Pickleball elbow is the same condition as tennis elbow (lateral epicondylitis). The tendons that attach the forearm extensor muscles to the outside of the elbow get overloaded from repeat backhand strokes. The pain shows up at the lateral epicondyle, sometimes radiates down the forearm, and gets worse with gripping.
Most patients we see have already tried two things: rest and a counterforce brace. Both help reduce pain. Neither rebuilds the tendon. The tendon is what actually has to heal for the case to resolve.
Why cortisone is the wrong move for most cases
Cortisone reduces pain in the short term. The research on long-term outcomes for tennis elbow specifically is bad. Multiple studies have shown that patients who get cortisone injections have worse outcomes at 6 and 12 months than patients who do nothing or who do conservative care. Cortisone also weakens the tendon over time, which sets up recurrence and sometimes rupture.
We will refer for cortisone in stubborn cases that have failed 12 weeks of conservative care, and even then prefer it as a one-time intervention. Repeat injections are the worst version.
The protocol that actually works
The combination that has the strongest evidence and that we use day-to-day:
- Manual therapy on the forearm extensors. Active Release Technique or Graston, focused on the common extensor tendon and the muscle bellies above. Reduces pain, restores normal tissue glide.
- Erchonia low-level laser therapy for cases that have plateaued. Supports tendon recovery between visits.
- A graded eccentric loading program. This is the part that rebuilds the tendon. Slow tempo wrist extension eccentrics with progressive load, done at home, daily.
- Activity modification during recovery. Counterforce bracing during play, grip changes, paddle weight, sometimes a temporary break.
The eccentric program (do this at home)
Eccentric loading is the slow lengthening phase of a contraction. For tennis elbow, the easiest version uses a light dumbbell or a soup can.
- Sit with your forearm resting on a table, palm facing down, wrist hanging off the edge.
- Hold a light weight in your hand. Use the other hand to lift the weighted hand up (so your wrist is bent up).
- Slowly lower the weight back down over a 4 to 6 second count, controlled.
- Use the other hand to lift it back up. Only the lowering phase is loaded.
- Three sets of 10. Daily.
Some discomfort during the exercise is fine. Sharp pain is not. Increase the weight as the discomfort fades, usually every 5 to 7 days.
Realistic timeline
Most cases improve significantly in 6 to 12 weeks. Pain reduction usually shows up first, around week 2 to 4. Tendon strength and load tolerance lag behind, around week 6 to 12. Returning to full pickleball volume too fast is the most common cause of recurrence.
Related: Tennis elbow detail · Pickleball injuries · Active Release Technique