Summer is approaching, and with it comes a return to tennis, cricket and other sports that some of us have neglected over winter. Unfortunately, sometimes our enthusiasm exceeds our preparation. As a result, summer is also a time where we see a lot of load-related problems, including tendon pain.

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I have some personal experience with this having developed something of an obsession with tennis recently. While I now have a 'devastating' top spin forehand, I have also developed ulnar-sided wrist pain and a very unhappy extensor carpi ulnaris (ECU) tendon. There is not great mystery about the cause. Too much tennis, too quickly.

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It's been incredibly frustrating. As a Sport and Exercise Physician, I spend plenty of time advising patients about managing load and gradually increasing their activity. It turns out that following your own advice isn't always quite so straighforward.

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Tennis is a great example of sport where enthusiasm can quickly outstrip preparation. Our tendons often bear the brunt of this enthusiasm. An extra game during the week, a longer session at the weekend and perhaps a few more serves than usual, can all add up.

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For some players, the result is shoulder or elbow pain. Others, like me, develop pain on the ulnar side of the wrist. These are different conditions, but they raise a similar clinical question. How do we manage tendon pain while helping people continue doing the sport they enjoy?

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As we all know, tendons respond to loading. When the demands placed on them increase faster than their capacity to adapt, symptoms may develop. As a clinician facing this type of problem, the first step is generally understanding what has changed.

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1. Has the player increased their court time?
2. Are they serving more frequently?
3. Have they changed their racquet, strings or technique?

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Sometimes relatively small changes make a big difference. Managing these factors, alongside a progressive strengthening programme, remains central to treatment.
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Is there a role for injections?

Many of the patients we see at Axis have been advised to have an injection, often a corticosteroid (steroid) injection. For many years, these injections were the treatment of choice for refractory tennis elbow. They often provide rapid pain relief, which is clearly attractive to patients and clinicians.

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They have gone out of vogue over the past decade, largely due to research from Australian physiotherapist Bill Vicenzino. In a randomised trial published in JAMA, patients with lateral elbow tendinopathy who received corticosteroid injections experienced better short-term outcomes but worse results at one year than those receiving placebo injections.

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This did not mean that everyone got worse. His data showed that in 12 months, 83% of the corticosteroid group reported recovery or substantial improvement, compared with 96% in the placebo group. Recurrence was also considerably more common following corticosteroid injection.

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I remember Bill visiting Auckland around the time this research was published and presented at AUT on the North Shore. I remember thinking that the results were compelling, but I wasn't convinced they meant we should abandon corticosteroids altogether. I still think that they have a role for patients who have significant pain and who have not responded to appropriate rehabilitation.

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As a result of this data, corticosteroid injections have quite rightly become less popular for tendon problems, and exercise-based rehabilitation has increasingly become the key treatment.

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It has been interesting to see how others have used steroids to treat tendon problems. While preparing the tendon module for the FIFA Diploma in Football Medicine, I had the opportunity to discuss this with Professor Jill Cook and her team at La Trobe Sport and Exercise Medicine Research Centre.

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What I found interesting was that her group started to advise on the use of corticosteroids again, especially in patients presenting with acute tendinopathy symptoms. Rather than treating every tendon problem in the same way, she encouraged consideration of the stage of the condition and what we are actually trying to achieve with treatment.

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That doesn't mean ignoring Bill Vicenzino's research. The concerns about recurrence and longer-term outcomes remain important. Nor does it mean that corticosteroids are appropriate for every tendon.
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What does the evidence say about PRP?

As the popularity of steroid injections diminished, platelet-rich plasma (PRP) emerged as another option for patients with persistent tendon pain. The premise is plausible. Rather than simply suppressing symptoms, advocates of PRP stressed that these injections might influence the biological environment around the injured tendon and provoke 'healing'.

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Some studies comparing PRP with corticosteroid injections for elbow tendinopathy have reported better longer-term outcomes following PRP. However, that doesn't necessarily establish that PRP is effective because as we haVe already highlighted corticosteroids themselves may produce poorer longer-term results, making PRP look comparatively better.

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A 2026 meta-analysis of six placebo-controlled trials involving 355 patients found no statistically significant improve4ment in pain or function following PRP for lateral elbow tendinopathy. The available evidence therefore doesn't support routinely recommending PRP for this condition.

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Again, this doesn't mean PRP has no role in tendon medicine, but we should be cautious about presenting it as a proven solution. Differences in PRP preparation, injection techniques and patient selection also make the evidence difficult to interpret.

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For patients considering an injection, the discussion should include the likely benefits, uncertainties, coast and how the treatment fits alongside rehabilitation.
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Getting people back on court

The challenge with tendon pain is that patients generally want to keep doing the activities that caused the problem in the first place, which is usually a good thing. Our aim should be to help them remain active, not simply eliminate pain by stopping sport.

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For most patients, this starts with making an accurate diagnosis, sensible load modification and progressive rehabilitation. For others, particularly those with persistent symptoms or uncertainty about the diagnosis, additional assessment or treatment may be worthwhile.

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At Axis, we have several specialist physiotherapists who can help with this. Pete Gallagher was the longstanding All Blacks physiotherapist and now works with a range of professional sporting teams as a consultant, alongside his clinical practice in Dunedin.

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In Auckland, Rebecca Longhurst and Jenn Scott have longstanding relationship with Olympic athletes and High-Performance Sport New Zealand. All three are available to provide specialist physiotherapy advice, generally working alongside a patients existing physiotherapy to review rehabilitation and guide a return-to-sport.

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The experience they have gained working with elite athletes is just as relevant to helping recreational athletes manage persistent problems. Our sport and exercise physicians can also help clarify the diagnosis and discuss whether treatments such as corticosteroid or PRP injections have a role.

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If tendon pain is getting in the way of your patient's summer sport, come and talk to our team. Sometimes a fresh look at the diagnosis, the loading programme or the available treatment options can make a real difference.

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And for those of us becoming a little too enthusiastic about tennis, perhaps the most useful lesson is remembering that enthusiasm and tendon capacity don't always develop at the same speed.