The "-itis" names lie. Once the pain is more than a few weeks old there is little inflammation left in the tissue β what you find is a tendon that lost its tight collagen structure and is repairing slower than you're loading it 1. So you can't anti-inflame your way out. The tendon needs a different signal, and that signal is load 2.
The cortisone shot backfires. Across three trials in tennis elbow it looked best at six weeks and worst at a year: one found about 54% recovered with the shot versus 78% with a placebo injection, and adding physiotherapy didn't rescue it 3 4 5. The likely trap: it kills the pain, so you load the tendon straight back into trouble.
Slow loading does the opposite. A daily eccentric wrist exercise added to standard care beat standard care alone 6, and progressive loading is the endorsed cornerstone across tendinopathies 7. If it hurts too much to move, holding a load still calms the pain for hours 8.
The wrist is the exception. De Quervain's, the thumb-side one, responds to a single well-placed shot: about five in six cured at six weeks versus one in seven with a splint alone 9. One shot, not three.
Turn the aggravating activity down, don't stop it. Then load the tendon daily.
Holds quiet the pain in a day or two. The loading work usually shows an obvious shift by week three or four 6: grip returns, the kettle and the jar stop being a problem, people stop asking about your arm. By months two and three the sport or the job comes back at graded volume. Most people recover within one to two years anyway 10; the point is to get there faster and skip the shot that leaves a chunk of people worse off.
The fine print β when to skip it, and what people get wrong
Why it stalls: you resumed full activity the day pain dropped (pain heals before the tendon does); you never made the load harder; or you quit before week four, when the effect shows 6.
Get checked first if: a sudden tearing feeling or you can't use the arm; night pain, fever, or weight loss; finger numbness or weakness; or many sore joints with morning stiffness. On fluoroquinolone antibiotics or with poor diabetes control, start light.
Rest deconditions the tendon and the pain returns on resumption. Anti-inflammatories dull pain but leave the tissue unchanged 1. A scan shows the tendon's appearance, which tracks poorly with how much it hurts.
- 1Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF (2002). Time to abandon the "tendinitis" myth: painful, overuse tendon conditions have a non-inflammatory pathology. BMJ. link
- 2Cook JL, Purdam CR (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. link
- 3Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B (2013). Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. link
- 4Smidt N, van der Windt DA, Assendelft WJ, DevillΓ© WL, Korthals-de Bos IB, Bouter LM (2002). Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. The Lancet. link
- 5Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B (2006). Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. link
- 6Tyler TF, Thomas GC, Nicholas SJ, McHugh MP (2010). Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. Journal of Shoulder and Elbow Surgery. link
- 7Vicenzino B, de Vos RJ, Alfredson H, Bahr R, Cook JL, Coombes BK, et al. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy. British Journal of Sports Medicine. link
- 8Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine. link
- 9Peters-Veluthamaningal C, van der Windt DA, Winters JC, Meyboom-de Jong B (2009). Corticosteroid injection for de Quervain's tenosynovitis. Cochrane Database of Systematic Reviews. link
- 10Sayegh ET, Strauch RJ (2015). Does nonsurgical treatment improve longitudinal outcomes of lateral epicondylitis over no treatment? A meta-analysis. Clinical Orthopaedics and Related Research. link
Related in the handbook (8)
- β Taken with vitamin C before your loading exercises, collagen may give the tendon a little extra raw material to rebuild with.
- β The loading protocol that actually fixes tennis and golfer's elbow is built on slow eccentric reps.
- β If a tendon flared up right after an antibiotic course, ask which one β this whole drug class can damage tendons and even rupture them.
- β Wrist and hand symptoms overlap with carpal tunnel; sort out whether it's tendon or pinched nerve.
- β Hip-side tendon pain follows the same load-it-don't-rest-it rule as the elbow and wrist tendons.
- β Heel and Achilles tendons follow the exact rule your elbow does: load it, don't rest it.
- β A cranky cuff and a cranky elbow share the same cause and the same loading fix.
- β Awkward wrist angles at the keyboard are a classic driver of forearm tendon pain β fix the geometry first, then load the tendon back up.