Why won't tennis elbow heal? What is the next step after trying physical therapy, rehabilitation, shockwave therapy, and injections?

Among patients with tennis elbow, very few are actually regular tennis players.

In the clinic, most of the patients who come for consultation are housewives, chefs, carpenters, or office workers who use a mouse for eight hours a day, as well as those who do weight training. They have only one thing in common: repetitive wrist exertion, which causes the tendon on the outside of the elbow to be stretched over a long period of time.

Most people will improve after a few weeks of rest.
This article is about another situation - clearly you have rested, done physical therapy, tried shockwave and injections, and even tried physical therapy and needle knife, but six months or a year has passed, and wringing a towel still causes a faint, aching pain.
If you want to look at the causes of elbow pain first, you can refer to this site's article on the causes of elbow pain.

I've done rehabilitation, why is it still not getting better?

Because the phase of the pain has changed.

The formal name for tennis elbow is lateral epicondylitis. The pain point is at the bony prominence on the outside of the elbow, and it is most noticeable when gripping things, wringing a towel, or carrying a bag.
At the beginning, it is acute inflammation. At this stage, rest, ice, anti-inflammatory medication, or changing the way you exert force will usually bring improvement.

However, if the tendon is repeatedly subjected to stress and does not get real rest, the tissue will transition from simple inflammation to degenerative changes: the collagen fibers become disorganized, and abnormal new blood vessels and nerve endings grow locally.
By this stage, if you still use "anti-inflammatory" methods to manage the pain, you can no longer truly address the main source of the pain. That's why shots are effective for a while, and then the pain feels like it's back and you return to the clinic, but the duration of effectiveness becomes shorter and shorter.

What we want to say is, this is not because you didn't work hard enough at rehabilitation. It's just that the stage is different.

What does it mean if the pain lasts more than six months?

It means it's worth re-confirming the source, rather than running through the same treatment course all over again.

Clinically, "pain that persists or recurs for more than six months with limited response to conservative treatment" is considered the boundary for refractory pain. At this point, the question to ask changes: it's not "how to reduce inflammation," but "at which stage is the source of the pain" - is it degeneration of the tendon itself? An intra-articular problem? Or is it not in the elbow at all?

Is pain on the outside of the elbow always tennis elbow?

Not necessarily. This step is often skipped.

Cervical nerve root compression can refer pain to the forearm and outer elbow; compression of the radial nerve in the upper forearm (radial tunnel syndrome) has a pain point very close to tennis elbow; degeneration of the elbow joint itself, loose bodies, or problems with the lateral collateral ligament of the elbow can also present very similarly.

Differentiation relies on physical examination along with imaging. If combined with finger numbness, weakness, or pain extending up and down the arm, the cervical spine segment must be confirmed first. Numbness follows the path of neurological examination, which is a different matter from tendon degeneration.

Conservative treatment has limited effects, what other directions are there?

The order is roughly like this.

First, confirm the diagnosis and staging clearly. A physical examination combined with ultrasound or imaging can show the actual state of the tendon, whether there is a tear, or abnormal new blood vessels. Getting the examination done properly in this step prevents over-guessing later on.

Next is load adjustment and eccentric training. This part cannot be skipped. Tendon repair requires moderate mechanical stimulation; complete immobility is actually disadvantageous. Have a physical therapist guide you through the movements and intensity. If you watch videos on your own and perform the movements incorrectly, it can easily worsen the symptoms.

Injection therapy is the next level. Prolotherapy (high-concentration glucose, autologous platelet-rich plasma PRP, BMAC, amniotic matrix) aims to assist in tendon tissue repair; Si-Yi Clinic also has other injection repair agents available for evaluation. Which type to use and how many injections are needed will be determined by the physician based on imaging and clinical conditions.

If the response to injections is limited and the pain has lasted for more than six months, we will evaluate whether transcatheter arterial microembolization (TAME) is suitable. It does not treat inflammation, but rather addresses those abnormally proliferating microvessels and accompanying nerve endings in the degenerated area of the tendon, which is the stage described earlier. The elbow is classified as a superficial area, and ultrasound-guided simple s-TAME is often within the scope of evaluation; catheter-based C-TAME is only considered when the lesion is deeper or the vascular pathway is complex. For the difference between the two, please see "What is the difference between C-TAME and s-TAME?".

For the overall sequence of treatment and how to connect the various stages, please refer to "What treatment options are there for chronic pain?".

Does that mean surgery is still needed?

In most cases, no.

Surgery is usually reserved for a small number of patients whose symptoms still seriously affect their work and life after both conservative and interventional treatments have been tried. If treatment reaches this stage, orthopedics or hand surgery will assist in diagnosis and evaluation.

What can I adjust in my daily life?

Start with the movement you do the most times every day.

Wringing, lifting, and gripping—these three are the biggest sources of stress for tennis elbow. Change carrying bags to using your forearm crook or palms facing up, change wringing towels to folding the whole thing and pressing it, and adjust the height of your mouse and keyboard so your wrists don't tilt upward for long periods of time. Elbow braces (forearm bands) can reduce stress on the tendon during the acute phase, but wearing them all day is not recommended as a solution.

However, in practice, adjusting daily movements is harder to sustain than any type of treatment, after all, it is what you do every day. But as long as the source of pain is still being repeatedly stretched, treatment is just racing against it.

What if I want to have an evaluation?

If the pain on the outside of your elbow has lasted for more than six months, and both rehabilitation and injections have been tried but the pain keeps recurring, you can first undergo a treatment evaluation via LINE.
Please bring your past treatment imaging data (X-ray, ultrasound, MRI) and treatment records to your appointment, including how many injections you have had, what the injectables were, and what your response and feelings were at that time.
Si-Yi Clinic is located at 2F-1, No. 40, Section 2, Heping East Road, Da'an District, Taipei City. It operates entirely on an appointment-only basis. Phone: (02) 2366-0186.

Author: Dr. Ping-Sheng Lu

Last Updated: August 6, 2026

Disclaimer: This article is for health education purposes only and cannot replace a doctor's diagnosis and treatment advice. The suitability of any treatment should be evaluated and decided by a doctor.

Reference materials for Dr. Yuji Okuno's papers on transcatheter arterial microembolization:
Iwamoto W, Okuno Y, Matsumura N, et al. Transcatheter arterial embolization of abnormal vessels as a treatment for lateral epicondylitis refractory to conservative treatment: a pilot study with a 2-year follow-up. J Shoulder Elbow Surg. 2017;26(8):1335-1341. doi:10.1016/j.jse.2017.03.026