Tennis and Pickleball Elbow: Cortisone, PRP, or Neither?

Tennis and pickleball elbow can make a simple backhand, serve, or kitchen-line dink hurt. Then comes the question I hear often: "The cortisone shot helped for a few weeks, so should I try PRP now, or neither?"

In plain terms, this is an overuse problem in the tendon that lifts your wrist and steadies your grip. That tendon attaches to the bony bump on the outside of the elbow, and repeated hitting and squeezing can load it faster than it can adapt. The good news is that surgery is rarely needed. For most people, the best next step is a well-designed rehabilitation program rather than another injection.

What tennis and pickleball elbow actually is

Tennis elbow, also called lateral epicondylitis or lateral elbow tendinopathy, causes pain at the outside of the elbow. The problem usually involves overload and degeneration in the wrist extensor tendon where it attaches to the outer elbow. It is not simply inflammation that needs to be switched off.

Gripping, lifting, serving, and repeated wrist extension load this tendon. Pickleball can create the same problem, especially when a player grips the paddle tightly, uses a paddle that is difficult to control, or increases playing time quickly. A review of pickleball injuries notes that beginners commonly choose heavier paddles and grip too tightly, although equipment recommendations are based mainly on expert opinion rather than trials.

Most cases improve without surgery. Even among patients referred to a surgeon after more than 10 months of symptoms, only 9% had undergone surgery by two years in one recent study.

The short answer on cortisone and PRP

Cortisone is the faster pain reliever. In a randomized trial, it produced better results at six weeks, but many early responders later worsened. Forty-seven of 65 early successes regressed.

That pattern matters. A cortisone shot can make it easier to use the arm, but it does not necessarily restore the tendon's ability to tolerate load. In another randomized trial, corticosteroid treatment had an 83% rate of complete recovery or substantial improvement at one year, compared with 96% after a placebo injection. Recurrence was 54% after corticosteroid treatment and 12% after placebo.

PRP may be the better injection for longer-term improvement. Recent reviews found that corticosteroid performed better during the first month, while PRP had better pain and function results at three to six months or later. The evidence is not uniform. A placebo-controlled randomized trial found no PRP advantage over saline at one year.

PRP also has a practical disadvantage: insurance coverage is uncommon. A national study found prices ranging from $350 to $2,815 per injection, with a median price of $800.

My usual approach is straightforward: use cortisone sparingly for severe pain, emphasize rehabilitation, and discuss PRP when symptoms persist despite appropriate loading and activity changes. That decision should follow an examination, because outer elbow pain can also come from a radial nerve problem, elbow arthritis, instability, or a tendon tear.

Why rehabilitation comes first

The tendon needs progressive loading. The goal is not complete rest. The goal is to restore strength and tolerance in a controlled way.

A rehabilitation plan may include:

• Isometric wrist extension when movement is too painful.
• Progressive wrist extensor strengthening.
• Slow resistance exercises using a dumbbell or resistance band.
• Eccentric loading, including the FlexBar Tyler twist, when appropriate.
• Gradual return to gripping, hitting, lifting, and work tasks.

A systematic review of 30 randomized trials found that exercise had better outcomes than passive treatments, including steroid injection, beyond the short term, although the effects were small and the certainty of evidence was low. A smaller randomized trial found better disability and pain scores when eccentric wrist extensor exercise was added to standard treatment. Another randomized study found that 12 weeks of home heavy slow resistance improved disability through one year, while adding a steroid injection did not improve the result and slightly worsened one disability measure at 52 weeks.

The exact exercise matters less than the progression. If every session causes a flare that lasts into the next day, the load is too high. If the tendon never receives a meaningful challenge, it does not regain capacity. A sports physical therapist can adjust the resistance, repetitions, and grip position, and can help you plan a gradual return to the court.

When cortisone makes sense

Cortisone can be useful when pain is severe enough to prevent sleep, work, or participation in rehabilitation. Its benefit is usually front-loaded. The injection may reduce pain over the first four to eight weeks, but the advantage often fades by six to twelve months.

That is why I do not view a cortisone shot as the main treatment for chronic elbow tendon pain. I view it as a limited tool that may create a short window for rehabilitation.

Repeated injections deserve caution. In a cohort of 580 patients treated at a tertiary center, prior injection was associated with later surgery, with an odds ratio of 5.6. This does not prove that the injection caused the surgery. Patients who receive injections may have more severe or persistent symptoms in the first place. In a large surgical database, three or more preoperative injections were associated with a higher risk of revision surgery, while one or two were not statistically significant.

Surgery itself remains uncommon. These associations are reasons to avoid serial injections, not reasons to fear that one injection has damaged your elbow or made surgery inevitable.

For more detail about broader concerns involving cortisone injections, see our post on are cortisone shots bad for your cartilage. The cartilage question is different from the tendon question discussed here.

When PRP is worth discussing

PRP uses a concentrated preparation from your own blood. The proposed goal is to change the tendon environment and support a longer recovery rather than provide the rapid numbing effect of cortisone.

PRP is most reasonable to discuss when:

• Symptoms have lasted for several months.
• A structured loading program has been tried and adjusted.
• You have changed the activity or equipment that keeps provoking pain.
• You understand that improvement may be gradual.
• The out-of-pocket cost is acceptable.

PRP does not help everyone. One randomized trial of 230 patients found no difference between PRP and its active control at 12 weeks, while success at 24 weeks favored PRP, 83.9% versus 68.3%. Another randomized trial found no benefit over saline at one year. The best summary is that PRP may outperform cortisone later, but the average benefit is modest and not certain for every patient.

Avoid choosing PRP simply because cortisone wore off. First ask why the tendon is still being overloaded. If gripping mechanics, weekly play, strength, or technique have not changed, a different injection may not solve the central problem.

Braces and activity changes

A tennis elbow brace can reduce symptoms during gripping. Low-quality evidence supports short-term pain relief from a forearm counterforce strap, while a small randomized study found that a wrist extension splint gave better pain relief than a forearm strap. Use a brace as an aid for activity, not as a replacement for progressive strengthening.

For tennis, review the basics with a qualified instructor or racquet professional:

• Check grip size rather than assuming a larger grip is better.
• Consider lower tennis string tension.
• Ask about softer multifilament or natural gut strings instead of very stiff polyester strings.
• Use a racquet and head size you can control.
• Work on contacting the ball near the sweet spot.
• Have your backhand technique assessed. Novice players may hit with the wrist in a position that increases eccentric demand on the wrist extensors.
• Reduce sudden jumps in weekly playing time.

Grip size can affect grip force and wrist extensor tendon loading in laboratory and modeling research, but equipment changes do not replace treatment. Vibration dampeners may change feel, but they are unlikely to address the main cause of chronic tendon overload.

For pickleball, the evidence is thinner. There are no strong trials proving that one paddle design prevents pickleball elbow. Expert recommendations include choosing a paddle that feels controllable, avoiding unnecessary weight, sizing the grip so you do not squeeze it, and starting with a neutral continental grip.

Keep the wrist relaxed during the swing. Avoid repeatedly flicking the ball with the wrist. Build playing time gradually, especially if you are new to the sport or have increased from occasional games to several sessions per week. A brief warm-up and a few practice swings can prepare you for play, but neither replaces strength work.

When to see an elbow specialist

Arrange an evaluation if pain persists despite several weeks of sensible activity modification and progressive rehabilitation, if weakness is increasing, or if pain is present at rest or at night. Seek an earlier examination after a sudden injury, a pop, marked swelling, numbness, or loss of motion.

The diagnosis should fit the examination. Imaging is not always necessary at the first visit, but ultrasound or MRI may help when the diagnosis is uncertain, weakness is substantial, or a tendon tear is suspected.

The next step for most people is not another injection. Schedule an assessment with a sports medicine clinician or physical therapist, bring the details of your recent play and any prior injection, and begin a progressive wrist extensor program that can be adjusted to your symptoms. If pain remains limiting after that process, discuss whether PRP offers enough possible long-term benefit to justify its cost.