to think ‘elbow, elbow, elbow’ and concentrate only on the bit that hurts. But to get the elbow better, attention also needs to be paid to shoulder stability, core stability, ergonomics at work / in the gym, general fitness, diet, sleep, anxiety / stress, nerve irritation / sensitisation, or other medical conditions. All of these can contribute to elbow pain and might need addressing in order to get things better.
When things aren’t getting better, it is important to get a qualified healthcare professional to assess you, whether it is your GP, a physiotherapist or a sports medicine physician. Just in case it isn’t what you thought it was.
Unfortunately, a great deal of patience is often required for lateral elbow tendinopathy to get better. And we’re talking months, if not more, most of the time. Why? Most likely because it is REALLY HARD to offload an elbow tendon that you use every day for simple things, like pouring a kettle, opening doors and having a drink. When a tendon is irritated enough to cause pain doing these normal activities, it needs a lot of time and patience to settle down.
It is always worth trying simple treatment and rehab first, before seeking further interventions such as injections, shockwave therapy and surgery. Most of the time, the basics when done correctly can not only solve the issue but address some of the underlying causes that went with it.
Injections with corticosteroid have more recently been shown to provide short-term benefit, but symptoms tend to be worse in the intermediate term and the long term effects are not yet known. Research has also shown that Platelet Rich Plasma (PRP) injections have been ineffective in the treatment of persistent lateral elbow tendinopathy. Another recent clinical trial compared the outcomes for surgery for chronic lateral elbow tendinopathy with ‘sham surgery’ and found that both groups improved and were no different to each other at follow up – suggesting it wasn’t what was done in surgery that helped, it was what they did afterwards during rehabilitation that mattered. Food for thought.
About the Author
Steph is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports and Exercise Medicine. You can follow Steph on LinkedIn.
Scott A, Docking S, Vicenzino B, et al (2013) Sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second International Scientific Tendinopathy Symposium (ISTS) Vancouver 2012 British Journal of Sports Medicine; 47:536-544
de Vos R, Windt J, Weir A (2014) Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review British Journal of Sports Medicine; 48:952-956