Tennis elbow and golfer's elbow are tendon-related pain presentations on opposite sides of the elbow. Tennis elbow usually involves the common extensor tendon at the lateral epicondyle. Golfer's elbow involves the common flexor-pronator origin on the inside. Chronic cases can involve tendon degeneration, disorganized collagen and reduced load tolerance rather than simple inflammation. But pain near the elbow is not automatically tendinopathy. Nerve irritation, joint problems and other structures can produce similar symptoms. At Novo Soft Tissue in the Denver Tech Center, the first visit is an examination. It determines whether shockwave, manual treatment, rehabilitation, imaging or referral fits.
Background
What Happens in a Chronic Elbow Tendon
Chronic lateral elbow tendinopathy is primarily a degenerative tendon disorder rather than ongoing inflammation. In 11 surgical specimens from refractory tennis elbow, every one was histologically abnormal, with focal hyaline degeneration in all 11 and vascular proliferation in 10. None of 12 cadaver controls showed these changes (Regan, 1992). A later biopsy study of 11 chronic cases found disorganized collagen, hyaline degeneration, loss of tendon cells, fibrocartilage changes, calcification and new blood vessels, often in limited zones beside normal tissue (Galliani, 2002).
These findings do not mean every painful elbow has the same pathology. Tenderness cannot reveal tendon histology. Pain also involves how the tendon is loaded, motor control and how the nervous system processes pain.
The name lateral epicondylitis implies inflammation. Lateral elbow tendinopathy, or lateral epicondylalgia, fits chronic cases better. "Tennis elbow" is fine for everyday use, and most people with it do not play tennis.
Tennis Elbow vs. Golfer's Elbow
| Tennis elbow | Golfer's elbow | |
|---|---|---|
| Location | Outside (lateral) elbow | Inside (medial) elbow |
| Typical tendon | Common extensor origin, often involving ECRB | Common flexor-pronator origin |
| Common provocation | Gripping, resisted wrist or middle-finger extension | Gripping, resisted wrist flexion or pronation |
| Shockwave evidence | Substantial | Much thinner |
The pattern points toward a diagnosis. It does not establish one.
Examination
What We Examine in Persistent Elbow Pain
- Exact pain location and how long it has lasted
- Grip tolerance and grip strength
- Resisted wrist extension, wrist flexion and pronation
- Tenderness at the tendon origin and in the forearm muscles
- Elbow range of motion and any catching or locking
- Numbness, tingling or other nerve-related symptoms
- A neck and upper-quarter screen when symptoms suggest it
- Previous imaging and treatment, and how you responded
- Anything that calls for imaging or referral
Differential diagnosis
Lateral Elbow Pain Is Not Always Tennis Elbow
- Lateral elbow tendinopathy Tenderness at the common extensor origin and ECRB region, with pain on gripping and resisted wrist extension.
- Radial tunnel / radial nerve Pain often a few centimeters farther down the forearm, sometimes provoked by nerve-related loading. It can coexist with tendinopathy. See tennis elbow vs. radial tunnel syndrome.
- Radiocapitellar joint Catching, locking, clicking or lost motion suggest the joint and may need a different workup.
- Cervical referral Arm symptoms with neck pain, numbness or weakness may originate in the neck.
- Significant tendon tear A sudden injury or marked weakness may need imaging.
- Distal forearm and wrist Pain closer to the wrist than the elbow, on the thumb side or the little-finger side, usually involves different tendons. See wrist and forearm tendon pain.
Medial Elbow Pain Is Not Always Golfer's Elbow
- Common flexor-pronator tendinopathy Tenderness just below the medial epicondyle, with pain on gripping, resisted wrist flexion or pronation.
- Ulnar nerve / cubital tunnel Numbness or tingling into the ring and small fingers, or hand weakness. An irritated or unstable ulnar nerve is not a shockwave target.
- Ulnar collateral ligament (UCL) Medial pain with throwing, especially in overhead athletes, needs a ligament assessment.
- Joint or traumatic injury A fall, swelling or mechanical symptoms call for a different workup.
Treatment selection
How Treatment Is Selected
Many people improve with activity changes, a brace, time or an injection. Progressive loading and strengthening remain central to lateral elbow rehabilitation. When pain keeps limiting you despite appropriate care, the exam determines whether another intervention such as ESWT fits.
Radial shockwave spreads energy across a broad, superficial area, which suits the superficial common tendon origin in appropriate cases. It has a substantial tennis elbow evidence base and ranked strongly for pain at rest and longer-term disability in a 2026 network analysis.
Focused shockwave concentrates energy in a smaller zone. It is also supported by tennis elbow trials and ranked higher for grip strength and tennis elbow-specific function in the same analysis.
Manual treatment may address restricted forearm muscle and fascia found on exam. It does not reorganize tendon collagen.
Both radial and focused ESWT have clinical evidence for lateral elbow tendinopathy. Different protocols lead on different outcomes, so the research does not support one universal winner. You do not need to choose before the visit. Treatment follows the examination. All four tools are compared on the services page, and broader tendon problems are covered on chronic tendinopathy.
Imaging & referral
When Elbow Pain Needs Medical Evaluation First
See a physician promptly after a fall or significant trauma, or for a visible deformity, marked swelling, fever or a hot joint. The same applies to sudden weakness after a pop, locking, or progressive numbness or hand weakness.
Pain at the front of the elbow, especially when turning the palm up, raises a different set of questions involving the distal biceps tendon and brachialis. See biceps, brachialis and anterior elbow pain. Pain at the back of the elbow, with pressing or over the tip of the elbow, is covered on triceps tendinopathy and posterior elbow pain.
Evidence
Does Shockwave Help Tennis Elbow?
For tennis elbow (lateral epicondylopathy), pooled reviews report that shockwave reduces pain compared with placebo and ultrasound, although the underlying trials are inconsistent. The evidence for golfer’s elbow is much thinner.
- Tendon pathology: biopsy studies directly documented disorganized collagen and degenerative change in symptomatic common extensor tendon tissue (Regan, 1992; Galliani, 2002).
- Shockwave overall: a 2025 umbrella review of 9 meta-analyses found ESWT reduced pain compared with placebo and ultrasound, while noting overlap and inconsistency in the underlying trials.
- Radial vs. focused: a 2026 network meta-analysis of 23 randomized trials (1,484 participants) found each modality ranked best on different outcomes.
- Versus steroid injection: in a 2024 meta-analysis of 6 trials, injection did better at one month, while pooled outcomes favored ESWT at three and six months.
- Golfer's elbow: the evidence is much thinner. An older trial in 30 patients with chronic medial epicondylitis reported only 7 good or excellent results at one year, worse than an identically treated tennis elbow group. Tennis elbow results should not simply be assumed to apply medially.
Read the full tennis elbow shockwave evidence review → · Tennis elbow vs. radial tunnel syndrome →
Sources: Regan et al., Am J Sports Med 1992 · Galliani et al., Eur J Histochem 2002 · Zhu et al., J Orthop Traumatol 2025 · Cha et al., J Clin Med 2026 · Zhang et al., Orthop Surg 2024 · Krischek et al., Arch Orthop Trauma Surg 1999 · Lucado et al., JOSPT 2022
Golfers can also see our TPI golf performance page.