Back Pain Doctor
Tennis & Golfer's Elbow
Tennis elbow (lateral epicondylitis) and golfer’s elbow (medial epicondylitis) are tendinopathies of the muscles that attach around the elbow. Despite the names, they are usually related to repetitive load rather than to playing a particular sport.
The most important treatment is a graded exercise program that progressively loads the affected tendon, alongside modifying the activities that aggravate it. This is well-evidenced and effective for many people, though it requires patience as tendons respond slowly.
For cases that do not settle with first-line measures, additional options such as shockwave therapy and PRP have been studied for elbow tendinopathy. We assess your elbow, confirm the diagnosis, and give you an honest view of which options are worth considering and which are not.
Common symptoms
- Pain over the outer elbow (tennis elbow) or inner elbow (golfer's elbow)
- Pain with gripping, lifting or twisting movements
- Tenderness over the affected tendon attachment
- Weakness of grip
Commonly seen in
Evidence for twelve treatment options in tennis & golfer's elbow
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation — diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan — with weight management where that is clinically relevant.
What the evidence shows
Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself — and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).
Pairing reviewed 2026-09-02.
Where it fits for you
This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Dry needling evidence
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with 0.02-0.08% lignocaine is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling — the same technique with nothing injected — is not offered here.
What the evidence shows
This is the best-evidenced needling target in the tendinopathy group, but the evidence is for dry needling rather than for an injection. A meta-analysis of 17 randomised trials in 979 people found dry needling improved pain within the first week (mean difference -0.95 points, 95% CI -1.88 to -0.02), elbow disability both within the first week and beyond it (SMD -1.37, -1.88 to -0.86; and -1.32, -2.23 to -0.40) and grip strength, with better pain results when the needling produced a local twitch response (Ma, Arch Phys Med Rehabil 2024). An earlier meta-analysis of seven trials in 320 people found similar effects on pain (SMD -1.13, -1.64 to -0.62) and disability (SMD -2.17, -3.34 to -1.01), rated low to moderate certainty and concentrated at short term (Navarro-Santana, Clin Rehabil 2020). The injection trials at this elbow test the tendon with platelet-rich plasma, corticosteroid or dextrose rather than testing a trigger point.
Pairing reviewed 2026-09-11.
Where it fits for you
Directed at tender bands in the forearm extensor or flexor muscles that reproduce part of your pain, alongside the loading programme. Expect the benefit to be early and to need the loading work behind it.
Ultrasound-guided injections Guidance means we can see the needle reach the target. What goes into the needle depends on the diagnosis. Only if relevant
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis — and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Ultrasound improves needle-placement accuracy, but guidance is not a treatment in itself: benefit depends on a valid injectable target and what is injected. Condition reviewed: tennis golfers elbow.
Evidence source: Oo et al., ultrasound-guided injection systematic review (2024)
Pairing reviewed 2026-08-30.
Where it fits for you
For tennis golfers elbow, an ultrasound-guided injection is considered only when there is a specific diagnostic question or a separate joint, bursa, sheath or nerve target. The injectate and purpose are stated before treatment.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible — no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits for you
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Worth discussing
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue — including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Where the device subgroups were separated, RADIAL shockwave showed a benefit on pain in lateral epicondylitis and focused did not (Yoon, Clin Orthop Relat Res 2020, confirmed in the accompanying CORR Insights commentary). A 40-trial network meta-analysis ranked shockwave the best option for grip strength recovery and better than corticosteroid injection (Liu, Arthroscopy 2022).
Pairing reviewed 2026-08-30.
Where it fits for you
The form of shockwave the evidence supports for this diagnosis. Offered where symptoms have run beyond six months, which is the subgroup that benefited.
Focused shockwave (ESWT) A true shock wave converging at depth — for tendon, joint, ligament and bone. Evidence mixed
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form we use for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Genuinely contested, and the device matters. A 40-trial network meta-analysis found shockwave beat placebo for short and medium-term pain and ranked best of all options for grip strength recovery (Liu, Arthroscopy 2022), and a 2025 umbrella review found it beats both ultrasound therapy and corticosteroid injection (Zhu, J Orthop Traumatol 2025). Against that, two large reviews found no clinically important difference versus sham (Yoon, Clin Orthop Relat Res 2020; Karanasios, Clin Rehabil 2021) — and Yoon's device subgroup found the benefit was in RADIAL shockwave, not focused.
Pairing reviewed 2026-08-30.
Where it fits for you
Where shockwave is used for tennis elbow here, radial is the form the evidence supports. Worth knowing that shockwave outperformed corticosteroid injection in both network syntheses.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Painless, no contact. Plausible — no studies
What it involves
You sit with the applicator positioned over the area for a short session. Painless, no gel or contact required, and usually delivered as a course — commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that we can point to. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative — a randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits for you
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why we describe it this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Good support
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
A meta-analysis of 11 randomised trials and 730 patients found PRP worse than corticosteroid in the first two months but clearly better at six months and beyond — VAS mean difference -2.18, DASH -8.13, Mayo Elbow Performance Score +16.53 (Xu, Am J Sports Med 2024). A 2-year four-arm randomised trial of 231 patients found PRP the best of PRP, prolotherapy, shockwave and physiotherapy at 24 months, with a DASH reduction of 31.2 points against 17.6 for shockwave (Lhee, Am J Sports Med 2025).
Pairing reviewed 2026-08-30.
Where it fits for you
The strongest long-term data of any injection option for tennis elbow. The trade-off is that it is slower than corticosteroid to take effect, and dearer.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Good support
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
A 40-trial network meta-analysis ranked dextrose prolotherapy the single best option for both short-term and medium-term pain relief in lateral epicondylitis (SUCRA 87.3% and 98.6%) (Liu, Arthroscopy 2022). A 2-year randomised trial of 231 patients found prolotherapy outperformed both physiotherapy and shockwave at 24 months on DASH and satisfaction (Lhee, Am J Sports Med 2025). A systematic review of 20 randomised trials found prolotherapy superior or equal to control in 83% of lateral epicondylitis and rotator cuff studies (Capotosto, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits for you
One of the strongest indications for prolotherapy. Best data of any injection option here at two years apart from PRP.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Plausible — no studies
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
A meta-analysis of 19 randomised trials found hyaluronic acid produced short and mid-term pain benefit across several soft-tissue indications including rotator cuff, elbow, ankle sprain, Achilles and patellar tendinopathy — but with very high heterogeneity, mostly single trials per indication, and uncertain benefit for trigger finger (Khan, Sports Health 2022).
Pairing reviewed 2026-08-30.
Where it fits for you
Not a routine option outside the knee. Mentioned where someone asks about it, with the weakness of the data stated.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve—not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Plausible — no studies
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
A PubMed search returns no study of perineural dextrose injection in lateral or medial epicondylalgia. The dextrose nerve literature around the elbow and forearm concerns radial nerve palsy and radial nerve entrapment at the wrist, which are different diagnoses (Chen, Medicine 2018; Yoon, Diagnostics 2026).
Pairing reviewed 2026-09-05.
Where it fits for you
Not offered for the tendon problem. It would only come into the conversation if the forearm symptoms proved to be nerve entrapment rather than tendinopathy, which is a change of diagnosis rather than an added treatment.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Only if relevant
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
The elbow hydrodissection evidence is for nerve entrapments that mimic or accompany tennis elbow, not for the tendon problem itself. In radial tunnel syndrome, which is readily mistaken for tennis elbow, 11 surgical candidates treated with ultrasound-guided hydrodissection all had complete symptom resolution lasting at least two years and none went on to surgery, alongside a review of seven studies covering 61 patients that reported benefit in every one (Gill, Curr Sports Med Rep 2022). A clinical review names radial tunnel syndrome and ulnar neuropathy at the elbow among the entrapments that may suit the technique in selected cases (Colorado, Muscle Nerve 2025). We found no study of hydrodissection for lateral or medial epicondylalgia itself.
Pairing reviewed 2026-09-08.
Where it fits for you
Only where examination and ultrasound point to a nerve as part of the problem — the radial nerve in the radial tunnel, or the ulnar nerve at the elbow — rather than for the tendon at the epicondyle.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So we do not build treatment plans around it. Where an injection is the right call, we review the specific diagnosis and target, discuss what is being injected and why, keep the number low, and pair it with the loading work that changes the longer-term course.
When we would still consider it
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal — a trip, a procedure, a return to work
- Diagnostic use, where the response tells us where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other elbow, wrist & hand conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
How long does tennis elbow last?
Should I rest it completely?
What if it does not settle?
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