The Cortisone Shot Won at Six Weeks. Physiotherapy Won at 52. Here's What That Means.

This study is now a foundational reference for how tennis elbow should be managed. It is worth understanding in detail — because the pattern it revealed still plays out in clinical practice every day.

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The Problem the Research Was Trying to Solve

Corticosteroid injection for tennis elbow has been in use since the 1950s. Clinically, the results look good in the short term: pain settles rapidly, patients report improvement, and the treatment is quick and definitive. For many clinicians and patients, injection feels like the obvious choice — particularly when the alternative, physiotherapy, requires ongoing appointments and effort over weeks.

The problem is that short-term outcomes and long-term outcomes are not the same thing. And for a condition that typically lasts six to 24 months, the distinction matters enormously.

By the early 2000s, there was a growing body of evidence suggesting that corticosteroid injection for tendinopathy might be producing short-term improvements that came at the expense of long-term recovery — potentially disrupting the matrix remodelling processes that tendon repair depends upon. What the field lacked was a large, well-conducted randomised trial that followed patients long enough to see the full picture.

The Brisbane-based research group led by Bill Vicenzino and Leanne Bisset at the University of Queensland designed exactly that trial.

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The Study: What They Did and What They Found

Bisset and colleagues recruited 198 participants from community settings in Brisbane with a clinical diagnosis of tennis elbow (lateral epicondylalgia) of at least six weeks' duration. [1] Participants were randomised to one of three groups: eight sessions of physiotherapy — consisting of mobilisation with movement (MWM) at the elbow, manipulation, and progressive exercise — a single corticosteroid injection, or a wait-and-see approach with reassurance and analgesia as needed.

At six weeks: the injection group was significantly superior on every primary outcome — pain, global improvement, and grip strength. The physiotherapy group was better than wait-and-see, but meaningfully behind injection. If the trial had ended here, the conclusion would have been straightforward: injection works best.

At 52 weeks: the picture reversed dramatically. The physiotherapy group achieved a global success rate of 72% — meaning nearly three-quarters of participants had meaningfully improved at one year. The wait-and-see group had largely caught up over the year of natural recovery: 56% success. The injection group, by contrast, had a success rate of just 9% — because the majority of those who had improved at six weeks had relapsed. The recurrence rate following corticosteroid injection was significantly higher than in both other groups. [1]

The injection group also sought more additional treatment over the course of the year — more anti-inflammatory medication, more further injections, more physiotherapy — than either other group.

The clinical conclusion drawn by Bisset and colleagues was carefully worded: physiotherapy provides sustainable benefit with a low recurrence rate as a reasonable alternative to injection, while corticosteroid injection, despite its short-term superiority, is associated with high recurrence and significantly poorer long-term outcomes than physiotherapy or natural recovery. [1]

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Why the Injection Seems to Work — and Then Doesn't

The explanation for this pattern lies in what cortisone actually does to tendon tissue.

Tennis elbow — lateral epicondylalgia — is not a tendinitis. A 2009 integrative model by Coombes, Bisset, and Vicenzino established that the core pathology in the extensor carpi radialis brevis tendon is tendinosis: angiofibroblastic hyperplasia, collagen disorganisation, and neovascularisation, with no acute inflammatory infiltrate. [2] The tissue is not inflamed. It is degenerating.

Corticosteroid injection suppresses the tissue response at the injection site — which produces pain relief. But it does so by reducing the cellular and matrix activity that tendon repair depends upon. The tendon's already-impaired attempt at remodelling is interrupted by the injection. When the corticosteroid effect wears off, the underlying tendinosis is still present — and in some cases may have progressed during the period of apparent improvement, when load management has been relaxed because symptoms had settled.

This is why the recurrence rate is so high, and why it peaks in the weeks following the end of the injection's effect. The treatment addressed the symptom, not the pathology. The pathology is still there.

Physiotherapy — specifically, manual therapy and progressive exercise — addresses the pathology directly. Loading the tendon through progressive resistance exercise drives collagen synthesis and matrix remodelling. Mobilisation with movement modifies the central and peripheral pain processing that contributes to the sensitisation component of the condition. Cervical and thoracic manipulation addresses the neurophysiological contribution from the upper spine that influences elbow pain threshold and motor output. [3] These approaches take longer to produce their effect — which is why injection wins at six weeks — but they address the underlying mechanisms rather than suppressing them.

The 2022 lateral epicondylalgia clinical practice guideline by Lucado and colleagues synthesised the entire subsequent evidence base and reached consistent conclusions: multimodal physiotherapy — combining local tendon loading, manual therapy, and exercise — is the recommended approach. [4] Corticosteroid injection is not recommended as a standalone management strategy, particularly beyond the initial reactive phase.

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Why This Matters for Our Approach

The Bisset 2006 trial is not just a piece of research we cite — it is a primary reason why our approach to elbow tendinopathy is built the way it is.

We do not view the cortisone injection as an adversary. In a highly reactive presentation — where an acutely overloaded tendon is sufficiently sensitised that progressive loading cannot begin — a short-term reduction in irritability through injection may create a window in which rehabilitation can commence. The problem is when injection is used as a standalone treatment, without the rehabilitation that addresses the underlying mechanisms. That is the pattern Bisset and colleagues documented: injection, apparent improvement, relapse, further injection, gradual deterioration.

The Menon 2020 MRI study demonstrated that Fascial Manipulation at the elbow produces measurable structural changes in the deep fascial tissue — changes in the water-binding properties of the tissue consistent with a reduction in fascial densification. See: [For the First Time, MRI Has Captured What Happens to Fascia After Manual Therapy] This adds a dimension to the management of elbow tendinopathy that neither injection nor standard exercise addresses: the fascial environment in which the tendon operates, and the load distribution across the forearm compartments that determines how much of every gripping or wrist-loading task is concentrated at the ECRB origin.

Our approach to lateral epicondylalgia combines progressive tendon loading, manual therapy directed at both the elbow and the cervical spine where indicated, and assessment of the forearm fascial system — because the tendinosis at the ECRB origin is rarely the only finding in a presentation that has persisted for months. → Lateral Epicondylalgia

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What This Means for You

If you have been offered a corticosteroid injection for tennis elbow, the Bisset trial is relevant information for your decision. A single injection is associated with significantly higher recurrence rates and poorer outcomes at one year compared to physiotherapy or even natural recovery. If you have a highly irritable, acute presentation, a short-term injection may create a window for rehabilitation — but it is not a substitute for rehabilitation. The question to ask is: what is the plan after the injection?

If you have already had one or more injections and your tennis elbow keeps returning, you are not unusual. The recurrence pattern documented in Bisset 2006 — apparent short-term success followed by relapse — is the most common clinical trajectory following injection. The appropriate next step is addressing the underlying pathology: progressive tendon loading, manual therapy, and assessment of what is concentrating load at the elbow in the first place.

If you have been told to rest and see how it goes, the wait-and-see group in this trial is instructive: over 52 weeks, 56% achieved meaningful improvement without specific treatment. That is a reasonable baseline for a self-limiting condition. But for people whose livelihood, sport, or daily function is significantly affected, waiting up to two years for natural resolution is a high cost — particularly when a structured rehabilitation approach achieves better outcomes, faster.

If your elbow pain has not responded adequately to local treatment alone, the cervical and thoracic spine may be contributing. A systematic review by Hoogvliet and colleagues found moderate evidence that cervical and thoracic spine manipulation, added to local elbow exercise and mobilisation, produced better short and medium-term outcomes than local treatment alone. [3] The upper cervical spine supplies the nerve roots that innervate the elbow; its contribution to elbow pain threshold and motor control is a routine part of a complete assessment.

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