Tendon Archives - Praxis Physiotherapy

Why Tennis Elbow Takes So Long to Get Better (And What Actually Works)

by Stephen Timms | Feb 21, 2026 | Elbow, Pain, Sports Injury, Tendon

Ifyou’ve had tennis elbow (also called lateral epicondylalgia), you’ll know it’s not just a “sore elbow.”It’s pain when lifting a coffee cup. Pain shaking hands. Pain turning a door handle. Pain gripping the gym bar or picking up your kids.

And frustratingly, it can hang around for months. So why does tennis elbow take so long to improve? And are injections like cortisone really the quick fix people hope they are?

Let’s unpack it during this installment of Praxis What You Preach

First — It’s Not Really “Inflammation”

Despite the name lateral epicondylitis, most modern research shows that tennis elbow is not primarily an inflammatory condition.

Histological studies consistently demonstrate degenerative tendon changes such as disorganised collagen, increased fibroblasts and vascular changes — rather than classic inflammatory cells. In other words, it’s more accurate to call it a tendinosis or tendinopathy rather than a true “-itis” condition (Herd & Meserve, 2008; Pathan & Sharath, 2023).

This distinction matters. Inflammatory problems (like a sprained ankle in the first few days) often respond quickly to anti-inflammatory treatments.

Degenerative tendon problems do not.

What’s Actually Happening?

In around 90% of cases, the extensor carpi radialis brevis (ECRB) tendon is involved (Pathan & Sharath, 2023). This tendon is heavily loaded during gripping and wrist extension — especially repetitive tasks like typing, manual labour, racquet sports, or gym training.

Over time, repeated micro-loading can exceed the tendon’s capacity. When the tendon fails to adapt effectively, it begins to:

Lose collagen organisation
Develop microtears
Show reduced tensile capacity
Become painful with load

This process develops gradually. And that’s one key reason recovery isn’t instant.

“But I’ve Rested It — Why Is It Still Sore?”

Because tendons don’t heal well with complete rest. They need progressive, appropriate load to stimulate remodelling.

Without mechanical stimulus:

Collagen alignment worsens
Tendon capacity reduces
Grip strength declines
Pain can actually persist longer

This is why high-quality physiotherapy programs focus on graded strengthening, tendon capacity rebuilding, and load modification, rather than pure rest (Pathan & Sharath, 2023; Yelland et al., 2019).

Natural History: Does It Just Go Away?

Tennis elbow is often described as “self-limiting.” Some reports suggest many cases improve within 8–12 months (Houck et al., 2019), and older literature even suggested high rates of improvement at one year (Herd & Meserve, 2008).

However, that doesn’t mean:

It resolves quickly
It resolves optimally
It resolves without recurrence
It resolves without strength deficits

Up to 10% of patients develop persistent symptoms severe enough to consider surgery (Yelland et al., 2019).

And in working adults, particularly manual workers, the functional and economic impact is significant.

So while time helps, structured intervention helps more.

What About Cortisone Injections?

Corticosteroid injections are still widely used for tennis elbow. They are:

Relatively inexpensive
Quick to administer
Often very effective for short-term pain relief

And the evidence supports that. Multiple systematic reviews demonstrate that corticosteroid injections are more effective than other treatments in the short term (typically under 12 weeks) (Houck et al., 2019).

The problem? The long term. The same high-level evidence shows that corticosteroid injections:

Provide only temporary benefit
Are associated with worse long-term outcomes compared to physiotherapy or even a wait-and-see approach (Coombes et al., 2013)
Are less effective than platelet-rich plasma (PRP) in the intermediate and longer term (Houck et al., 2019; Kemp et al., 2021)

A 2021 systematic review of systematic reviews concluded:

Cortisone = better short-term pain relief
PRP = better long-term pain relief and improved function (Kemp et al., 2021)

From a cost-effectiveness perspective, physiotherapy was favoured as a first-line option, while corticosteroid injections showed greater variability and lower probability of being cost-effective over 12 months (Coombes et al., 2013).

Why Might Cortisone Underperform Long Term?

Corticosteroids:

Suppress inflammation
Reduce pain rapidly
Do not improve tendon structure
May temporarily weaken tendon tissue

In degenerative tendinopathy, masking pain without improving load capacity can lead to premature return to aggravating activities, and recurrence. For this reason, corticosteroid injections are rarely our first-line strategy at Praxis.

What About PRP?

Platelet-Rich Plasma (PRP) is a biological injection derived from your own blood. It contains concentrated platelets and growth factors intended to stimulate tissue repair.

The evidence is not perfect but it is increasingly supportive in certain contexts.

A large systematic review and meta-analysis found that PRP resulted in improvements exceeding minimal clinically important difference (MCID) thresholds across commonly used outcome measures (VAS, DASH, PRTEE) from 4 weeks through to 104 weeks in many studies (Niemiec et al., 2022).

When compared directly to corticosteroid injections:

Cortisone tends to win early
PRP tends to win at 3–12 months (Houck et al., 2019; Kemp et al., 2021)

The 2021 review in the International Journal of Sports Physical Therapy concluded that PRP appears to be a more effective long-term treatment option for patients who have failed conservative care (Kemp et al., 2021).

Important Caveats

PRP:

Is not a magic bullet
Has variability in preparation methods
Works best when combined with appropriate load rehabilitation

At Praxis, if PRP is considered, it is typically:

For recalcitrant cases
After structured rehab has failed
Integrated into a progressive strengthening program

So What Actually Works Best?

High-quality evidence consistently supports physiotherapy-directed exercise programs for both short- and long-term improvement (Yelland et al., 2019; Pathan & Sharath, 2023).

Manual therapy combined with exercise has demonstrated meaningful clinical benefits compared to placebo or corticosteroid injection (Yelland et al., 2019).

There is also evidence supporting certain manipulative therapy techniques for symptom reduction (Herd & Meserve, 2008), though exercise remains the cornerstone of recovery.

Importantly, a well-designed physiotherapy program is not just:

“Do some wrist curls”
“Stretch your forearm”
“Wear a brace”

Effective rehab addresses:

Tendon load tolerance
Grip strength deficits
Kinetic chain contributions (shoulder and cervical loading)
Work or sport-specific demands
Progressive capacity building
Assessment of cervical and local nerve contributors to pain and dysfunction

We don’t give away all the details publicly, but it’s far more nuanced than a generic exercise sheet.

Why It Takes Time

Tendons remodel slowly. Unlike muscle tissue, which may respond in weeks, tendon adaptation can take:

8–12 weeks for meaningful structural adaptation
3–6 months for substantial capacity restoration
Longer in chronic cases

And if the condition has been present for 6–12 months already, the tissue changes are well established.

Add to that:

Poor early management
Repeated cortisone injections
Ongoing load without strength progression
High occupational demands

And recovery timelines extend further.

The Takeaway

Tennis elbow takes time because:

It is primarily degenerative, not inflammatory (Herd & Meserve, 2008; Pathan & Sharath, 2023)
Tendons adapt slowly
Quick fixes often don’t address load capacity
Short-term pain relief is not the same as long-term recovery

Cortisone may reduce pain quickly — but does not appear to be the best long-term solution (Houck et al., 2019; Coombes et al., 2013).

PRP shows more promising longer-term outcomes in persistent cases (Niemiec et al., 2022; Kemp et al., 2021) — but still works best when combined with progressive rehabilitation.

Tennis elbow rarely improves by accident — it improves with the right load, at the right time.

If you’re tired of resting, taping, or chasing temporary fixes, our team can guide you through a structured, evidence-based program designed to rebuild tendon capacity and reduce recurrence.

Book an appointment at one of our Brisbane clinics today and start moving forward with a clear plan.

Until next time, Praxis What You Preach…

📍 Clinics in Teneriffe, Buranda, and Carseldine

💪 Trusted by athletes. Backed by evidence. Here for everyone.

Achilles Tendinopathy: How to treat your Achilles Pain

by Stephen Timms | Jul 31, 2023 | Ankle and Foot, Return to Sport, Running Injuries, Tendon

Today on the Praxis What We Preach blog, where we shed light on Achilles tendinopathy, a common condition affecting athletes and active individuals. In this article, we will explore the causes, symptoms, and effective treatment strategies for managing Achilles tendinopathy, empowering suffers to return to the things. I draw from personal experience from someone who has had Achilles pain limit my running!

Achilles tendinopathy refers to the degeneration or overload of the Achilles tendon, the band of tissue connecting the calf muscles to the heel bone (calcaneus). This condition primarily affects people engaged in activities involving repetitive jumping, running, or sudden increases in training intensity. Patients with Achilles tendinopathy often experience pain, stiffness, and swelling in the achilles, which can gradually worsen over time. Stiffness and pain is most commonly experienced first thing in the morning, after a long period of sitting or when the achilles has been compressed. Pain can occur in the “mid portion” (pictured below) on in the insertion (as it attaches to the heel bone). This is in an important distinction as these are rehabilitated differently!

Mid Potion Achilles Tendinopathy Location

Causes and Risks

Achilles tendinopathy typically results from a combination of intrinsic and extrinsic factors. Intrinsic factors include age, reduced flexibility, reduced calf strength / endurance and poor lower limb biomechanics. Extrinsic factors encompass inappropriate footwear, training errors (such as a spike or change in workload), and inadequate warm-up or cool-down routines. Additionally, individuals with systemic conditions like diabetes or rheumatoid arthritis may be more prone to developing Achilles tendinopathy. Understanding these factors is crucial for tailoring treatment plans to address the root causes and minimize the risk of recurrence. But in the most reductionist of terms, Achilles tendinopathy develops due in large part due to a mismatch between loading and the capacity of the tissue.

Diagnosis and Assessment

Accurate diagnosis of Achilles tendinopathy relies on a thorough clinical examination and patient history. Physiotherapists employ various assessment techniques, such as palpation, functional tests, and imaging modalities like ultrasound or MRI, to evaluate the severity and extent of the condition. A self administered questionnaire (VISA-A) can help evaluate symptoms and their effect on physical activity and in turn, the clinical severity. This comprehensive assessment helps determine the appropriate treatment approach, including targeted exercise programs, manual therapy, and other interventions.

Treatment Strategies

Physiotherapy plays a pivotal role in the management of Achilles tendinopathy. Treatment strategies focus on reducing pain, promoting healing, and improving function. These will include calf strengthening exercises, stretching routines and activity modification as frontline options. Moreover, physiotherapists can guide patients in proper footwear selection, gait retraining, and implementing preventive measures to minimize the risk of reinjury.

Rehabilitation and Prevention

Rehabilitation programs are essential for individuals recovering from Achilles tendinopathy. Gradual progression of exercise intensity, functional training, and sport-specific drills enable patients to regain strength, flexibility, and proprioception while minimizing the risk of relapse. Educating patients on proper warm-up and cool-down routines, appropriate footwear selection, and regular monitoring of training loads can significantly contribute to preventing Achilles tendinopathy in the future. One of the common errors patients make is making rehabilitation too easy, or returning to sport too quickly. Again, physiotherapy play a pivotal role in ensuring you undertake a graduated return to loading as the application of mechanical stress to the Achilles tendon promotes tendon healing and remodeling.

Conclusion

Achilles tendinopathy requires a comprehensive approach for effective management. As physiotherapists, our knowledge and expertise are invaluable in helping you overcome this condition and return to their active lifestyles. To discuss your Achilles issues with us to get you back to what you love doing, book online with Praxis today.

Until next time, Praxis What Your Preach.

Team Praxis

Jumper’s Knee (Patellar Tendinopathy)

by Stephen Timms | May 17, 2022 | Knee, Return to Sport, Sports Injury, Tendon

Do you play a jumping sport such as volleyball, basketball or AFL? Have pain in the front of your knee when jumping, landing or changing direction? Have you lost some jumping power recently? Well read on friends as you may have a grumbly knee tendon.

Summary:

Patellar tendinopathy is summarised clinically as pain and dysfunction in the patellar tendon
Most commonly affects jumping athletes from adolescence to early middle age.
Return to sport can be slow with physio useful as a front line management tool
Often requires prolonged rehabilitation centred around education, strength training and load management

Jumper’s knee (or patellar tendinopathy) as its name suggest predominantly affects athletes who engage in sports which require large volumes of jumping. Jumping dynamically loads the knee and places large loads on the patellar tendons due the large and repeated requirements of the thigh muscles (quadriceps). These include sports that require repeat jump / landing efforts and/or high volumes of load during training and competition. Elite adolescent male athletes tend to be at a higher risk, especially if you play volleyball.

Like most injuries, patellar tendinopathy reflects an overload of the tissue and a failed healing response. Tendons tend to most susceptible to long periods of dynamic loading given their role in storing and releasing energy like a spring. The stiffer the spring, the more effective the spring and the more punishment it can take before the function deteriorates.

This injury is one that can be mild or moderate in nature and as such allow playing to some degree. As such, player’s tend to not to miss a lot of games like more “traditional” injuries such as ankle sprains or hamstring tears. It can typically slowly present and have a “warm up phenomena” (as in it can get better during a game), however aches after activity and the next morning. The pain is often at the very bottom of the knee cap, and on the space between the kneecap and the top of the shin bone where the tendon lies.

Key management strategies include ensuring the correct diagnosis and an understanding of tendon pathology (for more on tendon pathology, check out this blog). From there, pain management strategies and workload management is a key tenant to rehabilitation. Above and beyond workload management and good patient education, we at Praxis Physio also test the strength and range of the hip, knee and ankle musculature as well as jumping / landing biomechanics to understand where the likely reasons are for your knee pain.

After a comprehensive assessment, targeted and graduated strengthening is provided. The premise of these early phases are to reduce pain, improve strength, improve function, increase power (specifically the energy storage potential of the tendon) then finally sports specific training and management on symptoms.

As someone who has had an 18 month history of patellar tendinopathy, I personally can attest to the frustration this injury provides. I made many mistakes along my rehabilitation journey – though this was before I was a physiotherapist and took a clinical interest in tendinopathies. Thankfully, the research has come a long way in the last decade, so if you are having ongoing knee pain that you suspect is jumper’s knee, book in with us so we can get you jumping back to your best.