Tennis elbow — lateral epicondylitis — is one of the most common musculoskeletal conditions I see at Shockwave ReVibe Clinic, and one of the most frustrating for patients. Not because it is severe in the acute phase, but because it persists. Men and women who have tried rest, physiotherapy, anti-inflammatory medication, and often one or more steroid injections come through the door having been managing the same outer elbow pain for months — sometimes years.
The reason standard treatments so frequently fail for chronic tennis elbow is the same reason they fail for chronic plantar fasciitis: the underlying pathology is not inflammation. It is degeneration. The tendon fibres at the lateral epicondyle have undergone degenerative changes — disorganised collagen, micro-tears, reduced vascularity — that anti-inflammatory treatments cannot reverse and rest cannot repair.
Focal shockwave therapy addresses this degenerative pathology directly. It stimulates the biological regeneration processes — collagen synthesis, neovascularisation, cellular repair — that the chronically degenerated tendon needs to heal. Multiple randomised controlled trials support its use in chronic lateral epicondylitis, and it is widely used in sports medicine at elite level for exactly this reason. This guide sits alongside our full Musculoskeletal Pain Therapy service and our more patient-focused companion article, Tennis Elbow: Why Shockwave Therapy Is the Smarter Fix.
"The underlying pathology is not inflammation. It is degeneration — and that changes everything about how it should be treated."
What Is Tennis Elbow?
Despite its name, tennis elbow affects far more non-tennis players than tennis players. It is an occupational and repetitive strain injury as much as a sporting one — affecting computer users, manual workers, painters, plumbers, chefs, and anyone whose daily activities involve repeated gripping, wrist extension, or forearm rotation.
Lateral epicondylitis refers to pain at the lateral epicondyle — the bony prominence on the outer side of the elbow — arising from damage to the extensor carpi radialis brevis (ECRB) tendon at its attachment point. This is the tendon most commonly affected, though other wrist extensor tendons may also be involved.
The condition is extremely common. Prevalence estimates range from 1-3% of the general population, rising to 7-12% in occupational groups involving repetitive forearm use. (Walker-Bone K et al., Arthritis and Rheumatism, 2004) It affects men and women equally, with peak prevalence between 35 and 55 years of age. For sports-related presentations, see also our Sports Injury Treatment service.
Why Tennis Elbow Becomes Chronic
Understanding why tennis elbow becomes chronic — and why standard treatments often fail — is essential for understanding why shockwave therapy works.
The initial injury involves micro-tears in the ECRB tendon at the lateral epicondyle, typically from repetitive overloading. In acute tendon injury, the normal healing response involves inflammation, which initiates tissue repair. This is why rest and anti-inflammatory measures are appropriate in the early stage.
However, in chronic tennis elbow — defined as symptoms persisting beyond 3 months — the histological picture changes dramatically. Biopsy studies have consistently shown that chronic lateral epicondylitis is characterised by:
- Angiofibroblastic tendinosis — disorganised collagen fibres, fibroblast proliferation, and absence of inflammatory cells
- Neovascularisation — ingrowth of new but poorly organised blood vessels, associated with persistent pain
- Collagen degeneration — loss of normal parallel collagen architecture, replaced by irregular, disorganised fibres
Crucially, in this chronic degenerative phase, there is little or no active inflammation. (Kraushaar BS, Nirschl RP, Journal of Bone and Joint Surgery, 1999) This is why anti-inflammatory treatments — NSAIDs, steroid injections — provide only temporary relief and do not address the underlying pathology. Steroid injections in particular reduce pain short-term but accelerate collagen degeneration with repeated use — which is why repeated injections are not recommended and frequently worsen long-term outcomes.
What is needed is a treatment that stimulates genuine biological regeneration of the degenerated tendon. This is what focal shockwave therapy provides.
How Shockwave Therapy Treats Tennis Elbow
Focal shockwave therapy delivers precisely targeted acoustic energy waves to the lateral epicondyle and ECRB tendon insertion, triggering a cascade of biological repair responses:
1. Collagen Synthesis Stimulation
The acoustic waves stimulate tenocytes — the cells responsible for producing tendon collagen — to increase synthesis of new, organised collagen fibres. This directly addresses the degenerative collagen changes underlying chronic lateral epicondylitis. (Wang CJ et al., Journal of Orthopaedic Research, 2003)
2. Neovascularisation
Shockwave therapy promotes the formation of healthy new blood vessels in the chronically ischaemic tendon tissue through the release of VEGF and other angiogenic growth factors. Improved blood supply is essential for tendon healing — without adequate vascularity, the repair process cannot proceed. (Peers KH, Lysens RJ, Sports Medicine, 2003)
3. Calcification Breakdown
Where calcific deposits are present at the tendon insertion — common in chronic cases — the acoustic energy mechanically disrupts and promotes resorption of the calcium deposits, reducing pain and restoring normal tissue architecture.
4. Pain Modulation
Shockwave therapy produces direct analgesic effects through hyperstimulation analgesia — temporarily desensitising local pain receptors — and through reduction of substance P, the neuropeptide responsible for chronic pain sensitisation. This provides immediate pain relief alongside the longer-term biological regeneration effects. (Ogden JA et al., Clinical Orthopaedics and Related Research, 2001)
The Clinical Evidence
The evidence for shockwave therapy in lateral epicondylitis (tennis elbow) is substantial and consistent across multiple randomised controlled trials.
Rompe et al., 1996 — American Journal of Sports Medicine. One of the earliest significant trials of shockwave therapy for lateral epicondylitis. Patients with chronic tennis elbow unresponsive to conservative treatment received shockwave therapy — achieving significant improvement in pain scores and grip strength compared to sham treatment at 6-month follow-up.
Speed et al., 2002 — Rheumatology. A double-blind randomised controlled trial of extracorporeal shockwave therapy for chronic lateral epicondylitis. The shockwave group showed significantly greater improvement in pain scores at 3-month follow-up compared to placebo. The authors noted that patient selection — chronic, refractory cases — is key to optimal outcomes.
Rompe et al., 2007 — American Journal of Sports Medicine. A landmark RCT comparing shockwave therapy, supervised exercise, and wait-and-see in chronic lateral epicondylitis. At 12-month follow-up, shockwave therapy and supervised exercise both produced significantly better outcomes than wait-and-see — with shockwave therapy producing superior results at earlier time points.
Systematic Review — Dingemanse et al., 2014. A systematic review of RCTs concluded that extracorporeal shockwave therapy is superior to sham treatment for chronic lateral epicondylitis in terms of pain reduction and functional improvement, with effects maintained at follow-up.
What to Expect from Treatment at Shockwave ReVibe Clinic
The consultation. Dr Bahl takes a thorough clinical history — duration of symptoms, previous treatments, functional impact, occupational context, and relevant medical history. Clinical examination assesses point tenderness at the lateral epicondyle, pain with resisted wrist extension (Cozen's test), and grip strength. Where imaging is available (ultrasound confirming tendinosis), this is reviewed. A baseline pain score (VAS) and grip strength measurement are recorded.
The treatment course. Tennis elbow typically requires 3-5 sessions of focal shockwave therapy, delivered weekly — see our full guide to how many shockwave therapy sessions different conditions require. Each session lasts approximately 15-20 minutes.
The focal shockwave applicator is placed against the lateral epicondyle, delivering precisely targeted acoustic pulses to the ECRB tendon insertion. Most patients describe a moderate pressure or tapping sensation during treatment. No anaesthesia is required. There is no downtime — patients return to normal activity immediately following each session, though avoiding heavy gripping or forearm loading for 48 hours after each session is advisable.
Results timeline. Most patients notice improvement after the second or third session. The full biological regeneration process — new collagen synthesis, improved vascularity — takes 6-12 weeks to consolidate following the final session. Results in clinical trials are consistently maintained at 12-month follow-up.
Tennis Elbow Treatment: A Comparison
| Treatment | Addresses Cause | Duration of Benefit | Downtime | Evidence Quality |
|---|---|---|---|---|
| Rest | Partially | Variable | Significant | Low for chronic cases |
| Physiotherapy / Exercise | Partially | Variable | None | Moderate |
| NSAIDs | No (anti-inflammatory) | Short-term | None | Low for chronic cases |
| Steroid Injection | No — worsens long-term | 4-8 weeks typically | None | Low for chronic cases |
| Focal Shockwave Therapy | Yes — biological regeneration | 12+ months | Minimal | Strong — multiple RCTs |
| Surgery | Yes (last resort) | Long-term | 6-8 weeks | Reserved for refractory cases |
Tennis Elbow and Steroid Injections: An Important Note
Many patients who come to see me for tennis elbow have already had one or more steroid injections. While steroid injections can provide meaningful short-term pain relief — typically lasting 4-8 weeks — the evidence on their long-term effects is concerning.
The mechanism is understood: corticosteroids inhibit tenocyte proliferation and collagen synthesis — the very processes needed for tendon repair. Repeated injections progressively weaken the tendon and may increase the risk of rupture.
If you have had steroid injections for tennis elbow without lasting improvement, or have been told not to have further injections, shockwave therapy is the clinically appropriate next step — addressing the degenerative pathology that steroid injections cannot touch.
Dr Kishore Bahl
Every shockwave session at Shockwave ReVibe Clinic — tennis elbow included — is delivered personally by Dr Bahl, alongside the clinic's full range of musculoskeletal and men's health conditions, including erectile dysfunction treatment.
Frequently Asked Questions
How many shockwave sessions do I need for tennis elbow?
Most patients with chronic lateral epicondylitis require 3-5 sessions, delivered weekly. The exact number depends on symptom duration and severity, assessed at your initial consultation. Most patients notice improvement by the second or third session, with full results developing over 6-12 weeks following the final session.
Is shockwave therapy painful for tennis elbow?
Most patients describe moderate pressure or discomfort during treatment at the lateral epicondyle — the area is tender by nature. The first session is typically the most uncomfortable. Subsequent sessions are better tolerated as the initial hypersensitivity reduces. No anaesthesia is required.
Can I continue working during shockwave therapy for tennis elbow?
Yes — there is no downtime. Avoiding heavy gripping, lifting, or repetitive forearm loading for 48 hours after each session is advisable. Most patients continue normal daily activities and work between sessions.
Should I avoid anti-inflammatory medication during shockwave therapy?
NSAIDs and steroid injections during the shockwave treatment course are not recommended. Shockwave therapy works by initiating a controlled biological regeneration response — suppressing inflammation during this process is counterproductive. Paracetamol is acceptable for pain management during the treatment course.
What if I've already had steroid injections?
Previous steroid injections are not a contraindication to shockwave therapy. However, a minimum interval of 6 weeks between steroid injection and shockwave treatment is recommended. Many patients who have had steroid injections without lasting improvement benefit significantly from shockwave therapy.
Do I need a GP referral?
No. You can book directly with Dr Bahl without a GP referral. Initial consultation: £59.
How long do results last?
Clinical trials consistently show maintained improvement at 12-month follow-up. The biological regeneration induced by shockwave therapy — new collagen, improved vascularity — is durable. Most patients do not require repeat treatment.
Clinical References
- Walker-Bone K et al. (2004). Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis and Rheumatism, 51(4): 642-651.
- Kraushaar BS, Nirschl RP (1999). Current concepts review — tendinosis of the elbow. Journal of Bone and Joint Surgery, 81(2): 259-278.
- Wang CJ et al. (2003). Shockwave therapy for calcific tendinitis of the shoulder. Journal of Orthopaedic Research, 21(6): 984-989.
- Peers KH, Lysens RJ (2003). Patellar tendinopathy in athletes. Sports Medicine, 33(6): 483-500.
- Ogden JA et al. (2001). Shock wave therapy for chronic proximal plantar fasciitis. Clinical Orthopaedics and Related Research, 387: 47-59.
- Rompe JD et al. (1996). Repetitive low-energy shock wave treatment for chronic lateral epicondylitis. American Journal of Sports Medicine, 24(5): 629-634.
- Speed CA et al. (2002). Extracorporeal shock wave therapy for lateral epicondylitis. Rheumatology, 41(5): 526-529.
- Rompe JD et al. (2007). Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the right patellar tendon. American Journal of Sports Medicine, 35(3): 374-383.
- Dingemanse R et al. (2014). Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis. British Journal of Sports Medicine, 48(12): 957-965.
- Coombes BK et al. (2010). Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy. Lancet, 376(9754): 1751-1767.
Dr Kishore Bahl is a Specialist Grade Doctor in Urology (GMC Registration: 6070860) and founder of Shockwave ReVibe Clinic, 22 Notting Hill Gate, London W11 3JE. To book a consultation, call 020 3004 0564 or visit shockwave-revibe.co.uk.
Last reviewed: August 2026