Tennis Elbow (Lateral Epicondylitis)

Tennis elbow, known medically as lateral epicondylitis, is pain where the forearm extensor tendons attach to the outside of the elbow. Despite the name, most people who get it do not play tennis. In a Finnish population study it affected 1.3% of working-age adults, peaked between 45 and 54, affected men and women equally, and was linked to repetitive, forceful arm work and smoking (Shiri 2006).

At Modal Pain Management in Midtown Manhattan, Dr. Alex Movshis combines a focused exam, ultrasound when it adds something, and a plan built on load management and strengthening, with ultrasound-guided cortisone or PRP (platelet-rich plasma) for selected cases, and referral for percutaneous tenotomy or surgery for the few that do not settle.

This page covers what tennis elbow actually is, how it is diagnosed, what the trials actually show for PRP versus cortisone, and the full evidence-based treatment ladder we use to get patients back to gripping, lifting, working, and playing without pain.

What Is Tennis Elbow?

Tennis elbow is a tendinopathy — a chronic, degenerative injury — of the common extensor tendon at the lateral epicondyle of the humerus (the bony bump on the outside of the elbow). The most commonly involved tendon is the extensor carpi radialis brevis (ECRB), with frequent involvement of the extensor digitorum communis. Despite the name “epicondylitis”, which implies inflammation, tissue examined under the microscope shows that established tennis elbow is mainly a tendinosis: disorganized collagen, microtears and abnormal blood vessel ingrowth rather than active inflammation (Kraushaar 1999). That helps explain why cortisone gives relief that tends to fade or reverse over 6 to 12 months in tendon problems (Coombes 2010), and why treatment focuses on loading the tendon back to health.

Common triggers are long hours of mouse work, racquet sports including pickleball and padel, manual trades, and gym work that loads the forearm palm-down.

Tennis Elbow vs. Other Causes of Elbow Pain

Lateral elbow pain has several possible causes that look similar on the surface but require different treatment. At Modal Pain Management we systematically rule out each one:

• Tennis elbow (lateral epicondylitis) — pain on the outer elbow, reproduced by Cozen’s, Mill’s, and Maudsley’s tests, with tenderness directly over the lateral epicondyle.
• Golfer’s elbow (medial epicondylitis) — pain on the inner elbow involving the wrist flexor tendons. Same treatment principles, opposite location.
• Posterior interosseous nerve syndrome / radial tunnel syndrome — pain a few centimeters below the lateral epicondyle rather than directly over it, with deep aching that can worsen at night, reproduced by resisted middle-finger extension and resisted forearm supination.
• Cervical radiculopathy (C6/C7 nerve root) — referred pain from the neck into the lateral elbow and forearm. It is often mistaken for tennis elbow when the pain pattern is atypical or persistent.
• Lateral collateral ligament injury — instability with lateral pivot stress, usually after trauma.
• Posterolateral elbow plica — inflamed synovial fold catching as the elbow bends and straightens. Less common, but real.
• Synovitis or early osteoarthritis of the radiocapitellar joint — joint-line pain rather than tendon-attachment pain.

A focused exam sorts out most of these, with ultrasound when it helps. MRI is kept for atypical or refractory cases.

Diagnosis at Modal Pain Management

A first-visit tennis elbow evaluation at Modal Pain Management includes:

1. Focused history — onset (acute vs. insidious), occupational and athletic exposures (mouse use, racquet sport, gripping demands), prior treatments and their effect, and any neck or hand symptoms that might suggest a different diagnosis.
2. Physical examination — inspection, palpation of the lateral epicondyle and surrounding structures, range of motion, grip strength testing, and the three classic provocative tests (Cozen’s, Mill’s, Maudsley’s).
3. Ultrasound when needed — a look at the common extensor tendon to grade it (tendinosis, partial tear, full-thickness tear), find calcifications, and guide any injection.
4. Targeted imaging — X-ray if there is concern for a calcification or arthritis, and MRI for atypical presentations or before surgery.

Image-Guided Treatment Ladder

Treatment follows a ladder. Most people move through it from the top, and some start further down based on how long the pain has lasted and what the exam shows.

Step 1: Conservative Treatment (Weeks 0–6)

For most patients with acute or mild symptoms, the first 4–6 weeks emphasize load reduction and the start of structured eccentric exercise:

• Activity modification — temporary reduction in gripping, lifting palm-down, racquet sport, and aggravating workplace tasks.
• Counterforce brace placed about a finger’s width below the elbow during unavoidable load. Some people find it eases pain while gripping.
• Anti-inflammatories for short-term symptom control, an over-the-counter ibuprofen or naproxen at the label dose for a week or so, if it is safe for you.
• Eccentric strengthening — slow, lengthening contractions of the wrist extensors with a light dumbbell or the Tyler twist exercise with a FlexBar. Adding the Tyler twist to standard therapy improved pain and function in a 21-patient trial (Tyler 2010).
• Workplace and equipment ergonomics — vertical mouse, ergonomic keyboard, racquet weight and string tension review, grip technique coaching.

Most people improve over the following months. In one trial, most of those who simply waited reported success at one year, and physiotherapy helped more than waiting in the first six weeks (Bisset 2006).

Step 2: PRP (Platelet-Rich Plasma) Injection

For pain that persists despite a real strengthening program, PRP injection is one option Dr. Movshis discusses. PRP uses a small sample of the patient’s own blood, processed in-office into leukocyte-poor PRP, then injected directly into the damaged tendon under real-time ultrasound guidance. Platelets release growth factors that are thought to support tendon repair. That rationale is plausible, but the clinical trials are mixed.

PRP takes longer to work than cortisone. In the trials that found a benefit, the difference showed up at three to six months rather than in the first weeks, and soreness for several days after the injection is common. The trials point in different directions. In a 230-patient trial, tendon needling plus leukocyte-rich PRP was no better than needling alone at 12 weeks and was ahead at 24 weeks (71.5% versus 56.1% pain improvement) (Mishra 2014). Another trial found PRP better than cortisone at 2 years (Gosens 2011). A smaller trial found no benefit over saline at three months (Krogh 2013), and a 2026 meta-analysis of six placebo-controlled trials, 355 patients, found PRP no better than placebo at any time point (Antunes Júnior 2026). We tell patients this before they decide. Avoid anti-inflammatories for 2 weeks before and 2 weeks after the injection, and follow the activity schedule on our PRP aftercare page. Most insurers consider PRP unproven and do not cover it, so it has an out-of-pocket cost, which we discuss transparently before scheduling.

Step 3: Referral for Percutaneous Tenotomy in Refractory Cases (Months 3–6+)

For tennis elbow that has lasted more than about six months despite a real strengthening program, ultrasound-guided percutaneous tenotomy is an option before surgery. Under local anesthesia, a needle or a dedicated device is used under ultrasound to break up and remove degenerated tendon tissue. Small case series without a control group, of 19 and 20 patients, reported lasting improvement at one and three years (Barnes 2015, Seng 2016). It has not been tested against a sham procedure. Modal Pain does not perform tenotomy and refers patients who are candidates for it.

When Cortisone Is Used

Corticosteroid injection fits selected cases, usually severe pain when someone has to function in the next few weeks. It gives the fastest relief, but the benefit does not last. In a placebo-controlled trial, one cortisone injection was followed by worse results at one year (83% versus 96% recovered or much improved) and more recurrences (54% versus 12%) (Coombes 2013). A network meta-analysis of injection trials found it no better than placebo beyond 8 weeks (Krogh, Bartels 2013). Dr. Movshis uses it selectively and does not repeat it in the same tendon within three months.

When Surgery Is Considered

Surgery (open or arthroscopic ECRB tendon release) is for the few people with severe tennis elbow that has not responded to 6 to 12 months of structured non-operative care. Dr. Movshis refers to NYC orthopedic upper-extremity surgeons when surgery becomes the right step. Most people never need it.

Physical Therapy and Self-Care

Injections can ease pain, but lasting recovery depends on the tendon getting stronger and the load on it changing. A targeted rehabilitation program for tennis elbow typically includes:

• Eccentric wrist extensor strengthening — the Tyler twist (FlexBar) or slow dumbbell lowering, progressed gradually over weeks.
• Forearm and grip strengthening progression — slow eccentric grip, then concentric grip, then dynamic grip as pain allows.
• Shoulder and shoulder-blade strengthening — weakness higher up the arm may shift load onto the elbow tendons.
• Workplace ergonomic evaluation — mouse, keyboard, monitor height, chair position, vertical mouse trial.
• Equipment review for racquet sport athletes — racquet weight, string tension and grip size, and for golfers, club fitting and grip technique.
• Self-care — counterforce brace during load, ice for 15 minutes after activity, gradual return-to-sport progression.

Most people notice progress within a few months of steady rehab.

When to Seek Specialist Care

See a pain specialist for tennis elbow evaluation if any of the following apply:

• Lateral elbow pain that has not improved with 4–6 weeks of activity modification, NSAIDs, and a counterforce brace.
• Pain that is interfering with work, sleep, or daily activities (gripping a coffee cup, opening a jar, shaking hands).
• Symptoms that have been present for more than 3 months despite home treatment.
• A previous episode that resolved and has now recurred.
• Pain that is atypical (located more than 3 cm distal to the elbow, worse at night, associated with neck symptoms or hand numbness) — these patterns suggest a different diagnosis that needs to be ruled out.

Red-flag symptoms — sudden severe pain after a “pop,” visible deformity, bruising, complete loss of grip strength, or numbness in the hand — require prompt evaluation rather than an outpatient tennis elbow workup.

Why Modal Pain Management for Tennis Elbow in NYC

Modal Pain Management is a focused, physician-owned interventional pain practice in Midtown Manhattan. Dr. Alex Movshis is dual board-certified in Anesthesiology and Pain Medicine and completed an ACGME-accredited interventional pain medicine fellowship at the Icahn School of Medicine at Mount Sinai. NPI 1942741160 — see our evidence and credentials page and the physician bio for full verification.

Three things differentiate tennis elbow care at Modal Pain Management:

• Ultrasound in the office. When the tendon needs a closer look or an injection, ultrasound is in the office suite, so there is no separate imaging appointment.
• Honest injection choices. Cortisone’s early benefit in tennis elbow tends to fade or reverse by 6 to 12 months (Coombes 2013), and PRP has negative placebo-controlled trials (Antunes Júnior 2026). Dr. Movshis goes through both, with cost, timeline and realistic outcomes, before anything is scheduled.
• Coordinated medical, interventional, and rehabilitation plan. Modal’s in-house physical therapists, on the same floor, treat upper-extremity tendinopathy and coordinate care with Dr. Movshis so that injection benefits convert into durable recovery, not a temporary reprieve.

Office: 369 Lexington Avenue, Floor 25, New York, NY 10017. Same-week appointments available. Modal Pain Management accepts most commercial PPO plans, including Aetna, Anthem Blue Cross Blue Shield, Cigna, Empire Blue Cross Blue Shield, the Empire Plan, Oscar, Oxford, UMR and UnitedHealthcare, and does not accept Medicare, Medicaid, HMO plans, or workers’ compensation. PRP is self-pay. Verify your benefits or call (646) 290-6660 and our team will check coverage for you.

References

• Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006;164(11):1065–74. doi:10.1093/aje/kwj325 · PubMed
• Kraushaar BS, Nirschl RP. Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, immunohistochemical, and electron microscopy studies. J Bone Joint Surg Am. 1999;81(2):259–78. PubMed
• Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751–67. doi:10.1016/S0140-6736(10)61160-9 · PubMed
• Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA. 2013;309(5):461–9. doi:10.1001/jama.2013.129 · PubMed
• Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006;333(7575):939. doi:10.1136/bmj.38961.584653.AE · PubMed
• Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg. 2010;19(6):917–22. doi:10.1016/j.jse.2010.04.041 · PubMed
• Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463–71. doi:10.1177/0363546513494359 · PubMed
• Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625–35. doi:10.1177/0363546512472975 · PubMed
• Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med. 2013;41(6):1435–46. doi:10.1177/0363546512458237 · PubMed
• Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011;39(6):1200–8. doi:10.1177/0363546510397173 · PubMed
• Karjalainen TV, Silagy M, O’Bryan E, Johnston RV, Cyril S, Buchbinder R. Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain. Cochrane Database Syst Rev. 2021;9(9):CD010951. doi:10.1002/14651858.CD010951.pub2 · PubMed
• Antunes Júnior CR, Santos RSS, Barreto ESR, et al. Platelet-Rich Plasma Does Not Improve Pain or Function in Patients With Lateral Epicondylitis as Compared With Placebo: A Meta-analysis of Randomized Clinical Trials. Am J Sports Med. 2026;54(5):1247–1257. doi:10.1177/03635465251383039 · PubMed
• Barnes DE, Beckley JM, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. J Shoulder Elbow Surg. 2015;24(1):67–73. doi:10.1016/j.jse.2014.07.017 · PubMed
• Seng C, Mohan PC, Koh SB, et al. Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 Years. Am J Sports Med. 2016;44(2):504–10. doi:10.1177/0363546515612758 · PubMed