Understanding Tennis Elbow: Causes, Symptoms, and Treatments

KEY TAKEAWAYS

• Tennis elbow is a tendon problem at the outer elbow caused by repetitive gripping, wrist use, and loading. You do not have to play tennis to get it.
• It is not really an inflammation. It is a tendon that has been overloaded and has not finished healing, which is why rest alone often does not fix it.
• Cortisone injections give fast short-term relief but tend to do worse than other treatments by 12 months. Long-term, they are not a solution.
• Focused shockwave therapy and progressive loading exercise are the two treatments with the strongest current evidence for stubborn tennis elbow.
• At Unpain Clinic in Edmonton, we build a plan that combines those two with manual therapy and a look at the chain above and below the elbow. We tell you honestly if we are not the right fit.

If lifting a coffee mug or turning a doorknob sends a jolt through the outside of your elbow, you already know how disruptive tennis elbow can be. The good news is that most people get better without surgery, and the strongest current evidence supports treatments that actually heal the tendon rather than only mute the pain. This guide covers what tennis elbow really is, why it tends to stick around, what the research says works, and how we put a plan together at Unpain Clinic in Edmonton.

WHAT IS TENNIS ELBOW AND WHAT CAUSES IT?

Tennis elbow, known clinically as lateral epicondylitis or lateral elbow tendinopathy, is a condition that involves the tendons attaching your forearm extensor muscles to the bony bump on the outside of your elbow. The main culprit is the tendon of the extensor carpi radialis brevis, which sits right at that spot. Repetitive gripping, twisting, and wrist movement load that tendon over and over, and small micro-injuries can accumulate faster than the tendon can repair. Over time, the tissue starts to break down at a structural level, which is what produces the pain and the weakness in grip that people describe.

The term "epicondylitis" is misleading, and the science has moved past it. A 2022 review of tendon pain mechanisms in the Scandinavian Journal of Pain lays out the current understanding: chronic tendon pain is not driven mainly by acute inflammation but by tendon degeneration, disordered nerve ingrowth into tissue that should not have nerves growing into it, and a sensitised nervous system. That matters for treatment, because pure anti-inflammatory approaches do not address any of those three things.

Despite the name, you do not need to swing a racquet to develop tennis elbow. The condition is common in trades that involve heavy or repetitive gripping (plumbers, electricians, mechanics, carpenters, chefs), in office work involving long hours with a mouse, in hobbyists who pick up an intensive project for a few weekends (renovations, gardening, painting), and in racquet sport players. The peak age is roughly 35 to 55, but anyone who loads the forearm enough can get it.

Several factors stack the odds. Sudden increases in load (a new tool, a new sport, a new job task) are the most common trigger. Weakness or stiffness elsewhere in the chain matters too. A stiff thoracic spine, weak rotator cuff, or restricted shoulder can push more load onto the wrist and elbow during everyday tasks. Tendons in general also do not love being loaded heavily when the rest of the body is fatigued or under-recovered, so poor sleep, smoking, and overall deconditioning can tilt the balance.

WHAT DOES TENNIS ELBOW FEEL LIKE?

The pattern is recognizable once you know what to look for. The pain sits on the outside of the elbow, sometimes spreading down into the forearm. It is worst with gripping and with wrist movements that load the extensor tendons. Common triggers include shaking hands, turning a doorknob, lifting a kettle, twisting a screwdriver, or carrying a grocery bag with the palm facing down.

Other typical features include tenderness when you press the bony bump on the outside of the elbow, weakness in your grip, stiffness in the elbow and forearm in the morning, and a sense that the arm just is not as strong as it used to be. The pain usually develops gradually rather than suddenly, and most people can recall a period of heavier use that preceded it.

There is usually no dramatic swelling or redness. If your elbow becomes obviously swollen, locked, deeply bruised, or accompanied by numbness in the hand, that is a different problem and you should get it checked promptly.

DOES TENNIS ELBOW HEAL ON ITS OWN, AND HOW LONG DOES IT TAKE?

Some cases do settle on their own, especially mild ones caught early. The natural history of tennis elbow is generally favourable, and most people improve without surgery. But there are two important caveats.

The first is that "improvement" in studies usually does not mean "fully resolved." A lot of people who get better still report some lingering symptoms a year out, and recurrence is common if the load that caused the problem is not addressed.

The second is that the timeline is long. Once a tendon has been irritated for several weeks, the recovery is usually counted in months rather than weeks. A typical course for a moderately stubborn case is somewhere between three and six months of consistent management. Tendons heal slowly because their blood supply is limited, and the structural remodelling that needs to happen takes time.

This is where active treatment changes the picture. Doing nothing and waiting often works eventually, but it takes longer and tends to leave more residual symptoms. A targeted plan tends to be faster and more complete.

WHAT DOES THE RESEARCH SAY WORKS BEST FOR TENNIS ELBOW?

Three findings frame the modern evidence on tennis elbow.

The first is that shockwave therapy outperforms several traditional alternatives over the medium term. A 2025 umbrella review of meta-analyses in the Journal of Orthopaedics and Traumatology compared extracorporeal shockwave therapy with placebo, ultrasound therapy, and corticosteroid injections for lateral epicondylitis across multiple high-level reviews. Shockwave came out ahead of placebo and ahead of standard ultrasound therapy. Most notably, while a corticosteroid injection produces faster short-term relief, by three months and beyond, the outcomes with shockwave were better than with steroid injections.

The second is that corticosteroid injections, despite the appealing short-term effect, tend to do worse than other approaches over time. The Coombes 2010 systematic review of injections for tendinopathy in The Lancet found that corticosteroid injections offered short-term pain relief but were associated with worse long-term outcomes compared with no injection or non-injection treatments. That finding has held up in the years since and is one of the reasons routine use of cortisone injections for tennis elbow has fallen out of favour in most modern guidelines.

The third is that progressive loading exercise is foundational. A 2010 study in the North American Journal of Sports Physical Therapy describes a simple eccentric wrist extension exercise using a flexible bar that produced large improvements in pain and grip strength in tennis elbow. Eccentric loading is one of the more effective ways to drive tendon remodelling, and it remains a cornerstone of modern rehab programs. The exercise alone is not always enough for stubborn cases, but tendons that are loaded progressively tend to do meaningfully better than tendons that are only rested.

These three findings line up. Shockwave restarts a stalled healing response. Loading exercise rebuilds the tendon's capacity. Cortisone, while tempting in the short term, is not what most people need long term. A 2024 systematic review and meta-analysis of randomized trials in BMC Sports Science, Medicine and Rehabilitation reinforced the broader picture, finding that shockwave meaningfully reduced pain across a range of tendinopathies including lateral elbow pain.

HOW DO WE TREAT TENNIS ELBOW AT UNPAIN CLINIC IN EDMONTON?

A typical first visit is a 60-minute one-on-one assessment. We take a history, examine the elbow itself, and assess the chain above and below it. The wrist, the shoulder, the thoracic spine, and even grip mechanics often matter more than people expect for a stubborn elbow. If your shoulder or upper back is stiff or weak, your forearm ends up doing extra work it was not designed for.

If you are a fit for our approach, the plan usually has four parts.

Focused shockwave therapy on the painful tendon at the lateral epicondyle. Sessions run about 15 to 20 minutes. You will feel a strong tapping sensation that we adjust to your tolerance. Most courses for tennis elbow are three to six weekly visits. There is no needle and no recovery downtime, although some patients feel a few hours of mild soreness in the area afterward, which is part of the healing response. If you want to understand the technology in more depth, our article on how focused shockwave therapy works walks through the mechanics.

EMTT for the surrounding region when appropriate. EMTT uses pulsed electromagnetic fields delivered through a loop applicator placed over the area. It is painless, you feel nothing during the session, and it pairs naturally with shockwave when the irritation extends beyond the immediate tendon insertion. It is not used on every tennis elbow case, but it is a useful addition when the forearm and elbow are diffusely irritated.

Manual therapy and joint mobility work. The forearm extensor and flexor muscles are usually tight in tennis elbow, the wrist is often stiff, and the thoracic spine and shoulder can be restricted enough to push extra load onto the elbow. Soft tissue work, joint mobilization, and targeted stretching are part of most sessions.

Progressive loading exercise. This is the part you own. You will get a short, specific exercise program for the wrist extensors, the grip, and the shoulder and scapula. Eccentric and isometric loading are usually where we start, and we progress as the tendon tolerates more. Most patients do these at home five to seven days per week, with adjustments at each visit.

For patients whose pain has been around for a long time and whose nervous system has clearly been sensitised, we may discuss NESA neuromodulation as an additional layer. It is not used on every tennis elbow case, and it is not a stand-alone treatment for this condition.

WHAT CAN I DO AT HOME FOR TENNIS ELBOW?

What happens between sessions matters as much as what we do in clinic. The following habits make a real difference. None of them is a cure on its own.

1. Modify the loads that are flaring you, do not eliminate movement. Bed rest is not the answer. Cut back on the specific activities that reproduce the pain, especially heavy gripping with the palm facing down. Keep moving in pain-free ranges. The goal is to load the tendon enough to drive recovery without overloading it.
2. Use a counterforce strap during aggravating tasks if it helps. A forearm strap placed two to three finger widths below the elbow can reduce the pull on the irritated tendon during work or hobbies. It is not a treatment, it is a support. Take it off at rest.
3. Set up your workstation so the wrist is neutral. If you spend hours on a mouse, drop the keyboard height a little, use a mouse that does not force your wrist into extension, and take a one or two minute mobility break every hour.
4. Ice after heavy use, heat for stiffness. Ten to fifteen minutes is enough. A cloth barrier protects the skin.
5. Do your exercises consistently. A small dose every day beats a large dose once a week. Tendons respond to repeated, gradual loading over weeks and months, not heroic single sessions.

If you have done this consistently for six to eight weeks without progress, that is the cue to get reassessed. Something in the load, the technique, or the surrounding chain is usually the missing piece.

WHAT WE DO NOT OFFER

To save you time and set honest expectations:

• We do not perform injections of any kind, including cortisone injections, platelet-rich plasma, or autologous blood injections.
• We do not prescribe oral or topical pain medications. We are physiotherapists and registered massage therapists, not physicians.
• We do not perform surgery. If your tennis elbow has not responded to a year of well-executed conservative care and surgery is on the table, we will tell you and refer you to a hand or upper-extremity surgeon for an opinion.
• We do not promise cures. Tendons heal slowly, recovery rates vary, and anyone who guarantees a specific outcome should be approached with caution. What we offer is an honest plan, regular review, and a team that will tell you if we are not the right fit.

FREQUENTLY ASKED QUESTIONS

Does shockwave therapy actually work for tennis elbow?

The current evidence is the strongest it has ever been. A 2025 umbrella review of meta-analyses in the Journal of Orthopaedics and Traumatology found that extracorporeal shockwave therapy outperformed placebo and ultrasound therapy for lateral epicondylitis, and outperformed corticosteroid injections in the longer term. It is most useful when the tennis elbow has been around for more than a few months and has not responded to rest and basic rehab on its own.

Should I get a cortisone injection for tennis elbow?

In most cases, no, especially if you have time to do this properly. A cortisone injection gives fast short-term relief, but a Lancet systematic review of injection therapies for tendinopathy found that cortisone injections were associated with worse long-term outcomes compared with no injection or non-injection care. They have a role in very specific situations, but routine cortisone for tennis elbow has fallen out of favour in most modern guidelines.

How many shockwave sessions will I need?

A typical course is three to six weekly sessions. Some milder cases settle in three; more stubborn cases need five or six. We reassess as we go and will tell you honestly if a course is not moving you in the right direction.

Does shockwave hurt?

The pulses are uncomfortable on an irritated tendon, and most people rate them four or five out of ten during the session. We adjust the intensity to what you can tolerate. After the session, a few hours of mild soreness is common. There is no needle, no incision, and no medication to react to.

Do I need a doctor's referral to come to Unpain Clinic?

No referral is needed. Physiotherapists and registered massage therapists in Alberta are primary contact providers, so you can book directly. Some extended health plans require a doctor's referral for reimbursement, so it is worth checking your benefits.

I have had tennis elbow for over a year. Is it too late?

Often not. Chronic, long-standing tendon problems are exactly what shockwave therapy was developed for. A year of pain is not a barrier on its own. What matters more is whether the tendon still has enough capacity to remodel and whether the rest of the chain can be unloaded enough to give it a chance.

Can I keep playing tennis or doing my job while I rehab?

Usually yes, with modifications. Stopping all activity is rarely necessary and is often counterproductive. The goal is to dial back the specific loads that flare you, keep doing what you can without provoking sharp pain, and gradually rebuild capacity through your home program. We coach the pacing.

“My husband and I both were suffering from tennis elbow for about half a year and tried many different things to alleviate the pain. I have done shockwave before for sciatica and tendinitis in my foot. I scheduled an appointment with Dr. Lacina Barsalou. Within 3 sessions each our tennis elbow was cured.
She was very thorough and knowledgeable. She did an absolute bang up job.

A couple of weeks ago, my back went out and I could barely walk. The only solace I had was sleeping and sitting on the floor. I went for one shockwave treatment with Lacina and she also adjusted my hips while I was there. The relief I feel now is like night and day. I definitely recommend Dr. Lacina for all your shockwave and chiropractic needs!” - Sherry Lucas

ABOUT THE AUTHOR

Written by Uran Berisha, PT, RMT, Founder of Unpain Clinic and Medical Shockwave Institute. Uran is a physiotherapist based in Edmonton, Alberta, and an International Educator in Shockwave Therapy. Medically reviewed by Uran Berisha, PT, RMT.

READY TO STOP CHASING THE PAIN AND START TREATING THE CAUSE?

If your outer elbow pain has not budged with rest, a brace, and the usual anti-inflammatories, the next step is a 60-minute one-on-one assessment in Edmonton where we look at the elbow and the chain around it, and build you a clear, written plan. No referral needed. No pressure. We will tell you honestly if shockwave is the right call, and we will tell you just as honestly if a different path makes more sense for you. You can book a one-on-one assessment when you are ready.

REFERENCES

The following sources are linked inline in the body above. The full citations are listed here for completeness.

1. Zhu P, Tang P, Su J, Yang Y, Yang S, Zhang C, Xiao W, Zhou Y, Li Y, Deng Z. Comparison of extracorporeal shockwave therapy, ultrasound therapy, and corticosteroid injections for treatment of lateral epicondylitis: an umbrella review of meta-analyses. Journal of Orthopaedics and Traumatology. 2025;26(1):55. doi:10.1186/s10195-025-00871-w. PMID: 40824407. PMCID: PMC12361003. https://pubmed.ncbi.nlm.nih.gov/40824407/
2. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. The Lancet. 2010;376(9754):1751-1767. doi:10.1016/S0140-6736(10)61160-9. PMID: 20970844. https://pubmed.ncbi.nlm.nih.gov/20970844/
3. Page P. A new exercise for tennis elbow that works! North American Journal of Sports Physical Therapy. 2010;5(3):189-193. PMID: 21655385. PMCID: PMC2971639. https://pmc.ncbi.nlm.nih.gov/articles/PMC2971639/
4. Majidi L, Khateri S, Nikbakht N, Moradi Y, Nikoo MR. The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized controlled trials. BMC Sports Science, Medicine and Rehabilitation. 2024;16(1):93. doi:10.1186/s13102-024-00884-8. PMID: 38659004. https://pubmed.ncbi.nlm.nih.gov/38659004/
5. Ackermann PW, Alim MA, Pejler G, Peterson M. Tendon pain: what are the mechanisms behind it? Scandinavian Journal of Pain. 2023;23(1):14-24. doi:10.1515/sjpain-2022-0018. PMID: 35850720. https://pubmed.ncbi.nlm.nih.gov/35850720/