Tennis elbow: why is cortisone a trap, and why is wait-and-see reasonable?

Short answer

Tennis elbow (lateral epicondylitis) is a problem caused by overload in the tendon of the wrist muscles that attach to the outer prominence of the elbow, and despite its name the great majority of patients do not play tennis — only a small portion of the cases seen in clinic are racket-sport players. The good news: its natural course is mostly benign; the great majority of cases improve within a year, often without any special treatment — for example, in the wait-and-see arm of the Smidt trial, one-year recovery was about 83%; the rate varies between studies according to follow-up duration, patient selection, and how "recovery" is defined.

The most critical fact concerns cortisone: a cortisone (corticosteroid) injection markedly reduces pain in the first weeks, but in randomized trials, at one year, those who had cortisone are worse off than those who did not — with lower full recovery and a much higher recurrence rate. Short-term relief comes at a long-term cost. The evidence-based approach is to regulate the loads that flare the pain, gradual strengthening exercise, and patience. This article is for general information; it does not replace a physician's examination and an individualized diagnosis.

Its name is tennis, but it isn't

Tennis elbow affects about 1–3% of the population and is most common in the 40s–50s. In clinical series, only a small minority of patients (about 5–10%) play tennis; the main large group is people who use the wrist and gripping intensely. In occupational studies, the strongest risks are forceful gripping, repetitive forearm rotation, and high mechanical load: tradespeople, assembly workers, and those who do housework and gardening are typical examples. A consistent independent causal link with the often-blamed keyboard-mouse use has not been shown. On the other hand, the probability of regular racket-sport players experiencing this problem in their lifetime is indeed high (rates of up to 40–50% have been reported) — so the name is not entirely unjust, but it is misleading.

The suffix "-itis" in "epicondylitis" denotes inflammation; yet in chronic cases the tissue shows not classic inflammatory cells but a deterioration in the tendon's structure (degenerative change). For this reason the current literature prefers the term "lateral elbow tendinopathy." This distinction is not theoretical: because the problem is not inflammation, treatments aimed at "extinguishing inflammation" (such as cortisone) do not fit the nature of the disease.

Natural course: time is on most patients' side

In a randomized trial in the Netherlands (Smidt, Lancet 2002), about 83% of patients assigned to the "wait-and-see" arm — that is, only informed and using simple painkillers when needed — were assessed as recovered at one year. Other follow-up studies support a similar picture: the great majority of cases improve within 6–24 months. Still, these rates are not a universal constant; they vary between studies according to follow-up duration, patient selection, and how "recovery" is defined. This does not mean "do nothing"; regulating the loads that flare the pain and correct information are part of the wait-and-see approach. But it does mean: before accepting an aggressive intervention, the disease's own tendency to heal must be taken into account. Cases that persist beyond a year without improvement should be evaluated separately.

The cortisone paradox: gain in the short term, loss in the long term

Tennis elbow is one of the best-documented examples in medicine of "short-term outcome conflicting with long-term outcome":

Coombes et al. (JAMA 2013): In a placebo-controlled randomized trial, cortisone injection reduced pain in the first weeks; however, at 1 year full recovery was 83% in the cortisone group and 96% in the placebo (saline) group, and recurrence was much higher in the cortisone group at 54% versus 12%. That is, far from speeding recovery, the injection delayed it and increased recurrence.
Bisset et al. (BMJ 2006): Cortisone was superior to physiotherapy and wait-and-see at 6 weeks; but at 1 year the worst outcome was in the cortisone arm and the recurrence rate exceeded 70%.
Coombes et al. (Lancet 2010) meta-analysis: showed with pooled data that the short-term benefit of cortisone in tendinopathies reverses in the medium-to-long term.

Possible explanations include the adverse effects of cortisone on tendon tissue and the "early and excessive loading once the pain is gone" behavior. The practical conclusion is clear: a cortisone injection should not be routine treatment in tennis elbow. In selected situations where pain is very severe and other paths have not worked, it may come up exceptionally, with this long-term cost discussed openly with the patient.

The backbone of treatment: load management and gradual exercise

Load management: The movements that flare the pain (tight gripping, carrying loads with the wrist bent up, repetitive screwing/mouse use) are not completely forbidden; their dose and form are regulated. For example, carrying loads with the palm facing up reduces the load on the outer elbow.
Gradual strengthening: Progressive programs including isometric, eccentric, and concentric exercises for the wrist-extending muscles are used. The honest framing is this: load management and exercise are often used because they are low-risk and suited to re-establishing function; however, the magnitude of their added effect independent of the natural course is uncertain — the 2022 Canadian Shoulder and Elbow Society position statement also found no significant difference between strengthening exercise and follow-up without active treatment. The approach is consistent with the loading logic in other tendinopathies; patience matters, and meaningful change usually takes weeks–months.
Wait-and-see or physiotherapy? In randomized trials, physiotherapy (manual therapy + exercise) provides faster recovery than wait-and-see in the first 6–12 weeks; at 1 year the two groups largely converge. That is, physiotherapy does not change the destination much but can shorten the journey; the decision is made together according to the patient's job, pain level, and expectations.

Other options: what does the evidence say?

Method	Evidence status
Epicondylitis brace (counterforce brace)	May reduce pain in the short term; evidence quality low. A cheap and harmless adjunct; not a treatment on its own
Shock wave therapy (ESWT)	Conflicting: older reviews showed no clear benefit while newer meta-analyses are favorable especially versus cortisone; the evidence is not as strong as in Achilles/heel spur. Can be tried in resistant cases
PRP (platelet-rich plasma)	Conflicting; in higher-quality placebo (saline)-controlled randomized trials PRP has not shown significant superiority over placebo. Not routinely recommended; cost and the limit of evidence should be discussed with the patient
Cortisone injection	Effective short-term, worse than placebo at 1 year; should not be used routinely
Painkillers / anti-inflammatory drugs	May help in short-term symptom control; no evidence that they change the course of the disease

The limited place of surgery

Surgery comes up only in a small group of patients who do not improve despite at least 6–12 months of properly applied conservative treatment. Here too the evidence is thought-provoking: in the randomized, double-blind trial by Kroslak and Murrell (Am J Sports Med 2018), no difference in outcome was found between real surgery, in which the degenerate tendon tissue was removed, and placebo (sham) surgery in which only a skin incision was made — and moreover both groups improved markedly even in patients who had had complaints for an average of six years. The study is small; it does not permit a definite verdict on the effectiveness of surgery, nor does it on its own invalidate surgery. But it shows that the "surgery is a definitive solution" narrative is not supported by evidence and that the surgical decision must be made very selectively.

For clinicians

The diagnosis is largely clinical: tenderness over the lateral epicondyle, pain with resisted wrist extension (Cozen) and the middle-finger test; routine imaging is not needed. In the differential, radial tunnel syndrome, posterolateral rotatory instability, cervical radiculopathy (C6–C7), and plica/intra-articular pathology should be kept in mind; some resistant "epicondylitis" cases are these. Coombes 2013 (2x2 factorial, n=165) showed that corticosteroid reduced 1-year full recovery (83% vs 96%) and multiplied recurrence (54% vs 12%); adding physiotherapy did not compensate for the adverse effect of the steroid. Since 1-year recovery in the wait-and-see arms is ~80–90%, "success" rates in single-arm case series should not be confused with the natural course — this is the main interpretive trap of the PRP/orthobiologic literature; in placebo-controlled RCTs (Krogh 2013, Linnanmäki 2020) PRP is no different from saline. Heterogeneity is high in ESWT (focused/radial, energy, protocol); although umbrella reviews report superiority over cortisone, the effect size versus placebo is modest. In a surgical candidate, the Kroslak-Murrell sham-controlled data should be shared (small study; does not permit a definite verdict on the effectiveness of surgery).

Frequently asked questions

I don't play tennis; why do I have tennis elbow?

The name is misleading: only a small portion of the patients seen in clinic are racket-sport players. The main cause is repetitive and unaccustomed loading of the wrist-extending muscles — forceful gripping, repetitive forearm rotation, and jobs involving high mechanical load (working with hand tools, carrying, house-garden work) are the strongest known risks. An independent causal role for the often-blamed mouse/keyboard use has not been consistently shown. Age also plays a role; the tendon's load capacity decreases from the 40s onward.

Does it resolve on its own, or is treatment essential?

About 80–90% of cases improve within a year; for this reason "wait-and-see" with information and load regulation is a legitimate option for many patients. Physiotherapy can speed this process but does not change the picture much at one year. If your pain is severe, hinders your work, or exceeds a year, evaluation is needed.

My doctor recommended a cortisone injection; should I have it?

The decision is yours, but make it knowing the evidence: cortisone markedly reduces pain in the first weeks, but in randomized trials, at one year, those who had cortisone had lower recovery and a much higher recurrence rate than those who did not. Current evidence does not support the routine use of cortisone in tennis elbow; the long-term cost of short-term relief should be discussed openly with your physician.

Does an epicondylitis brace (strap) work?

A brace worn on the forearm can reduce pain in the short term by distributing the load on the tendon; although the evidence quality is low, it is cheap and harmless. Using it especially while working is reasonable — but a brace is not a treatment on its own; it does not replace load management and exercise.

Should I try PRP or shock wave therapy?

The evidence in shock wave therapy (ESWT) is conflicting; it is a generally safe option that can be tried in resistant cases. In PRP, quality placebo-controlled studies have not shown significant superiority; because the disease tends to resolve on its own anyway, "I got better after PRP" experiences can be misleading. In both, cost and the limit of the evidence should be discussed beforehand.

When does surgery come up?

Only in selected cases that do not improve despite 6–12 months of properly applied conservative treatment. It should also be known that: in a randomized, double-blind trial, no difference in outcome was found between real surgery and sham (placebo) surgery. This does not prove that surgery does not work at all, but it shows that it is not a "definitive solution"; the decision should be made very selectively.

Scientific references

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):461-9.
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. Lancet 2010;376:1751-67.
Smidt N ve ark. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62.
Canadian Shoulder and Elbow Society (CSES). Position statement: nonoperative management of lateral epicondylitis in adults. Can J Surg 2022;65(5):E625-E629.
Bisset L ve ark. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ 2006;333:939.
Kroslak M, Murrell GAC. Surgical treatment of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2018;46(5):1106-13.
Krogh TP ve ark. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med 2013;41(3):625-35.
Linnanmäki L ve ark. Platelet-rich plasma or autologous blood do not reduce pain or improve function in patients with lateral epicondylitis: a randomized controlled trial. Clin Orthop Relat Res 2020;478(8):1892-900.
Simental-Mendía M ve ark. Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: a systematic review and meta-analysis of randomized placebo-controlled clinical trials. Clin Rheumatol 2020;39:2255-65.
Sanders TL ve ark. The epidemiology and health care burden of tennis elbow: a population-based study. Am J Sports Med 2015;43(5):1066-71.
Shahabi S ve ark. The effects of counterforce brace on pain in subjects with lateral elbow tendinopathy: a systematic review and meta-analysis of randomized controlled trials. Prosthet Orthot Int 2020;44:341-54.
Buchbinder R ve ark. Shock wave therapy for lateral elbow pain. Cochrane Database Syst Rev 2005;(4):CD003524.
Zhang L ve ark. Extracorporeal shock wave therapy versus local corticosteroid injection for chronic lateral epicondylitis: a systematic review with meta-analysis of randomized controlled trials. Orthop Surg 2024;16(11):2598-607.

This information is for general guidance only; it does not replace an examination, a diagnosis, or your physician's individual advice. Please consult a physician for your symptoms. About the author: Doç. Dr. Oğuz Yüksel — Academic Profile.