Tennis Elbow Treatments: What the Research Says About Cortisone, Prolotherapy, and PRP

By Dr. Xiao Yuan, White Oak Pain Clinic July 23, 2026

Tennis elbow is one of the most common causes of pain on the outer side of the elbow. Most people who get it have never played tennis. It usually comes from repeated gripping, lifting, or twisting — the kind of movements involved in trades work, desk

work, cooking, or lifting children.

The pain sits over the bony bump on the outside of the elbow. It often spreads into the forearm. Simple things become difficult: turning a doorknob, carrying a bag, shaking hands.

Many people are offered a cortisone injection first. It is worth understanding what the research shows before choosing that path.

Tennis elbow is not really an inflammation problem

The medical name, lateral epicondylitis, ends in "-itis," which means inflammation. But when researchers examine the tendon tissue itself, they usually do not find much inflammation at all.

What they find instead is degeneration. The collagen fibres that give the tendon its strength become disorganized and start to break down. The tendon has tried to heal and has not fully succeeded.

In some cases there are also partial tears within the tendon. These are small tears that do not go all the way through, but that never fully heal on their own. They can keep the area painful long after the original injury, and they are one reason some people find that rest alone does not solve the problem.

This matters, because it changes what a useful treatment looks like. If the problem is a tendon that has failed to repair itself, then the goal is to help it repair — not simply to suppress inflammation that is not there.

Why cortisone often disappoints over time

Cortisone is a powerful anti-inflammatory. It usually does reduce pain quickly, often within days. That short-term relief is real.

The problem is what happens after.

A randomized controlled trial published in JAMA in 2013 followed 165 people with tennis elbow for a full year. Patients received either a cortisone injection or a placebo saltwater injection. At one year, the cortisone group had a lower rate of full recovery than the placebo group — 83 percent compared with 96 percent. Recurrence was far higher too: 54 percent of the cortisone group had their pain return, compared with 12 percent of the placebo group.[1]

Read that again. The people who received a saltwater injection did better after a year than the people who received cortisone.

One-year outcomes after cortisone injection compared with a placebo injection. Data from Coombes et al., JAMA, 2013.[1] Alt text: Bar chart showing 83% recovery and 54% recurrence after cortisone injection, compared with 96% recovery and 12% recurrence after placebo injection, at one year.

There is also laboratory evidence that corticosteroids reduce the tensile strength of collagen and can interfere with tendon repair.[2] Tendon ruptures after cortisone injection have been reported, though these reports are uncommon and the overall risk at the elbow has not been well measured. The clearer and better-documented concern is the long-term outcome data above.

None of this means cortisone is never appropriate. For some patients, rapid short-term relief is genuinely the priority. But it is reasonable to ask whether a treatment that trades short-term comfort for a worse one-year outcome is the right first step for a problem that is fundamentally about failed healing.

Regenerative injections for tennis elbow treatment: prolotherapy and PRP

Regenerative injections take the opposite approach. Rather than suppressing a healing response, they aim to restart one.

Prolotherapy uses a dextrose (sugar) solution injected into the damaged tendon and its attachment. The solution acts as a mild irritant. This prompts the body to send repair cells to the area and begin rebuilding the tissue.

A 2022 systematic review pooled eight randomized controlled trials involving 354 patients with lateral elbow tendon problems. It found that dextrose prolotherapy performed better than other active treatments at 12 weeks for both pain and function, by margins large enough to be clinically meaningful.[3]

PRP (platelet-rich plasma) uses the patient's own blood. A small sample is drawn and spun in a centrifuge to concentrate the platelets, which carry growth factors involved in tissue repair. That concentrate is then injected into the damaged tendon.

A double-blind randomized trial compared PRP with cortisone in patients with chronic tennis elbow. At one year, 73 percent of the PRP group met the study's definition of success, compared with 49 percent of the cortisone group.[4] The cortisone group improved first and then declined. The PRP group improved more slowly and kept improving. A two-year follow-up of the same patients found the benefit held.[5]

A network meta-analysis of 20 randomized trials, covering 1,271 patients, reached a similar conclusion: cortisone ranked best in the short term, and PRP ranked best in the long term across nearly every measure studied.[6]

Regenerative injections are not instant. Relief typically builds over weeks to months rather than days. That slower timeline is a fair trade for many patients, but it should be understood before starting.

Not all elbow pain is tennis elbow

This is the part that is most often missed.

Several other conditions cause pain in the same location and can look identical to tennis elbow on examination. If the diagnosis is wrong, treatment aimed at the tendon will not work — no matter how good that treatment is.

Radial nerve entrapment. The radial nerve travels through a fascial plane between the muscles of the lateral elbow. It needs to glide freely as the arm moves. When it becomes stuck to surrounding tissue, it produces pain that closely mimics tennis elbow.

This can be treated with ultrasound-guided hydrodissection. Fluid is injected precisely along the fascial plane around the nerve, separating it from the tissue binding it and restoring its ability to glide. A case series of patients with radial tunnel syndrome reported complete and lasting symptom resolution for at least two years after hydrodissection, with none going on to surgery.[7] The evidence base here is still small, but it is encouraging.

Chronic degeneration or tearing in the forearm muscles. Damage in the muscle belly itself, rather than the tendon attachment, is another frequent cause. This also responds to regenerative injections such as prolotherapy and PRP.

In our clinical experience, this type of forearm pain often improves quickly and substantially. We have seen patients with pain lasting more than 18 and 23 years resolve fully within two prolotherapy treatments. Responses vary from person to person, and these outcomes should not be expected as typical — but they illustrate why identifying the true source of pain matters so much.

Getting the diagnosis right comes first

Because so many conditions share the same location and symptoms, accurate diagnosis is the foundation of any treatment plan. Ultrasound examination allows the tendon, the nerve, and the forearm muscles to be assessed directly and while the arm is moving. It also allows any injection to be placed precisely where the problem actually is.

At White Oak Pain Clinic, our physicians assess and treat the tendon involved in tennis elbow, as well as the other conditions that can imitate it. Every injection is performed under ultrasound guidance.

If elbow pain has not resolved with rest, activity changes, or physiotherapy, an assessment can help clarify what is actually causing it and what options are reasonable.

References

1. 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):461-469.

2. Corticosteroids reduce the tensile strength of isolated collagen fascicles. Am J Sports Med. 2006;34(12):1918-1922.

3. Effects of hypertonic dextrose injection (prolotherapy) in lateral elbow tendinosis: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2022.

4. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38(2):255-262.

5. 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):1200-1208.

6. Platelet-rich plasma vs autologous blood vs corticosteroid injections in the treatment of lateral epicondylitis: a systematic review, pairwise and network meta-analysis of randomized controlled trials. PM&R. 2020.

7. Ultrasound-guided hydrodissection provides complete symptom resolution in radial tunnel syndrome: a case series and scoping review on hydrodissection for radial nerve pathology. Curr Sports Med Rep. 2022;21(9).

Primary keyword: tennis elbow treatment options

Secondary keywords: cortisone injection tennis elbow, prolotherapy tennis elbow, PRP tennis elbow, radial nerve entrapment elbow, lateral epicondylitis treatment, golfers elbow treatment, medial epicondylitis