Stubborn Tennis Elbow Pain? Our Guide to Safe Loading

Tennis injuries can affect more than just your performance on the court. Repetitive movements, gripping and twisting can place ongoing strain on the muscles and tendons around the elbow, leading to discomfort that can interfere with everyday activities. Tennis elbow is one such condition, and it can affect not only tennis players but also people who regularly use their arms for work, lifting or repetitive tasks.

If you're managing tennis elbow, studies show that safe elbow loading can support recovery. The pain may encourage you to stop using your arm altogether, but prolonged rest alone does not necessarily address the underlying tendon problem. A gradual strengthening approach can help restore the tendon's ability to manage everyday loads and reduce the likelihood of recurring symptoms.

Here is what that looks like in practice.

Why tennis elbow rest alone doesn't fix it

Rest calms the pain but does not rebuild the tendon's capacity. This suppresses the issue instead of eliminating it. You may notice flare-ups when, after a period of rest, you begin using your arm again.

Tennis elbow, or lateral epicondylitis, is an overuse problem in the forearm tendons that extend your wrist. Australian GPs manage 242,000 patients for tennis elbow each year, and it's usually caused by repetitive gripping and twisting of the wrist.

The review describes tennis elbow as a form of tendon degeneration, with disorganised collagen and changes to the tendon's structure, rather than straightforward inflammation. This distinction matters, as rest targets inflammation that isn't the main problem in tennis elbow.

Making sure it is actually tennis elbow

Tennis injuries can involve different muscles, joints and tendons, so it is important to identify the source of your pain before starting treatment. Before loading anything, confirm that you have a tennis elbow. A physio assessment is the best way to do this.

We look for tenderness right over the bony point on the outside of the elbow, and pain when you extend the wrist against resistance.

We also check your neck movement, sensation, reflexes, and muscle strength, because pain referred from the neck or irritation of the radial nerve can closely mimic tennis elbow. Those require a different plan entirely, which is why an accurate physiotherapy diagnosis matters.

Tennis elbow exercises: how to load properly

Loading means gradually increasing the work the tendon does so it adapts and gets stronger, the same way any other tissue responds to training. The 2022 review found strength training stimulates the tendon and increases collagen production in damaged tendons. It also found that combining isometric, eccentric and concentric work beat eccentric exercise on its own.

In practice, that progression looks like this:

1. 1
   Isometric holds. Hold the wrist in extension against resistance without moving. We often start with five sets of holds lasting 5 to 45 seconds, depending on how irritable the elbow is.
2. 2
   Slow lowering. As symptoms settle, start moving through range. Lower a light weight slowly with the palm facing down, using the other hand to lift it back up.
3. 3
   Through-range strengthening. Once lowering is comfortable, lift as well, using the same hand in both directions. This is where the concentric work comes in. Build up resistance, reps and sets as capacity improves, then add grip work and the specific tasks you need the arm for.

How much pain is acceptable?

Some discomfort during exercise is fine, as long as it stays manageable and returns to your normal baseline by the next day. If it is still worse the following morning, that session was too much. Take it day by day to see which exercises you can manage.

Where hands-on physio, braces and injections fit

Manual therapy

Research shows manual therapy and strengthening are the two treatments with the greatest benefit and the best value for money. As part of tennis elbow treatment, manual therapy can help settle your pain and make movement easier, while exercises help rebuild your capacity to handle load over time.

At Restore Physio, we reassess grip strength after each therapy session to see whether it actually made a difference.

Counterforce braces and taping

A counterforce brace applies pressure around the forearm and changes how force travels through the wrist extensor tendon, which can reduce pain when you grip or lift. We use them, particularly when someone is quite symptomatic and needs to keep working or playing sport.

Restricting movement can lead to muscle disuse, so a brace works best alongside strengthening rather than in place of it. It is a short-term tool for managing pain during aggravating activities, not a fix, and it should not replace the home program.

The same goes for taping and shockwave therapy. Both can reduce pain and perform better when paired with exercise than used alone.

Cortisone injections

Injections can give faster relief early on. In one trial included in the review, the injection group did better around six weeks, but the physiotherapy group kept improving steadily up to 12 months. Steroids may slow tendon healing over the longer term, so it's worth discussing with your GP before undertaking any injections.

If you need your arm for work while having tennis elbow

Most people cannot reasonably stop gripping, especially at the workplace. We recommend modifying your load rather than resting. This could mean:

• ✔  Ease off grip force where you can.
• ✔  Use two hands instead of one.
• ✔  Keep the wrist closer to neutral.
• ✔  Cut back repetitive twisting and heavy lifting.
• ✔  Break tasks into shorter bouts with brief recovery in between.

Where possible, modify the heaviest or most repetitive duties, and use tools or a counterforce brace if they give relief. At Restore Physio, we build the strengthening program around your work demands, so rehab doesn't add load to an already fatigued arm.

When to get assessed for tennis elbow

We recommend consulting a physiotherapist in these scenarios:

When to expect recovery

Tendons adapt slowly, so expect recovery in six to 12 months. Finishing your strengthening program can prevent relapse and support long-term recovery.

If your elbow has been giving you grief, our physios in Kew will confirm the diagnosis and build a program around your work and sport. Book an appointment or read more about tennis elbow treatment at Restore.