Shockwave therapy has a substantial research base for chronic tennis elbow, but the results depend on the comparator, the protocol and the outcome measured. Recent umbrella and network meta-analyses generally support pain improvement with ESWT. Newer evidence suggests radial and focused shockwave have different strengths rather than one being better across the board. Corticosteroid injections tend to work faster at first, while pooled results favor ESWT at later follow-up. The evidence applies mainly to lateral elbow tendinopathy, not to every cause of lateral elbow pain, and not automatically to golfer's elbow.
What kind of elbow pain has shockwave been studied for?
Almost all of the trials enrolled people with lateral epicondylitis: pain at the common extensor tendon origin on the outside of the elbow, usually lasting months and often after other treatment. That presentation is now often called lateral elbow tendinopathy, because biopsy studies of chronic cases show degenerative tendon change rather than ongoing inflammation.
That matters for how you read the evidence. The results do not automatically apply to lateral elbow pain from a radial nerve problem, a joint problem, a tendon tear or pain referred from the neck. They also do not transfer automatically to golfer's elbow on the inside of the elbow, covered below.
What do the meta-analyses show?
The 2025 umbrella review. Zhu and colleagues, in the Journal of Orthopaedics and Traumatology, reviewed 9 meta-analyses. Five were rated high quality, three moderate and one low. Many drew on the same trials, so their results are not independent patient populations.
- Versus placebo: ESWT reduced pain on a 10-point scale by an average of 0.68 points (95% CI 0.30 to 1.06), with substantial inconsistency between studies. It made people about 38% more likely to reach at least a 50% reduction in pain (RR 1.38).
- Versus therapeutic ultrasound: pain was lower with ESWT by 1.42 points at one month and 1.65 points at three months, again with high heterogeneity.
- Grip strength: the difference from placebo was statistically significant but not considered clinically important.
The 2025 ultrasound comparison. A meta-analysis of 9 randomized trials and 654 participants found ESWT reduced pain more than therapeutic ultrasound (mean difference 0.90 points). The difference in tennis elbow-specific function (PRTEE) was borderline and not clearly significant (p = .05), and heterogeneity was substantial.
Across these reviews the pattern is consistent: ESWT reduces pain more than placebo or ultrasound on average, functional advantages are less certain, and the trials vary a lot.
Shockwave vs. corticosteroid injection
Zhang and colleagues pooled 6 randomized trials comparing ESWT with a local corticosteroid injection, published in Orthopaedic Surgery in 2024. The answer depended on when outcomes were measured.
| Follow-up | Pain (VAS) | Grip strength | PRTEE function |
|---|---|---|---|
| 1 month | Injection better | Injection better | Injection better |
| 3 months | ESWT better (−1.15) | ESWT better (+2.04) | ESWT better (−9.50) |
| 6 months | ESWT better (−1.81) | ESWT better (+3.06) | Not reported |
Adverse events were similarly low in both groups, and all were mild. The authors concluded both treatments are effective and safe. A steroid injection is a reasonable option, particularly when faster short-term relief is the priority. The trade-off is in the time course, not in one treatment being harmful.
Radial vs. focused shockwave
Radial shockwave spreads energy across a broad, superficial area. Focused shockwave concentrates it in a smaller zone at a chosen depth. The common extensor origin is superficial, so both can reach it.
The 23-trial network meta-analysis. Cha and colleagues, in the Journal of Clinical Medicine in 2026, compared focused ESWT, radial ESWT and two types of platelet-rich plasma across 23 randomized trials and 1,484 participants. Treatments were ranked using SUCRA, a probability-based ranking from 0 to 100. A SUCRA of 92.9 does not mean 92.9% of patients improved. It means that treatment was most likely to rank first on that outcome.
- Radial ESWT ranked highest for pain at rest (SUCRA 86.6) and for arm disability on the DASH questionnaire, overall (92.9) and at six months or later (94.0).
- Focused ESWT ranked highest for grip strength, overall (82.6) and in the first three months (78.4), and for tennis elbow-specific function on the PRTEE (81.9).
The authors concluded that outcomes depend on the specific type of ESWT and that treatment should be matched to a patient's priorities. The results do not support declaring one modality universally superior.
An individual trial pointing the other way. Kaplan and colleagues (2023) randomized patients with acute lateral epicondylitis to focused, radial or sham ESWT, three sessions each. Both active groups improved on the PRTEE while sham did not. Focused ESWT improved function and total PRTEE scores more than radial at 5 and 13 weeks. Individual trials and network analyses do not produce one universal radial-versus-focused answer.
A focused trial with a co-intervention. Król and colleagues (2024) randomized 60 patients to focused ESWT, therapeutic ultrasound or placebo ultrasound, and every patient also received deep friction massage. All three groups improved by 12 weeks. Pain and function improved more with focused ESWT than with ultrasound, while strength gains were similar. Because everyone received massage, this trial does not show focused ESWT alone versus no treatment.
Why protocol matters
Jin and colleagues, in the Journal of Orthopaedic Surgery and Research in 2026, ran a second network meta-analysis splitting ESWT by type and intensity. It included 11 randomized trials and 2 cohort studies with 938 patients.
- Medium-intensity radial ESWT ranked highest for pain at one month.
- Low-intensity focused ESWT ranked highest for long-term pain relief and the Roles-Maudsley outcome score.
- Low-intensity radial ESWT ranked highest for DASH and PRTEE function.
- Sham ESWT outperformed waiting with no treatment on PRTEE, a reminder of how much non-specific effects contribute.
The authors noted the evidence is limited by the scarcity and quality of existing research. These rankings are not a recipe, and they do not prove any single setting is best. They do show that energy level and device type change results, which is one reason different trials disagree.
Why some trials show little or no advantage
Not every trial is positive. Capan and colleagues (2016) randomized 56 patients with lateral epicondylitis that had not responded to earlier treatment to radial ESWT or sham, three weekly sessions. Both groups improved in pain, function and grip strength, with no significant difference between them at one or three months. An earlier multicenter trial by Haake and colleagues (2002) randomized 272 patients to ESWT or placebo, both given with local anesthetic. At 12 weeks, 25.8% succeeded with ESWT and 25.4% with placebo, and about two-thirds of both groups had improved by one year. Local anesthesia and older protocols may have affected that result, but it remains part of the evidence.
Several factors can explain conflicting results:
- Patient selection: how chronic the condition is and whether other pain sources were excluded
- Device and dose: radial or focused, energy level, number of pulses and sessions
- Comparator: sham, ultrasound, injection, exercise or waiting list
- Co-interventions: exercise, massage or bracing given to every group
- Outcome and timing: pain, grip, DASH and PRTEE do not always move together, and short- and long-term results can differ
Does shockwave repair the tendon?
Clinical trials measure pain, function, grip strength and disability. Biological mechanisms have been proposed, mostly from laboratory and animal research. No human study in tennis elbow has shown that shockwave restores normal collagen architecture or regenerates the common extensor tendon. The supported claim is improvement in symptoms and function, not a rebuilt tendon.
Does shockwave replace strengthening?
No. The 2022 clinical practice guideline on lateral elbow pain from the Journal of Orthopaedic and Sports Physical Therapy describes symptoms as arising from an interaction of tendon structural changes, altered motor control and changes in pain processing. Progressive loading and strengthening remain important parts of lateral elbow rehabilitation. When pain remains limiting despite appropriate care, the examination determines whether another intervention such as ESWT fits.
Does this evidence apply to golfer's elbow?
Not automatically. Shockwave has been studied far more extensively for tennis elbow than for golfer's elbow (medial epicondylitis). In an older trial by Krischek and colleagues (1999), 30 patients with chronic medial epicondylitis received three weekly low-energy treatments. At one year, 7 had good or excellent results, 8 fair and 14 poor. Only 6 were satisfied, and average pain relief was 32%. Those results were significantly worse than for an identically treated tennis elbow group.
That trial used an older protocol, so it does not show that shockwave fails for golfer's elbow. It does show that the medial evidence is much less developed, and modern tennis elbow results should not be assumed to apply. Treating medial elbow tendinopathy relies more heavily on the individual exam, especially because ulnar nerve and ligament problems can also cause medial elbow pain.
Who may be a reasonable candidate?
- Pain at the common extensor origin, reproduced by gripping and resisted wrist extension
- Symptoms lasting several months
- Limited progress despite appropriate loading, activity changes or other care
- No features suggesting a nerve, joint or tear problem
Who needs a different diagnosis or workup?
- Pain mostly farther down the forearm, or numbness and tingling
- Catching, locking or loss of elbow motion
- A sudden injury, a pop or marked weakness
- Neck pain with arm symptoms
- Medial pain in a throwing athlete
How Novo approaches tennis elbow
We examine the elbow first and decide on treatment from there. Radial shockwave and focused shockwave are both options, chosen by what the exam shows, and they work alongside a loading program rather than replacing it. For the broader comparison, see radial vs. focused shockwave, and for tendon problems elsewhere, chronic tendinopathy. See how we approach tennis and golfer's elbow, or read about shockwave therapy in Denver.
References
- Zhu P, Tang P, Su J, et al. Comparison of extracorporeal shockwave therapy, ultrasound therapy, and corticosteroid injections for treatment of lateral epicondylitis: an umbrella review of meta-analyses. Journal of Orthopaedics and Traumatology. 2025;26(1):55. PMID 40824407. (link)
- Zhang L, Zhang X, Pang L, Wang Z, Jiang J. Extracorporeal shock wave therapy versus local corticosteroid injection for chronic lateral epicondylitis: a systematic review with meta-analysis of randomized controlled trials. Orthopaedic Surgery. 2024;16(11):2598-2607. PMID 39198038. (link)
- Cha JM, Yoon SY, Kim YW, Park JM, Lee SC. Comparative effectiveness of focused versus radial extracorporeal shockwave therapy and leukocyte-poor versus leukocyte-rich platelet-rich plasma for lateral epicondylitis: a network meta-analysis. Journal of Clinical Medicine. 2026;15(17):6679. PMID 42739684. (link)
- Jin R, Wang H, Lv W, et al. Comparison of the efficacy of different types and intensities of extracorporeal shock wave therapy for lateral epicondylitis: a systematic review and network meta-analysis. Journal of Orthopaedic Surgery and Research. 2026;21(1):435. PMID 42177532. (link)
- Alharbi M. Comparative efficacy of extracorporeal shockwave therapy and ultrasound on pain and functional outcomes in lateral epicondylitis: a systematic review and meta-analysis. European Journal of Orthopaedic Surgery and Traumatology. 2025;35(1):307. PMID 40668449. (link)
- Capan N, Esmaeilzadeh S, Oral A, et al. Radial extracorporeal shock wave therapy is not more effective than placebo in the management of lateral epicondylitis: a double-blind, randomized, placebo-controlled trial. American Journal of Physical Medicine and Rehabilitation. 2016;95(7):495-506. PMID 26544854. (link)
- Haake M, König IR, Decker T, et al. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. Journal of Bone and Joint Surgery (American). 2002;84(11):1982-1991. PMID 12429759. (link)
- Kaplan S, Sah V, Ozkan S, Adanas C, Delen V. Comparative effects of focused and radial extracorporeal shock wave therapies on lateral epicondylitis: a randomised sham-controlled trial. Journal of the College of Physicians and Surgeons Pakistan. 2023;33(5):554-559. PMID 37190692. (link)
- Król P, Łojewski B, Król T, Kuszewski M, Stania M. Focused shock wave and ultrasound therapies in the treatment of lateral epicondylitis: a randomized control trial. Scientific Reports. 2024;14(1):26053. PMID 39472446. (link)
- Krischek O, Hopf C, Nafe B, Rompe JD. Shock-wave therapy for tennis and golfer's elbow: 1 year follow-up. Archives of Orthopaedic and Trauma Surgery. 1999;119(1-2):62-66. PMID 10076947. (link)
- Lucado AM, Day JM, Vincent JI, et al. Lateral elbow pain and muscle function impairments: clinical practice guidelines. Journal of Orthopaedic and Sports Physical Therapy. 2022;52(12):CPG1-CPG111. PMID 36453071. (link)
