Tennis Elbow & Golfer's Elbow Treatment in Salt Lake City — Physical Therapy That Works

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Quick Answer: Tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis) are tendon overload injuries — not inflammation, despite the “-itis” suffix. The most effective treatment is a progressive eccentric loading program combined with manual therapy and dry needling, not rest alone. Most patients recover fully in 6–12 weeks with the right approach. Cortisone injections provide short-term relief but worsen long-term outcomes.

If you’re dealing with elbow pain that won’t go away — gripping a coffee mug hurts, shaking hands is painful, or you can’t open a jar without wincing — you probably have a tendinopathy. And it’s probably been bothering you for weeks or months because the advice you’ve received so far (rest, ice, brace, anti-inflammatories) isn’t addressing the actual problem.

I’m Dr. Emily Warren, a physical therapist with over 14 years of clinical experience in Cottonwood Heights, Utah. I treat tennis elbow and golfer’s elbow regularly, and I want to explain why these conditions persist, what’s actually happening in your tendon, and how we fix it.

Tennis Elbow vs. Golfer’s Elbow: What’s the Difference?

Both conditions involve tendon overload at the elbow, but they affect different sides:

Lateral Epicondylitis (Tennis Elbow)

• Pain on the outside of the elbow
• Involves the common extensor tendon, primarily the extensor carpi radialis brevis (ECRB)
• Aggravated by gripping, wrist extension, and forearm supination
• Most common: affects 1–3% of the general population (Shiri et al., American Journal of Epidemiology, 2006)
• Despite the name, only 5% of cases are related to tennis. Most are from occupational or daily activities — typing, mouse use, tool use, cooking, gardening

Medial Epicondylitis (Golfer’s Elbow)

• Pain on the inside of the elbow
• Involves the common flexor-pronator tendon
• Aggravated by gripping, wrist flexion, and forearm pronation
• Less common than tennis elbow (roughly 1/3 as prevalent)
• Often seen in climbers, weightlifters, manual laborers, and — yes — golfers

The Key Insight: It’s Not Inflammation

The traditional understanding of these conditions as “tendinitis” (inflammation of the tendon) has been thoroughly debunked. Histological studies by Kraushaar and Nirschl (Journal of Bone and Joint Surgery, 1999) showed that chronic lateral epicondylitis demonstrates tendinosis — degenerative changes in the tendon collagen — not active inflammation.

This matters because it changes the entire treatment approach. If the problem isn’t inflammation, then anti-inflammatory treatments (ice, NSAIDs, cortisone injections) are addressing the wrong mechanism. The actual problem is a tendon that has failed to properly heal and remodel, and the solution is controlled loading to stimulate tendon repair.

Why Rest Doesn’t Work (And Can Make It Worse)

I know this sounds counterintuitive. Your elbow hurts, so you rest it. That should help, right?

Here’s the problem: tendons need mechanical load to heal. When you rest a tendon completely, it undergoes further deconditioning — the collagen fibers become disorganized, the tendon loses its mechanical properties, and it becomes even less able to handle normal daily loads.

This is why many people with tennis elbow report that it felt better during a vacation (reduced activity) but came back worse when they returned to normal life. The tendon didn’t heal during rest — it deconditioned. Then when normal loads resumed, it failed again.

The research is clear on this. A landmark study by Bisset et al. (BMJ, 2006) followed lateral epicondylitis patients for one year and found that the “wait and see” approach (rest) had worse outcomes than physiotherapy at every time point up to 6 weeks. More importantly, they found that cortisone injections — while providing short-term relief — resulted in significantly worse outcomes at 12 months compared to both physiotherapy and wait-and-see.

Let that sink in: the most commonly prescribed medical treatment for tennis elbow (cortisone) produces the worst long-term outcomes.

The Eccentric Loading Protocol

The cornerstone of my treatment for tennis and golfer’s elbow is progressive eccentric loading. This approach was pioneered by Alfredson for Achilles tendinopathy and adapted for the elbow by Tyler et al. (Journal of Hand Therapy, 2010) using the FlexBar protocol.

What Is Eccentric Loading?

An eccentric contraction is when a muscle lengthens under load — the lowering phase of a bicep curl, for example. Eccentric loading specifically stresses the tendon in a way that stimulates collagen remodeling and reorganization. It’s essentially telling the tendon: “You need to get stronger in this specific way.”

The Tyler Twist (FlexBar Protocol)

For lateral epicondylitis, I teach the Tyler Twist using a TheraBand FlexBar:

1. Hold the FlexBar vertically in front of you with the affected hand on top
2. Twist the bar with the unaffected hand (wrist flexion)
3. Bring both hands in front of you, elbows extended
4. Slowly allow the affected wrist to extend (untwist) — this is the eccentric load
5. 3 sets of 15 repetitions, twice daily

Tyler’s research showed that this protocol produced a 72% improvement in pain scores and a 92% improvement in strength scores over an 8-week period. Those are remarkable results for a condition that often lingers for months with conventional treatment.

For medial epicondylitis, I use a modified version — the reverse Tyler Twist — which eccentrically loads the flexor-pronator group.

Progressive Loading Principles

The FlexBar is just the starting point. I progress patients through:

1. Isometric holds — pain-free tendon loading to start (especially if pain is acute)
2. Eccentric FlexBar protocol — the main treatment phase
3. Heavy slow resistance — weighted eccentric/concentric exercises at higher loads
4. Sport/activity-specific loading — gradually reintroducing the specific demands that caused the problem

The key principle: load must be progressive. Too much too soon re-aggravates the tendon. Too little fails to stimulate adaptation. I adjust your program based on your response — monitoring pain during exercise, pain within 24 hours after exercise, and functional improvement.

Dry Needling for Elbow Tendinopathy

Dry needling is one of my most effective tools for tennis and golfer’s elbow, and it works through multiple mechanisms.

Directly Into the Tendon

For chronic tendinopathies, I use a technique called percutaneous needle tenotomy — inserting the needle directly into the damaged tendon tissue. This creates a controlled micro-trauma that triggers a healing cascade: increased blood flow, release of growth factors, and stimulation of collagen synthesis.

A randomized controlled trial by Stenhouse et al. (Journal of Shoulder and Elbow Surgery, 2013) found that dry needling of the common extensor tendon produced significant improvements in pain and function at 6-month follow-up.

Muscle Trigger Points

I also needle the muscles associated with elbow tendinopathy:

• Extensor carpi radialis brevis and longus — directly involved in lateral epicondylitis
• Supinator — often harbors trigger points that refer to the lateral elbow
• Common flexor group — for medial epicondylitis
• Forearm extensors/flexors — downstream muscles that compensate and develop their own trigger points

The combination of tendon needling and muscular dry needling addresses both the structural tendon problem and the secondary muscle dysfunction that develops around it.

Manual Therapy

In addition to loading and dry needling, I use specific manual therapy techniques:

Joint Mobilization

The elbow is a complex joint — actually three joints in one (humeroulnar, humeroradial, and proximal radioulnar). Stiffness or restriction in any of these can alter mechanics and contribute to tendon overload. I assess and mobilize as needed, particularly the radial head, which is often restricted in tennis elbow patients.

Neural Mobilization

The radial nerve passes directly through the area affected by lateral epicondylitis. In some cases, radial nerve irritation mimics or coexists with tennis elbow — a condition sometimes called “radial tunnel syndrome.” I test for neural involvement and use nerve gliding techniques when indicated.

Cervical and Thoracic Assessment

Here’s something most providers miss: elbow tendinopathy can be influenced by the cervical spine. The C5-6 nerve root innervates the wrist extensors, and cervical dysfunction at these levels can sensitize the peripheral tissues, making the tendon more pain-sensitive and slower to heal.

I always screen the cervical and thoracic spine in elbow patients. If I find a cervical component — and I do more often than you’d expect — addressing it with the McKenzie Method accelerates elbow recovery.

What NOT to Do

Based on current evidence, here’s what I advise against:

Cortisone Injections

I mentioned the Bisset study above. Additional research by Coombes et al. (JAMA, 2013) confirmed that corticosteroid injections for lateral epicondylitis produce worse outcomes than placebo at one year. They provide 4–6 weeks of pain relief, but they weaken the tendon collagen and increase recurrence rates. If you’ve already had a cortisone injection, don’t panic — we can still treat effectively, but we need to account for the tendon’s compromised state.

Complete Rest

As discussed above, complete offloading allows further tendon degeneration. Relative rest — modifying aggravating activities while maintaining controlled therapeutic loading — is the correct approach.

Aggressive Stretching

Forceful stretching of an irritated tendon can aggravate symptoms. Gentle stretching has a role later in rehabilitation, but it’s not a primary treatment and shouldn’t be painful.

“Pushing Through” Pain

On the flip side, ignoring pain and continuing aggravating activities without modification will perpetuate the injury cycle. There’s a balance between load and rest, and finding that sweet spot is exactly why professional guidance matters.

A Patient Story

A 45-year-old avid rock climber came to me after dealing with medial elbow pain for five months. He’d tried rest (two months off climbing), a cortisone injection, and a forearm brace. The pain improved temporarily each time but returned as soon as he resumed climbing.

On examination, he had significant tenderness at the medial epicondyle, pain with resisted wrist flexion and pronation, and notable weakness in grip strength compared to his unaffected side. I also found restricted C6-7 cervical rotation and a trigger point in his pronator teres that reproduced his medial elbow pain.

His program:

• Weeks 1–2: Cervical McKenzie exercises to address the C6-7 restriction, isometric wrist flexion holds (pain-free), dry needling to the medial epicondyle and pronator teres
• Weeks 3–6: Progressive reverse Tyler Twist protocol, continued dry needling every 2 weeks, manual therapy for radial head mobilization
• Weeks 7–10: Heavy slow resistance training, gradual return to climbing (starting with easy routes, low volume)
• Weeks 11–12: Full climbing progression, discharge with maintenance program

By week 6, his pain was down 80%. By week 12, he was climbing at his pre-injury level with no pain. That was over a year ago — no recurrence.

As one of my patients shared in a review: “Dr. Warren identified my back and leg issues within just a few appointments, leading to immediate improvements.” The same investigative approach — finding the root cause, not just chasing symptoms — is what resolves stubborn elbow problems too.

When to Seek Help

You should see a physical therapist for your elbow pain if:

• It’s been present for more than 2–3 weeks and isn’t improving
• It’s affecting your ability to work, exercise, or do daily tasks
• Gripping, lifting, or twisting aggravates it
• You’ve tried rest and bracing without lasting improvement
• You’ve had a cortisone injection that provided only temporary relief
• The pain is spreading into your forearm or wrist

Early intervention produces better outcomes. A tendinopathy caught at 4 weeks responds faster than one that’s been smoldering for 6 months. Don’t wait for it to become chronic.

If you’re also dealing with any red flag symptoms — significant swelling, redness, fever, or sudden inability to move the elbow after a trauma — see a physician first to rule out fracture, infection, or ligament injury.

FAQ

How long does tennis elbow take to heal with physical therapy?

Most patients see significant improvement within 6–8 weeks and are fully recovered by 12 weeks. Chronic cases (6+ months of symptoms) may take longer — up to 16 weeks — because the tendon degeneration is more advanced. The eccentric loading protocol requires consistent daily exercise, so patient compliance is a major factor in recovery speed.

Should I wear a tennis elbow brace?

A counterforce brace (the strap that goes around your forearm) can reduce pain during activities by offloading the tendon attachment. It’s a useful short-term tool for managing symptoms while you’re doing the rehabilitation work. But it’s not a treatment — it doesn’t fix the underlying tendinopathy. Think of it as a crutch while you strengthen the leg.

Can I still exercise with tennis or golfer’s elbow?

Yes — in fact, you should stay active. Avoid or modify activities that directly aggravate your elbow (heavy gripping, repetitive wrist movements), but continue cardiovascular exercise and lower body training. Maintaining overall fitness supports recovery. I’ll help you identify exactly which activities to modify and which are safe to continue.

Is dry needling effective for tennis elbow?

Yes. Multiple studies support dry needling for lateral and medial epicondylitis. It reduces pain, stimulates tendon healing, and addresses muscular trigger points that contribute to the problem. Most patients notice improvement after 2–3 needling sessions combined with their loading program.

Why didn’t my cortisone injection work long-term?

Cortisone is an anti-inflammatory, but chronic tendinopathy is a degenerative condition, not an inflammatory one. The injection suppresses pain temporarily but doesn’t stimulate tendon healing — and evidence suggests it actually impairs healing by weakening collagen. This is why the pain returns (and often worsens) after the injection wears off.

Do I need an MRI or ultrasound before starting treatment?

Not typically. Tennis and golfer’s elbow are clinical diagnoses — I can identify them through history and physical examination. Imaging is useful if I suspect a tendon tear, loose body, or other structural pathology, but for the majority of tendinopathy cases, we can begin treatment immediately based on the clinical findings.

Get Your Elbow Fixed — For Good

If you’re tired of dealing with elbow pain that keeps coming back despite rest, braces, and injections, it’s time for a different approach. Eccentric loading, dry needling, and manual therapy address the actual tendon pathology — not just the symptoms.

Book your evaluation online or call/text (385) 332-4939. I offer cash-pay physical therapy with full hour-long sessions — no insurance referrals, no visit limits, no waiting weeks to be seen.

My clinic is located in Cottonwood Heights, serving the entire Salt Lake City area.

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About the Author

Dr. Emily Warren, DPT, is the owner of Mindful Movement Physical Therapies in Cottonwood Heights, Utah. With over 14 years of clinical experience, she specializes in spine care, dry needling, tendinopathy treatment, and the McKenzie Method. She is recognized as one of the best physical therapists in Salt Lake City.