Shockwave therapy offers non-surgical relief for elbow pain. Discover how it stimulates healing and helps treat chronic tendinopathy at Unpain Clinic.
KEY TAKEAWAYS
- Chronic elbow pain is usually a tendon problem, not an inflammation problem, which is why rest, ice, and anti-inflammatories often calm symptoms without holding.
- A 2020 meta-analysis of 13 randomized trials and over 1,000 patients found shockwave therapy reduced pain and improved grip strength in chronic tennis elbow with a good safety profile.
- A 2025 meta-analysis found shockwave therapy produced significantly better pain relief than therapeutic ultrasound in lateral epicondylitis.
- Compared with cortisone injections, shockwave is slower to act but tends to hold longer, because it is rebuilding the tendon instead of masking pain.
- A typical course is 3 to 6 weekly sessions, with most of the change continuing to build over the 4 to 8 weeks after treatment.
IN THIS ARTICLE
- Why elbow pain becomes chronic
- What the research actually says about shockwave for elbow tendinopathy
- How shockwave compares with cortisone, ultrasound, and surgery
- How many sessions, how soon, and what to expect
- How treatment works at Unpain Clinic
- What to do at home between visits
- FAQ
INTRODUCTION
If you have had elbow pain for months, tried rest, a brace, a cortisone shot, or physiotherapy, and still feel the same sharp jab when you grip, lift, or turn a doorknob, you are not stuck. Most chronic elbow pain is a tendon problem (either tennis elbow on the outer side or golfer's elbow on the inner side) and the tendon usually needs more than rest to rebuild. Focused shockwave therapy is a non-invasive treatment that targets the actual driver of that pain, and this article walks through what it can and cannot do, building on our podcast episode on stubborn elbow pain.
WHY DOES ELBOW PAIN BECOME CHRONIC?
Elbow pain becomes chronic because the tendon at the bony bump of the elbow does not finish healing on its own. In the first few weeks after overuse, there is some inflammation, but if the irritation continues, the tissue shifts into a degenerative state called tendinosis. The body lays down weaker, disorganized fibers instead of healthy tendon. Blood supply to that area is poor at the best of times, which is one reason these tendons heal so slowly. By three months in, you are dealing with structural change in the tendon, not just a flare to wait out.
This is why the standard "rest, ice, repeat" loop tends to fail. Rest calms symptoms and feels like progress, then activity returns and the pain comes back with a vengeance, often slightly worse because the tendon has also deconditioned. Anti-inflammatories quiet the volume on pain without changing what is happening in the tissue. Stretching can ease some of the surrounding tightness but does not rebuild the tendon's tolerance to load. Even a well-meaning physiotherapy program can stall if the eccentric loading work is not consistent or paced correctly.
There is also a clean diagnostic point that is worth surfacing. Inside-elbow or outside-elbow pain is usually a tendon issue, but it can overlap with nerve irritation. If your pain comes with tingling, numbness, or buzzing into the hand or fingers, the picture may include ongoing nerve pain or sensitivity, which changes what helps and what does not.
WHAT DOES THE RESEARCH ACTUALLY SAY ABOUT SHOCKWAVE FOR ELBOW TENDINOPATHY?
Honest version first. Older reviews on shockwave for tennis elbow were genuinely mixed, with some early trials showing no clear benefit over sham. The picture has improved as protocols and patient selection have improved.
A 2020 systematic review and meta-analysis pooled 13 randomized trials with more than 1,000 patients with chronic lateral epicondylitis. It found that shockwave therapy produced significantly better pain scores and grip strength than the comparator treatments, and concluded that shockwave is effective and generally safer than several alternatives for chronic tennis elbow. A separate 2020 meta-analysis confirmed shockwave patients had greater improvements in grip strength than controls at the three-month mark and were more likely to reach a meaningful pain reduction, even when the average pain score difference was modest. A 2025 meta-analysis specifically comparing shockwave therapy with therapeutic ultrasound in lateral epicondylitis found shockwave produced significantly greater pain improvement, although the two were comparable on functional grip scores.
The mechanism in the research is biological, not mechanical force on the tendon. A widely cited mechanistic review describes shockwave triggering mechanotransduction, increased local blood flow and new small-vessel growth, recruitment of growth factors, and pain modulation, all of which support the kind of tendon remodeling that chronic tendinopathy needs.
"Shockwave is not glue for a tendon. It is a way to wake the tendon up so it can finish what it was trying to do all along, finished off by the strength work." Uran Berisha, PT, RMT, Founder of Unpain Clinic
HOW DOES SHOCKWAVE COMPARE WITH CORTISONE, ULTRASOUND, AND SURGERY?
A clean way to think about elbow pain options is to compare what each one is actually doing. Some treatments quiet pain. Some try to rebuild the tendon. They are not the same job, and they age differently over weeks and months.
REST, ICE, AND ANTI-INFLAMMATORIES
- What it is doing: Lowers symptoms and calms acute inflammation.
- How fast: Days.
- How long it tends to hold: Tends to return with activity, because the tendon was not rebuilt.
CORTISONE INJECTION
- What it is doing: Suppresses pain and local inflammation.
- How fast: Days to weeks.
- How long it tends to hold: Strong short-term relief, but often does not hold by 3 to 6 months in lateral epicondylitis.
THERAPEUTIC ULTRASOUND
- What it is doing: A heat-based modality often used in physiotherapy.
- How fast: Gradual.
- How long it tends to hold: Less pain relief than shockwave in lateral epicondylitis on meta-analysis.
ECCENTRIC LOADING AND PHYSIOTHERAPY
- What it is doing: Rebuilds tendon load tolerance.
- How fast: Weeks to months.
- How long it tends to hold: Strong when it works, but a significant subset of cases stall.
FOCUSED SHOCKWAVE THERAPY
- What it is doing: Stimulates tendon remodeling, new blood vessels, and pain modulation.
- How fast: Builds over weeks.
- How long it tends to hold: Tends to hold because the tendon is healing, with pain and grip improvements documented in meta-analysis.
SURGERY
- What it is doing: Removes degenerated tissue.
- How fast: Days to weeks postoperatively, with rehab.
- How long it tends to hold: Reserved for severe cases, with only a small minority of patients ever needing it.
The two comparisons that come up most in clinic are cortisone and ultrasound. Cortisone tends to feel like the winner at four weeks and the loser at six months. One randomized trial in lateral epicondylitis showed the injection group had superior early relief, but the shockwave group had similar or better outcomes by twelve weeks [4]. The pattern is consistent with the underlying physiology. A steroid masks pain. Shockwave aims to actually remodel the tissue. Against therapeutic ultrasound, the 2025 meta-analysis was clear that shockwave produced significantly greater pain relief, although functional outcomes were comparable, which is why exercise and loading still matter alongside whichever passive modality you use.
Side effect-wise, shockwave is in a good position. Across the published literature, the most common side effects are short-lived local soreness, mild redness, or small bruising in the treatment area. Repeated cortisone injections, by comparison, can weaken tendon tissue over time, which matters when the goal is to make the tendon stronger.
HOW MANY SESSIONS, HOW SOON, AND WHAT TO EXPECT
A typical course for chronic elbow tendinopathy is 3 to 6 weekly sessions. Each session takes only a few minutes of actual shockwave application to the painful tendon attachment and the surrounding tissues. The sensation is best described as a strong tapping or pulsing over the area. We start at a comfortable intensity and adjust up as you adapt. Discomfort is usually adjustable and stops as soon as the device does. Mild soreness for a day or two afterward is common and tends to feel like post-workout tenderness.
Most people notice early shifts after the first 2 or 3 sessions, often easier gripping, less pain at night, or a stronger handshake. Bigger changes build over the 4 to 8 weeks after the last session as new blood vessels grow and tissue remodels. This is the part that surprises people the most. The improvement keeps unfolding after the sessions are done, which is why we usually pause and re-assess rather than running treatment indefinitely.
Response varies, and a few factors explain most of it.
- How long the symptoms have been present.
- Whether the diagnosis is purely tendon, or whether nerve irritation is also involved.
- Whether you are doing progressive loading alongside the treatment.
- Sleep, stress, workload, and overall conditioning.
HOW DOES TREATMENT FOR ELBOW PAIN WORK AT UNPAIN CLINIC?
At Unpain Clinic in Edmonton, the goal is not to chase the painful spot at the elbow, it is to answer the question of why the pain is still there. Most chronic elbow cases sit inside a longer chain of issues, a tight forearm, a stiff thoracic spine, a weak scapula, or an ergonomic load pattern at work that keeps reloading the tendon. The assessment is built to find that chain, not just the sore spot.
Your first visit is an assessment, not treatment. It usually follows this order.
- A full history of how the pain started, what aggravates it, what calms it, what treatments you have tried, and what you actually want to get back to.
- Orthopedic and neurological testing of the elbow, wrist, forearm, shoulder, and neck, including grip strength, resisted wrist extension and flexion, tenderness mapping at the epicondyle, and nerve screening.
- Motion and load analysis of how you actually use the arm at work, in sport, and through the day.
- A check for any red flags that mean a surgical or specialist opinion is the right next step.
- A clear, personalized plan that decides whether focused shockwave therapy belongs in your plan and what supportive tools belong with it.
From there, treatment sessions are built around a small set of high-leverage tools.
- Focused shockwave therapy as the main driver. Focused shockwave penetrates deeper than radial devices, which matters for reaching the tendon attachment at the bony epicondyle.
- EMTT therapy as an adjunct in some long-standing cases, paired with shockwave for added anti-inflammatory effect.
- Physiotherapy with progressive loading. Eccentric strengthening of the wrist extensors or flexors, scapular control work, and addressing the chain above the elbow.
- Cortisone is generally not added during a shockwave course, because the steroid effect can blunt the inflammatory healing response we are trying to encourage.
If you want a wider view, tennis elbow causes, symptoms, and treatment covers the lateral side in depth, why your golfer's elbow hasn't healed yet covers the medial side, and elbow pain explained, from overuse to injury covers the broader picture.
WHAT CAN I SAFELY DO AT HOME BETWEEN VISITS?
This is general education, not individual medical advice, and results vary. A few principles tend to help most people with chronic elbow tendinopathy stay better between visits.
- Modify the trigger movements, not your whole life. Find the specific motion that flares it (a backhand, a heavy grip, a screwdriver twist), and change that one thing. Keep using the arm in pain-free ranges. Total rest tends to make tendons weaker.
- Build eccentric strength. Slowly lowering a light weight with the affected wrist (palm down for tennis elbow, palm up for golfer's elbow) is one of the best-studied home tools. Start with very light load, 10 to 15 reps, controlled and pain-free.
- Stretch gently before strength work. A wrist flexor or extensor stretch, held 20 to 30 seconds, can warm the area up. Stretching is not a fix, but it pairs well with strength.
- Use a counterforce strap during the activities that flare it. The strap is a volume knob, not a cure. It buys you tolerable activity while the tendon rebuilds.
- Look upstream. Posture, shoulder blade control, and ergonomic setup at work or sport often feed elbow tendinopathy. Small changes there reduce repeated reload of the tendon.
Some symptoms are not "wait and see" symptoms. Get medical attention if you develop sudden severe elbow pain, inability to move the joint, significant swelling or warmth, or numbness and weakness in the hand that is rapidly worsening. Those can mean something other than tendinopathy.
FREQUENTLY ASKED QUESTIONS
Is shockwave therapy safe for elbow pain?
Shockwave therapy is generally safe for chronic elbow tendinopathy when delivered by a qualified clinician after proper screening. The most common side effects in published studies are short-lived local soreness, mild redness, and occasional small bruising, with no serious adverse events reported. It is non-invasive, with no injection, anesthesia, or medication involved. The clear contraindications are pregnancy in the treatment area, active blood clots or significant bleeding disorders, active infection in the treatment area, and active malignancy in the area being treated.
How many shockwave therapy sessions will I need for elbow pain?
There is no universal number. A common plan is 3 to 6 weekly sessions, with a re-assessment after the first three to see whether you are responding. Most of the change tends to build over the 4 to 8 weeks after the last session as the tendon remodels. Some people benefit from a single booster session several weeks later, and a small number of long-standing cases need more than 6 to 8 sessions overall.
Does shockwave therapy hurt?
Most people describe it as a strong tapping or pulsing pressure over the sore tendon. Discomfort is adjustable, since your clinician can change the intensity, target area, and pace. The sensation stops as soon as the device is off. Mild soreness for a day or two afterward is common and tends to feel like post-workout tenderness.
Can shockwave therapy help if I have had elbow pain for years?
Long-standing cases are exactly where shockwave is most often discussed. By the time pain has lasted more than 6 months, the tendon is usually in a degenerative state where the body has effectively given up trying to repair it. Shockwave is designed to restart that repair process by stimulating blood flow, cellular activity, and new tissue growth. Results vary, but long-standing tendinopathy is a population where shockwave has shown the most consistent benefit in research.
How does shockwave compare with a cortisone injection?
A cortisone injection tends to win on speed. Shockwave tends to win on durability. In trials on lateral epicondylitis, the injection group often does better at 4 weeks, but the shockwave group catches up and often surpasses it by 12 weeks and beyond. The reason is mechanical, a steroid masks pain and dampens inflammation temporarily, while shockwave aims to remodel the tendon itself.
Who should not have shockwave therapy?
Shockwave therapy is generally not used during pregnancy near the treatment area, over an active blood clot or in someone with a significant bleeding disorder, over an area with active infection, or over an active malignancy in the treatment area. We also avoid using high-energy shockwave directly over open growth plates in younger patients and are cautious in patients on strong anticoagulants or with pacemakers if the treatment area is near the device.
Is shockwave therapy covered by insurance?
Coverage depends on your insurer and plan. Many extended health plans reimburse shockwave under physiotherapy or chiropractic categories when it is provided by a licensed clinician. Public provincial health insurance does not typically cover it. Confirm with your plan, and a Health Spending Account through your employer can usually be used as well.
When should I stop self-treating and book an assessment?
If your elbow pain has lasted more than a few weeks despite smart load changes, keeps coming back, or includes numbness or tingling in the hand, it is worth getting properly assessed. Elbow pain can come from several different drivers, and the right plan depends on a real diagnosis, not on guessing.
PATIENT TESTIMONIAL
“Uran is absolutely the most effective health care practitioner I’ve ever met. I suffered from severe tennis elbow for 2 years. Being a hairstylist for over 20 years, it greatly impacted my ability to work. I tried everything before I met Uran - acupuncture, chiropractor, massage, physio, IMS needling, RNFR massage plus multiple cortisone injections. Nothing had worked, until I saw Uran. He gets to the root of the issue, which is why his treatment is so effective. There is no other treatment like this in Edmonton. Save yourself some money and just go directly to him for ANY chronic pain issues.” - Chrystal Strader
ABOUT THE AUTHOR
Written by Uran Berisha, PT, RMT, Founder of Unpain Clinic and the Medical Shockwave Institute in Edmonton. Medically reviewed by Uran Berisha, PT, RMT. Learn more at Unpain Clinic.
If your elbow pain has not budged and you want a clear answer on whether shockwave therapy fits your case, the next step is a one-on-one assessment. We will find the actual driver of your pain, screen for red flags, and tell you honestly whether you are a good candidate for this approach. No referral needed. No long contracts. Book your initial assessment with Unpain Clinic.
REFERENCES
- Yao G, Chen J, Duan Y, Chen X. Efficacy of Extracorporeal Shock Wave Therapy for Lateral Epicondylitis: A Systematic Review and Meta-Analysis. BioMed Research International. 2020;2020:2064781. https://pmc.ncbi.nlm.nih.gov/articles/PMC7106907/
- Zheng C, Zeng D, Chen J, Liu S, Li J, Ruan Z, Liang W. Effectiveness of extracorporeal shock wave therapy in patients with tennis elbow: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020;99(30):e21189. https://pubmed.ncbi.nlm.nih.gov/32791694/
- Beyazal MS, Devrimsel G. Comparison of the effectiveness of local corticosteroid injection and extracorporeal shock wave therapy in patients with lateral epicondylitis. Journal of Physical Therapy Science. 2015;27(12):3755-3758. https://pubmed.ncbi.nlm.nih.gov/26834345/
- Simplicio CL, Purita J, Murrell W, Santos GS, Dos Santos RG, Lana JFSD. Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine. Journal of Clinical Orthopaedics and Trauma. 2020;11(Suppl 3):S309-S318. https://pubmed.ncbi.nlm.nih.gov/32523286/
- 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;35:307. https://link.springer.com/article/10.1007/s00590-025-04419-w
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