Ross Hauser, MD; Danielle Matias, PA-C; Demi Foster, APRN

If pain on the outside of your elbow has continued despite rest, medication, bracing, physical therapy, or an injection, you may have been told that you have a stubborn case of “tennis elbow.” You do not need to play tennis to develop it. Repetitive gripping, lifting, keyboard work, tools, racquet sports, and weight training can all load the tendon attachment on the outside of the elbow.

The name can also be misleading. In a short-lived injury, inflammation may be part of the problem. In long-lasting cases, however, the medical literature often describes lateral elbow tendinopathy or lateral epicondylosis—degenerative change and failed healing at the common extensor tendon attachment—rather than simple, ongoing inflammation. This does not mean inflammatory signaling is absent from every chronic tendon problem; it means “inflammation” alone may be an incomplete explanation. (1)

For some patients, the tendon is not the only structure involved. The annular ligament, radial collateral ligament complex, radiocapitellar joint, cartilage, or a nearby nerve may contribute to the pain. Minor elbow instability is one possible explanation in a subset of people with persistent lateral elbow pain, but it should not be assumed to be the cause in every patient.

This article explains:

• why “tennis elbow” is sometimes an incomplete diagnosis;
• how tendon degeneration and elbow instability may overlap;
• what conservative care can and cannot do;
• what the research says about dextrose Prolotherapy, corticosteroid, PRP, and surgery; and
• when symptoms may point to a different elbow problem.

Tennis elbow is usually pain at the common extensor tendon attachment

The wrist and finger extensor muscles originate from the common extensor tendon near the lateral epicondyle, the bony prominence on the outside of the elbow. These muscles help extend the wrist and stabilize it during gripping.

Typical symptoms include:

• pain or tenderness on the outside of the elbow;
• pain with gripping, lifting a cup, turning a tool, or shaking hands;
• pain with resisted wrist or middle-finger extension;
• reduced pain-free grip strength; and
• symptoms that increase after repetitive arm use.

Pain at this location does not automatically identify the only injured structure. A careful differential diagnosis matters, especially when standard tennis-elbow care has repeatedly failed.

When “tennis elbow” may not explain the whole problem

Several conditions can produce lateral or poorly localized elbow pain:

These symptom patterns are clues, not stand-alone diagnoses. Neck-related referred pain or nerve-root irritation can also resemble an elbow problem, particularly when symptoms extend beyond the elbow. The broader Caring Medical elbow-pain overview can help readers compare these diagnostic categories.

Can elbow instability contribute to chronic lateral elbow pain?

Ligaments hold the humerus, radius, and ulna in coordinated alignment while the forearm rotates and the hand grips. The annular ligament encircles the radial head. The lateral collateral ligament complex supports the outside of the joint. If a ligament is injured or lax, abnormal joint motion could increase stress on the common extensor tendon and other structures.

Medical research supports considering this possibility, but it does not establish instability as the cause of every tennis elbow. A small diagnostic study of ten patients with recalcitrant lateral elbow pain found that specially designed clinical tests could help identify intra-articular abnormalities and possible minor lateral instability. Because the study was small and performed in a highly selected surgical population, it is a diagnostic lead—not proof that most lateral elbow pain is caused by lax ligaments. (2)

Our 2014 paper described ligament injury and joint instability as a proposed structural contributor to chronic musculoskeletal pain. This framework represents a review and our clinical and biomechanical interpretation; it should remain distinct from evidence obtained in controlled trials of a specific elbow treatment. (3)

Ultrasound documentation of lateral elbow motion

In this image, panel A shows the elbow at rest and panel B shows it under stress. A change in joint opening may contribute to an assessment of ligament function. Interpretation depends on technique, the amount of stress applied, the examination, and the patient’s symptoms. The image alone does not establish that ligament laxity is the source of pain.

When pain has become chronic

When we discuss an instability hypothesis, we are asking whether the pain pattern suggests more than an isolated tendon attachment problem. Findings such as painful rotation, recurrent clicking, a sense of looseness, symptoms with joint loading, or tenderness over ligament attachments may support broader investigation. These observations do not diagnose instability by themselves.

Ultrasound can show tendon thickening, tearing, vascularity, and in some circumstances motion under stress. MRI can help evaluate larger tendon tears, cartilage, bone, and other joint structures. Imaging should be interpreted with the history and examination because structural abnormalities do not always identify the pain generator. A British Elbow and Shoulder Society pathway recommends imaging mainly when the diagnosis is uncertain rather than as a routine requirement for every patient with typical lateral elbow tendinopathy. (1)

Conservative care: exercise, activity changes, braces, and symptom relief

Many people improve without an injection or surgery. The 2023 British Elbow and Shoulder Society pathway supports physiotherapy, selective imaging when the diagnosis is uncertain, and limited use of symptom-relieving measures. Persistent pain deserves attention, but it does not by itself establish that the tendon is permanently damaged. (1)

Activity modification and progressive exercise

Gripping with the wrist extended, repeated lifting, and forceful tool use can repeatedly load the painful tendon attachment. Reducing the most provocative load can make daily activity more manageable. Complete inactivity, however, does not rebuild the capacity needed for work or sport. Rehabilitation commonly involves gradually restoring strength and tolerance to load rather than repeatedly testing the elbow with the activity that hurts most.

Exercise may include slow strengthening of the wrist extensors and broader upper-limb work. Its intensity needs to reflect the diagnosis and current tolerance. Pain that is accompanied by locking, marked weakness, instability, or neurological symptoms calls for consideration of a different or additional problem. Exercise evidence is favorable overall, although the size and durability of benefit vary between studies. (1)

Counterforce straps, wrist splints, and tape

A strap or splint may change how load is transmitted during activity. Some people find these supports helpful for symptoms, but evidence does not establish a consistent lasting advantage. Feeling better while wearing a support does not demonstrate that a ligament is lax, and failure of a brace does not prove that surgery is necessary. The British pathway advises explaining the uncertainty of benefit when offering orthotics. (1)

Taping should likewise be judged by meaningful changes in comfort and function. It is not a test of whether a tendon has healed or whether an injection is required.

Medication and other physical treatments

Topical or oral nonsteroidal anti-inflammatory drugs may provide short-term pain relief. Their risks and suitability differ, and pain reduction should not be equated with reversal of tendon degeneration. The British pathway favors topical options when appropriate because oral drugs have additional gastrointestinal risks. (1)

Shockwave therapy, therapeutic ultrasound, laser, and other modalities have also been studied. Their protocols and comparisons differ, so a positive small trial does not establish a universal best treatment. Shockwave findings in particular remain inconsistent: the 2023 British pathway recommended against its use, while newer comparative research has continued to examine it. A 2024 review of persistent cases found a wide variety of interventions and no clear consensus on the most favorable option. (1) (4)

At Caring Medical, we retain these conventional options in the discussion because people who improve with them may never need an injection. Our clinical interest in persistent tendon and ligament problems does not mean that conservative treatment fails for everyone.

Corticosteroid injection: early relief does not necessarily mean durable recovery

Corticosteroid can reduce pain quickly. That early response may be valuable to some patients, but it should not be confused with evidence that the tendon has repaired. Research has repeatedly raised concern about recurrence or loss of the early advantage over longer follow-up. The British pathway recommends against corticosteroid injection for lateral elbow tendinopathy because its early symptom benefit does not translate into a favorable longer-term result. (1)

This time-dependent pattern becomes important when comparing steroid with regenerative injection approaches. A patient may reasonably value rapid symptom reduction, but the short-term pain score and the long-term functional result are different outcomes.

Surgery for persistent tennis elbow

Surgery is usually reserved for persistent, function-limiting symptoms after an adequate nonoperative effort and when the diagnosis is reasonably secure. Procedures may release or remove abnormal tendon tissue and address associated joint findings.

The evidence deserves caution. A 2024 scoping review included 35 surgical studies involving 1,564 patients. Many reported improvements, but techniques and outcome measures varied, patient numbers were generally small, and the authors concluded that stronger multicenter evidence is still needed. (5) Improvement after surgery does not by itself prove that excising tendon tissue was the active reason for improvement; rehabilitation, time, and natural history may also contribute.

A small randomized trial compared removal of abnormal extensor carpi radialis brevis tissue with a sham procedure involving incision and tendon exposure without excision. Thirteen patients were assigned to each group. Both groups improved, and the investigators found no significant added benefit from tendon excision. The study ended before its planned enrollment, and its findings apply to that procedure and population, rather than every possible elbow operation. (6)

A substantial tendon tear, a loose body causing mechanical locking, established ligament instability, or advanced arthritis may prompt a different surgical discussion. These conditions are not identical to uncomplicated tennis elbow. The important question is whether the proposed operation matches a defined source of symptoms, and whether the expected benefit justifies the risks. Persistent pain alone does not prove that removing tendon tissue is the necessary next step.

Prolotherapy research for chronic tennis elbow

Prolotherapy commonly uses a dextrose-based solution directed at painful tendon or ligament attachments. The proposed effects include local signaling, altered pain processing, and stimulation of a healing response. These mechanisms remain under study; symptom improvement should not automatically be described as proof that a tendon or ligament has regenerated.

For a broader explanation of the treatment, see our Prolotherapy overview. Elbow studies use different solutions, concentrations, targets, and accompanying rehabilitation. They should not be treated as interchangeable protocols.

Early randomized studies showed a possible benefit, but they were small

A double-blind pilot trial randomized 24 adults with refractory lateral epicondylosis to dextrose-morrhuate Prolotherapy or saline injections. The Prolotherapy group showed greater improvement in pain and strength testing, maintained at one year, with no adverse events reported. The sample was too small to assess uncommon harms or provide a definitive effect estimate. (7)

A later pilot randomized trial involved 26 adults and 32 elbows. Dextrose and dextrose-morrhuate groups improved in patient-rated pain and function compared with watchful waiting, while MRI severity scores did not differ. This distinction is important: clinical improvement did not equal documented structural change on MRI. (8)

A 120-person trial found no long-term advantage over physiotherapy

In a single-blinded randomized trial, 120 participants received Prolotherapy, physiotherapy, or both. All three groups improved substantially over 52 weeks, but the investigators found no significant long-term difference among the groups. Physiotherapy produced greater improvement than Prolotherapy at 12 weeks. (9)

This comparison suggests that improvement can occur with several approaches and that adding treatments does not guarantee a better result.

A 2025 randomized trial followed patients for two years

A 2025 randomized trial enrolled 231 adults with chronic lateral epicondylosis that had not improved with previous nonoperative care; 202 completed the study. Participants were assigned to physiotherapy, shockwave therapy, Prolotherapy, or PRP. Every group achieved a clinically meaningful improvement in DASH disability scores at 24 months. PRP produced the largest improvement. Prolotherapy produced greater improvement than physiotherapy at 18 months and higher satisfaction than physiotherapy and shockwave therapy at 24 months. (10)

The study strengthens the longer-term evidence base, but it does not show that every patient needs an injection. All four groups improved, and the abstract does not establish that changes were caused by tendon or ligament regeneration.

What 2026 reviews add

A 2026 network meta-analysis included 41 randomized trials and 3,285 participants across eight percutaneous treatments. Corticosteroid showed a short-term pain advantage but a later rebound pattern. Dextrose Prolotherapy showed a potential mid-term advantage for pain and function, while PRP and dry needling appeared more favorable for longer-term pain. Network rankings combine direct and indirect comparisons, so they should be read as estimates rather than a universal treatment hierarchy. (11)

A second 2026 review asked whether one dextrose concentration is best. Nine randomized trials with 490 participants were included, but only three trials and 111 participants could be connected in the network analysis. The apparent advantages of 5% and 15% dextrose over saline rested on one lateral-epicondylitis trial, and the certainty of evidence was low to very low. The review concluded that current evidence is insufficient to determine an optimal concentration. (12)

This review argues against presenting a particular dextrose concentration as definitively superior.

A 2026 observational imaging study

A prospective study followed 36 patients who received Prolotherapy and reported reduced pain plus changes in common extensor tendon thickness and elasticity on shear-wave elastography. Because every participant received the intervention and there was no comparison group, the study cannot separate the treatment effect from natural history, rehabilitation, expectation, or measurement effects. Imaging change is encouraging but does not by itself prove normalized tendon structure or durable recovery. (13)

The new 2026 tennis-elbow study: dextrose alone or dextrose plus corticosteroid

A 2026 retrospective study compared 42 patients, with 21 in each treatment group. One group received ultrasound-guided intratendinous hypertonic dextrose plus lidocaine; the other received the same intratendinous treatment plus a peritendinous corticosteroid and lidocaine injection. In other words, the investigators injected the dextrose into the tendon and the steroid around it in the combination group.

At 1 and 4 weeks, the combination group had lower pain scores and lower tendon thickness. At 12 and 24 weeks, however, pain improvement did not differ between the groups. Ultrasound differences were reported at later assessments, but their clinical meaning is uncertain. (14)

We read this study as a caution against reducing the discussion to “which injection won?” The addition of corticosteroid was associated with faster early pain relief, but it did not produce a longer-term pain advantage. The study was small, retrospective, and nonrandomized; both groups received dextrose, and there was no corticosteroid-only, placebo, or usual-care group. It therefore cannot show that the combination improves durable tendon healing or that adding corticosteroid should become routine. Its findings concern this particular tendon treatment, not proof of effectiveness for ligament instability.

How this changes the older “Prolotherapy versus cortisone” discussion

An earlier randomized study of 30 patients found that both dextrose Prolotherapy and methylprednisolone improved pain and function at one month. At three months, the Prolotherapy group continued to improve while the steroid group did not, favoring Prolotherapy at that assessment. The small sample and short follow-up limit the certainty of the result. (15)

Taken together, the research suggests a time-dependent pattern rather than a simple rule:

• corticosteroid may provide faster relief in some comparisons;
• dextrose Prolotherapy may show advantages at some intermediate or longer assessments;
• physical therapy, shockwave therapy, PRP, and time can also produce improvement; and
• study size, diagnosis, injection target, solution, rehabilitation, and outcome timing can change the apparent winner.

Platelet-rich plasma for tennis elbow

Platelet-rich plasma (PRP) is prepared from a patient’s own blood and contains a concentration of platelets and signaling proteins. PRP is not the same as dextrose Prolotherapy, and results from one treatment should not be used as proof for the other.

The PRP evidence remains mixed. A 2026 meta-analysis of six randomized trials and 338 participants found a clear early pain advantage for corticosteroid through four weeks. At longer follow-up, pain scores favored PRP, although the pooled difference fell just below the authors’ stated minimal clinically important threshold. The certainty and heterogeneity of the underlying trials remain important limitations. (16)

Placebo comparisons

A separate 2026 meta-analysis combined six randomized placebo-controlled trials involving 355 patients. It found no statistically significant advantage for PRP in pain or function at the assessed follow-ups through approximately six months. This is an important limitation on claims that PRP reliably treats tennis elbow. (17)

The findings address a different question from PRP-versus-steroid studies. A treatment can look better than corticosteroid later in follow-up if corticosteroid outcomes worsen; that does not necessarily establish a benefit over placebo. Conversely, a placebo-controlled review through six months does not settle every question about longer-term comparative outcomes.

The 2025 two-year comparative trial also favored PRP for disability and satisfaction, while every treatment group improved. (10) Differences in PRP preparation, platelet and white-cell concentration, injection target, comparator, and accompanying rehabilitation continue to make studies difficult to compare.

Can PRP and Prolotherapy be discussed together?

Our clinical discussions include both tendon attachments and surrounding ligaments when the symptoms suggest more than one injured structure. This is the rationale for discussing PRP and Prolotherapy together. It remains necessary to distinguish that clinical perspective from trial evidence: the 2025 study compared PRP and Prolotherapy in separate groups; it did not test their combination. It cannot show that combining them produces better results. (10)

Caring Medical’s published observational elbow-pain findings

In 2009, our group reported outcomes from 36 patients with unresolved elbow pain treated with dextrose Prolotherapy. These patients had experienced pain for an average of approximately four years and were followed for an average of 31 months after their last treatment. Reported average pain scores decreased from 5.1 to 1.6, average stiffness scores decreased from 3.9 to 1.4, and exercise ability and medication use improved. (18)

We preserve these results because they are part of Caring Medical’s clinical history and include longer follow-up than many injection studies. They should also be interpreted as observational clinic data. The report was retrospective, had no untreated or active-comparator group, included several elbow diagnoses, and relied heavily on patient-reported outcomes. It cannot establish how much improvement came specifically from Prolotherapy or whether the same results would occur in a broader patient population.

Video: Chronic elbow pain, tendinosis, and the importance of the diagnosis

Danielle Matias, PA-C, explains why chronic elbow pain may represent tendinosis rather than persistent acute inflammation. The discussion also emphasizes distinguishing tendon fraying or tearing from pain involving other elbow structures. The video presents Caring Medical’s clinical perspective; it should not be interpreted as proof that every chronic elbow problem is caused by instability.

Video: A patient with lateral elbow pain during hockey and weight training

This case discussion describes a patient whose lateral elbow pain and post-activity swelling had not responded to previous pain management or corticosteroid injection. The video shows the clinical reasoning behind considering both the common extensor tendon and nearby ligament attachments. A patient case illustrates an approach but cannot predict another patient’s outcome.

Video: Ross Hauser, MD reviews the Caring Medical elbow-pain study

Ross Hauser, MD, reviews the 36-patient retrospective report and demonstrates elbow anatomy. The study’s long follow-up and patient-reported changes are useful, while its uncontrolled design remains an important limitation.

When treatment has failed, reconsider the diagnosis before escalating treatment

Persistent pain does not necessarily mean that the only remaining choice is surgery or a stronger injection. It may mean that the painful structure, loading pattern, nerve involvement, joint surface, or degree of instability has not been adequately identified.

Questions that can help organize the diagnostic discussion include:

• Is the pain truly centered at the lateral epicondyle?
• Is there painful clicking, rotation, locking, or a sense of giving way?
• Does pain radiate into the forearm in a pattern suggesting nerve irritation?
• Is there marked loss of elbow motion or imaging evidence of arthritis?
• Did the symptoms begin after a dislocation, fracture, or major tendon injury?
• Is the pain actually medial, suggesting golfer’s elbow or a UCL injury?
• Does the imaging finding match the examination and the activity that provokes symptoms?

This is also why we do not treat ultrasound or MRI appearance as the outcome by itself. Pain, function, strength, work or sport tolerance, and durability matter alongside imaging.

Key takeaways

• Tennis elbow is usually a lateral elbow tendon problem, but the label can miss ligament, joint, nerve, cartilage, or muscle-tendon contributors.
• Minor elbow instability may contribute in a subset of persistent cases; the evidence does not support calling it the cause of every case.
• Physical therapy and progressive loading remain important evidence-based options, and many patients improve over time.
• Corticosteroid can provide faster short-term relief, but early pain reduction does not prove tendon repair or guarantee a durable result.
• Prolotherapy research includes promising randomized and observational findings, a neutral 120-person comparison with physiotherapy, and a favorable 2025 two-year comparative trial. The overall evidence is still heterogeneous.
• The new 2026 dextrose-plus-corticosteroid study found better early pain relief but no pain advantage at 12 or 24 weeks.
• PRP has favorable findings in some active-treatment comparisons, but a 2026 placebo-controlled meta-analysis found no significant pain or function advantage at its measured follow-ups.
• Surgery can help selected patients, particularly when a defined structural problem matches the symptoms, but the comparative evidence remains limited.

When elbow pain needs prompt medical attention

A visibly deformed elbow after injury, an open wound over a suspected fracture, or a cold or pale hand needs urgent medical care. A hot, swollen joint with fever, new or worsening hand weakness, or severe pain after trauma also requires prompt assessment. Progressive loss of motion, persistent numbness, or repeated locking should not simply be labeled tennis elbow. (1)

Medical disclaimer

This article is for educational purposes only and is not a diagnosis or treatment recommendation. Elbow pain can result from tendon, ligament, joint, nerve, bone, or referred-pain conditions. A qualified healthcare professional should evaluate persistent pain, weakness, traumatic injury, progressive loss of motion, numbness, or mechanical locking.

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