Understanding Lateral Epicondylitis
Tennis elbow (lateral epicondylitis) is a breakdown of the tendons on the outer side of the elbow, where the forearm muscles that extend the wrist attach to the bone. It's common in anyone who repeats gripping or wrist-extending motions, from tennis players to typists to manual laborers.
Causes
Tennis elbow develops from repetitive strain on the outer elbow tendons:
Repetitive wrist-extending or gripping motions, like a tennis backhand.
Manual labor, repetitive computer use, or tool use.
Poor technique or equipment (racquet grip size, tool handle size).
Age-related tendon degeneration.
Symptoms
Common symptoms include:
Pain and tenderness over the bony bump on the outer elbow.
Pain that worsens with gripping, lifting, or extending the wrist.
Weak grip strength.
Pain that may radiate down the forearm.
Seek prompt medical care if: Elbow pain follows a fall or injury with deformity or inability to move the elbow, or the joint becomes hot, red, and swollen, especially with fever.
Imaging Studies to Consider
Imaging helps confirm the diagnosis and rule out other causes:
Ultrasound is usually the first test; evaluates tendon health and can guide injections.
X-ray of the elbow rules out other bony causes of pain.
MRI of the elbow is used if the diagnosis is unclear or symptoms are severe and refractory.
Physical Therapy, Home Exercise & Other Conservative Techniques
A structured loading exercise program is well studied and usually the first treatment tried for tennis elbow:
Physical Therapy
Eccentric wrist extensor strengthening is one of the best-studied treatments for this condition.
Manual therapy to the forearm and elbow.
Activity and technique modification education.
Home Exercise Program
Eccentric wrist extension exercises with light resistance.
Forearm extensor stretching.
Other Studied Techniques
Counterforce brace, worn just below the elbow during aggravating activity.
Activity or technique modification (grip size, racquet tension, tool handles).
Ice after activity.
Interventional Treatment Options
When bracing, activity modification, and a structured loading exercise program aren't enough, several non-opioid procedures can help:
Ultrasound-guided PRP injection: One of the best-supported uses of PRP anywhere in orthopedics; a well-designed two-year trial found it clearly outperformed physical therapy, shockwave therapy, and prolotherapy, and it beats corticosteroid injection from about 3 months out to 2 years (though steroid still wins in the first few weeks). A single injection is often sufficient.
Peritendinous corticosteroid injection: Used selectively and placed around (not directly into) the tendon, due to a risk of tendon weakening or atrophy with repeated use.
Dry needling or percutaneous tenotomy: Stimulates a localized healing response in the degenerated tendon tissue.
Extracorporeal shockwave therapy: A non-injection adjunct treatment that can stimulate tendon healing.
Acupuncture: A technique that may reduce elbow tendon pain, especially in the short term, alongside a loading exercise program.
Neuromodulation: Spinal Cord & Peripheral Nerve Stimulation
Neuromodulation is not typically needed for tennis elbow, but may be considered for chronic, refractory elbow or forearm pain:
Peripheral nerve stimulation (PNS): May be an option for persistent forearm or elbow pain that doesn't respond to other treatments.
How Strong Is the Evidence?
A summary of the evidence supporting key treatments for lateral epicondylitis:
How to read this: Strong means consistent results from multiple high-quality studies. Moderate means generally favorable results with some limitations. Mixed or early means results so far are inconsistent or still emerging. Limited means few or lower-quality studies; these options can still be considered in select cases following a discussion with your healthcare provider.
Platelet-rich plasma (PRP): Strong evidence.
Corticosteroid injection: Strong evidence, short-term benefit.
Extracorporeal shockwave therapy: Moderate evidence.
Acupuncture: Moderate evidence.
Evidence reviewed November 2026. These ratings summarize published research and major medical society guidelines available at that time. Research continues to evolve, and we will go over the most current evidence for your situation at your visit.
Pain Psychology Techniques
Pain psychology techniques support tendon recovery:
Graded activity pacing: a gradual, structured loading program is key to tendon healing.
Cognitive behavioral therapy (CBT) for pain helps manage frustration with a slow, non-linear recovery.
Relaxation training and diaphragmatic breathing.
Non-Opioid Medication Options
Medications play a supporting role alongside a structured exercise program:
For pain relief
Short-term NSAIDs or topical NSAID gel can help during flare-ups, though prolonged oral use is generally avoided as it may impair tendon healing.
Acetaminophen is a good ongoing option that doesn't affect tendon healing.
Related Procedures
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Talk With Us About Your Options
Call 650-507-4113 or send us a message to schedule a consultation at our Daly City, Los Altos, or Stockton office. We will review what may be causing your pain and walk through the risks, benefits, and alternatives of each option with you.
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This information is provided for general patient education and does not replace individualized medical advice. Please discuss your specific symptoms, diagnosis, and treatment options with your pain management physician.
