Objective: To investigate the efficacy of physiotherapy compared to both a wait and see approach and corticosteroid injections over 52 weeks in tennis elbow. Design: Single blind randomised controlled trial Setting: Community setting, Brisbane, Australia Participants: 198 participants aged 18 to 65 years with a clinical diagnosis of tennis elbow of a minimum six weeks duration, who had not received any other active treatment by a health practitioner in the previous six months. Interventions: Eight sessions of physiotherapy versus corticosteroid injections or wait and see. Main outcome measures: Global improvement, grip force and assessor's rating of severity measured at baseline, 6 and 52 weeks. Results: Corticosteroid injection showed significantly superior effects at six weeks, but with high recurrence rates thereafter (47/65 of successes subsequently regressed), and significantly poorer outcomes in the long term when compared with physiotherapy. Physiotherapy was superior to wait and see in the short term; no difference was seen at 52 weeks, when most participants in both groups reported a successful outcome. Participants who had physiotherapy sought less additional treatment, such as non-steroidal anti-inflammatory drugs, than did participants who had wait and see or injections. Conclusion: Physiotherapy combining elbow manipulation and exercise has a superior benefit to wait and see in the first six weeks and to corticosteroid injections after six weeks, providing a reasonable alternative to injections in the to mid to long term. The significant short term benefits of corticosteroid injection are paradoxically reversed after six weeks with high recurrence rates, implying that this treatment should be used with caution in the management of tennis elbow.