Treatment options for Tennis Elbow: A Review of Recent Evidence (2021–2025)

By Dr. Debjyoti Dutta & Dr. Chinmoy Roy

Introduction

Lateral epicondylalgia, commonly referred to as tennis elbow, is one of the most frequently encountered causes of elbow pain in orthopedic, sports medicine, and pain management practice. The condition results from degenerative tendinopathy of the common extensor tendon, most commonly involving the extensor carpi radialis brevis (ECRB) tendon at the lateral epicondyle of the humerus. Histopathological studies have consistently demonstrated angiofibroblastic degeneration rather than classic inflammatory changes, leading modern literature to favor the term lateral epicondylalgia or tendinopathy rather than epicondylitis.

Treatment options for Tennis Elbow: A Review of Recent Evidence (2021–2025)

Conservative management—including activity modification, physiotherapy, eccentric strengthening exercises, and non-steroidal anti-inflammatory drugs—remains the first-line treatment for most patients. However, a subset of individuals continues to experience persistent symptoms despite several weeks of conservative therapy. For such patients, injection therapy has emerged as an important intermediate treatment option before considering surgery.

Over the past decade, there has been a significant shift in the conceptual approach to injection therapies. Traditional corticosteroid injections, once widely used for symptomatic relief, are increasingly being replaced by regenerative injections, such as platelet-rich plasma (PRP) and autologous blood injections. These treatments aim to stimulate tendon healing rather than merely suppress pain.

During the last five years (2021–2025), several randomized controlled trials, systematic reviews, and meta-analyses published in major medical journals have compared these injection modalities. This review summarizes the recent evidence regarding injection therapies for tennis elbow, focusing on corticosteroid injections, platelet-rich plasma, autologous blood injections, and other emerging regenerative treatments.

Corticosteroid Injection

Mechanism and Rationale as Treatment Options for Tennis Elbow

Corticosteroid injections have traditionally been used in tennis elbow because of their potent anti-inflammatory effects. Commonly used agents include triamcinolone acetonide, methylprednisolone acetate, and betamethasone, usually administered with a local anesthetic.

Although corticosteroids can rapidly reduce pain through suppression of inflammatory mediators and nociceptive pathways, modern understanding of tennis elbow pathology reveals that the underlying pathology is degenerative rather than inflammatory. Consequently, corticosteroid injections address symptoms rather than the structural tendon degeneration.

Evidence From Recent Studies

Multiple studies published in the last five years have evaluated corticosteroid injections against regenerative therapies.

A 2024 systematic review and meta-analysis by Xu et al. in the American Journal of Sports Medicine, which analyzed 11 randomized controlled trials involving approximately 730 patients, found that corticosteroid injections produced better short-term pain relief within the first two months following treatment. However, at longer follow-up intervals exceeding six months, patients treated with platelet-rich plasma demonstrated significantly greater improvement in pain and functional outcomes.

Similarly, Hohmann et al. (2023) published a meta-analysis in the Journal of Shoulder and Elbow Surgery comparing corticosteroid injections with PRP. Their analysis demonstrated that corticosteroids were superior in the first month after treatment, but PRP provided significantly better outcomes between three and six months, suggesting that steroid injections offer temporary symptomatic relief rather than durable improvement.

Additional studies have also reported that repeated corticosteroid injections may be associated with higher recurrence rates and potential tendon weakening, further limiting their role as a long-term therapeutic strategy.

Clinical Implications

Based on current evidence, corticosteroid injections remain useful for rapid short-term pain relief, particularly in patients requiring quick functional recovery. However, they are increasingly viewed as a temporary symptomatic treatment rather than a disease-modifying intervention, and repeated injections are generally discouraged.

Platelet-Rich Plasma (PRP)

Biological Mechanism

Platelet-rich plasma is an autologous blood product obtained by centrifugation of whole blood to concentrate platelets and growth factors. Platelets release numerous bioactive molecules that contribute to tissue repair and regeneration, including:

• Platelet-derived growth factor (PDGF)

• Transforming growth factor-β (TGF-β)

• Vascular endothelial growth factor (VEGF)

• Insulin-like growth factor-1 (IGF-1)

These growth factors promote fibroblast proliferation, collagen synthesis, angiogenesis, and tendon remodeling, thereby addressing the degenerative pathology underlying tennis elbow.

Evidence From Randomized Trials and Meta-Analyses

Over the past five years, PRP has become the most extensively studied injection therapy for tennis elbow.

A 2023 randomized controlled trial by Kıvrak et al., involving 120 patients, compared PRP, corticosteroid injection, and autologous blood injection. The study demonstrated that corticosteroid injections produced rapid pain relief in the early weeks, but PRP showed significantly superior improvement in pain and functional scores during long-term follow-up.

Further support for PRP comes from the 2025 meta-analysis by Maroun et al., which evaluated randomized trials comparing PRP with corticosteroid injections. This analysis concluded that although both treatments produced similar early improvements, PRP resulted in greater long-term functional recovery and sustained pain reduction, particularly in patients with chronic symptoms.

A 2025 comparative study by Dejnek et al. in the Journal of Clinical Medicine evaluated PRP against corticosteroid injection, hyaluronic acid injection, and placebo. The investigators found that PRP significantly improved both pain and functional outcomes compared with placebo, while corticosteroid injections produced faster early pain relief but less durable improvement.

Variations in PRP Preparation

Various PRP preparation techniques exist, particularly with respect to leukocyte content.

A 2022 systematic review by Li et al. compared leukocyte-rich PRP and leukocyte-poor PRP and found that both preparations resulted in significant improvement in pain and function, with no significant difference in clinical outcomes between the two formulations.

Another 2024 systematic review by Averell et al. investigated whether platelet concentration influences treatment outcomes. Their findings indicated that platelet concentration did not significantly correlate with pain outcomes, suggesting that extremely high platelet concentrations may not be necessary for clinical benefit.

Clinical Significance

Current literature suggests that PRP injections:

• Provide slower onset of pain relief compared with steroids

• Produce more durable improvements in pain and function

• May delay or prevent the need for surgical intervention

These characteristics have led many clinicians to consider PRP the preferred injection therapy for chronic tennis elbow.

Autologous Blood Injection

Autologous blood injection (ABI) represents a simpler and more cost-effective regenerative therapy. The technique involves injecting a small volume of the patient’s own venous blood directly into the degenerative tendon origin.

The injected blood contains platelets and cellular mediators that may initiate a healing response through local inflammation and collagen synthesis.

Evidence From Recent Studies

A 2024 prospective comparative study by Cakar et al. compared PRP with autologous blood injection. The investigators reported that both treatments significantly improved pain and functional outcomes, although PRP demonstrated slightly superior improvement in functional scores.

Similarly, a 2025 clinical study by Shahzad et al. compared autologous blood injection with corticosteroid injection. The study showed that patients receiving autologous blood injection experienced greater long-term pain relief and required fewer repeat procedures compared with those treated with corticosteroids.

Clinical Role

Autologous blood injection appears to be an effective regenerative treatment, particularly in settings where PRP preparation is not readily available. Although PRP may produce somewhat more consistent results, ABI remains a cost-effective alternative.

PRP Compared With Surgical Treatment

Surgical intervention is typically reserved for patients with persistent symptoms after six to twelve months of conservative therapy. However, recent research has explored whether regenerative injections might reduce the need for surgery.

A 2022 meta-analysis by Kim et al. found that PRP injections produced pain relief and functional improvement comparable to surgical outcomes in chronic lateral epicondylitis. These findings suggest that PRP may serve as a less invasive alternative prior to considering surgical treatment.

Cost-Effectiveness of Injection Therapies

Cost considerations are important when selecting treatment strategies.

A 2022 economic analysis by Klifto et al. evaluated the cost-effectiveness of PRP compared with corticosteroid injections over a five-year period. Although PRP had a higher initial cost, the analysis found that PRP provided greater long-term value due to sustained symptom improvement and reduced recurrence rates as Treatment options for Tennis Elbow.

Overall Evidence Summary (2021–2025)

Across multiple randomized trials and meta-analyses published during the past five years, a consistent pattern has emerged:

Short-term outcomes (≤6 weeks)

Corticosteroid injections provide rapid pain relief and functional improvement.

Intermediate outcomes (3–6 months)

Regenerative therapies such as PRP and autologous blood injections demonstrate superior improvement compared with corticosteroids.

Long-term outcomes (>6 months)

PRP consistently provides the most durable clinical benefit, with sustained pain reduction and improved functional outcomes.

A recurring finding across studies is that:

• Steroid injections act quickly but are associated with higher recurrence rates

• PRP produces slower onset of improvement but more sustained clinical benefit

Current Evidence-Based Consensus (2025–2026)

Based on the growing body of high-quality evidence, current clinical recommendations increasingly emphasize regenerative approaches for chronic lateral epicondylitis.

Consensus points include:

• Repeated corticosteroid injections should generally be avoided because of poorer long-term outcomes.

• Platelet-rich plasma is the most extensively studied regenerative injection therapy and has demonstrated favorable long-term outcomes.

• Autologous blood injection offers a cost-effective alternative, particularly where PRP preparation is not feasible.

• Injection therapies should be combined with physiotherapy and eccentric strengthening exercises to optimize outcomes.

• Surgical treatment should be reserved for refractory cases after at least six to twelve months of conservative management.