---
title: "Tennis elbow"
url: "https://acuiq.com/wiki/evidence/tennis-elbow"
updated: 2026-10-11
last_verified: 2026-10-11
license: CC-BY-4.0
license_url: "https://creativecommons.org/licenses/by/4.0/"
section: "evidence"
basis: "Modern research"
audience: "Anyone"
published: "2026-10-11"
reading_minutes: 10
sources: 19
---

# Tennis elbow

_What a 2002 Cochrane review, later systematic reviews, sham-controlled trials and two current guidelines report on acupuncture, electroacupuncture, moxibustion and dry needling for lateral epicondylitis._

Tennis elbow, also called lateral epicondylitis or lateral epicondylalgia, is pain at the bony point on the outside of the elbow where the tendons that extend the wrist attach, and it makes gripping and lifting painful. The acupuncture trials fall into three groups: European trials of manual acupuncture against a sham, Chinese trials against steroid injections, anaesthetic “blocking” injections and drugs, and trials of dry needling, in which a practitioner needles tender points in the forearm muscles or the tendon itself.

## The Cochrane review

The [Cochrane review of acupuncture for lateral elbow pain](https://doi.org/10.1002/14651858.CD003527), by Sally Green and colleagues at the Australasian Cochrane Centre, was published in 2002 with searches to June 2001. A 2008 amendment converted it to a new format; no update has been published, and PubMed carries no notice of withdrawal. It included four small randomised trials and could not pool them because of flaws in design, substantial loss to follow-up and clinical differences between them. Two trials compared needle acupuncture with a placebo: in one, pain relief after a single treatment lasted 18.8 hours longer than with placebo, and in the other more people reported overall improvement in the short term. Neither showed a difference at 3 or 12 months. A trial of laser acupuncture found no difference from placebo, and a Chinese trial found none between acupuncture with vitamin B12 injection and the injection alone. The review predates GRADE, the system that rates confidence in a result from high to very low. The authors found the evidence insufficient to support or refute acupuncture for lateral elbow pain, found no benefit lasting more than 24 hours, and noted that no trial assessed adverse effects.

## Later reviews

| Review | Searched to | Trials (people) | Compared with | Certainty |
| --- | --- | --- | --- | --- |
| Trinh 2004 | 2003 | 6 | Control treatments | All trials rated high quality on the Jadad scale |
| Gadau 2014 | June 2013 | 19 (1,190) | Sham (3 trials), conventional treatment (10), acupuncture alone (6) | Every trial at high or unclear risk of bias in at least one domain; not pooled |
| Tang 2015 | 2015 | 4 (309) | Sham (2), blocking therapy (2) | GRADE very low to low |
| Zhou 2020 | May 2019 | 10 (796) | Sham, drugs, blocking therapy | GRADE moderate for response rate, low for pain |
| Navarro-Santana 2021 | Not stated in the abstract | 14 | Any comparison group, manual acupuncture and electroacupuncture | GRADE low |
| Navarro-Santana 2020 | April 2020 | 7 (320) | Any comparison group, dry needling | GRADE low to moderate |
| Ma 2024 | Not stated in the abstract | 17 (979) | Other treatments, dry needling | Not stated in the abstract |
| Yin 2026 | January 2026 | 14 | Acupuncture with manipulation against either alone | Low |

[Trinh and colleagues](https://doi.org/10.1093/rheumatology/keh247) at McMaster University used a best-evidence synthesis, a narrative weighing of trials in place of pooled numbers. The Jadad scale, a five-point score of how a trial reports randomisation, blinding and dropouts, rated all six trials high quality, and five of the six found acupuncture more effective than the control. The authors called the evidence strong for short-term relief. In 2014 [Chang and colleagues](https://doi.org/10.1142/S0192415X14500815) at China Medical University in Taiwan pooled nine trials, six of manual acupuncture and three of laser acupuncture, and reported short-term pain relief with manual acupuncture, no notable long-term effect, and weaker evidence for laser.

[Gadau and colleagues](https://doi.org/10.1186/1472-6882-14-136) at Hong Kong Baptist University were the first to include trials published in Chinese and trials of moxibustion, the burning of mugwort on or near the skin. Three sham-controlled trials, which they rated moderate quality, favoured acupuncture for up to two months. Ten trials, mostly low quality, found acupuncture or moxibustion better than or equal to steroid or anaesthetic injections, anti-inflammatory drugs or ultrasound, and the authors said the trials’ quality limits what they show. [Tang and colleagues](https://doi.org/10.1155/2015/861849) at Sichuan Orthopaedic Hospital found four trials and drew no firm conclusion; two trials reported needle pain as the main reason people dropped out. [Zhou and colleagues](https://doi.org/10.1155/2020/8506591) at Guangzhou University of Chinese Medicine reported better response rates and pain scores against drugs and blocking injections, but the two trials against sham did not reach significance on either measure: the risk ratio for response was 1.95, with a 95% confidence interval of 0.78 to 4.90.

[Navarro-Santana and colleagues](https://doi.org/10.1177/0964528420967364) at Universidad Complutense de Madrid separated the two needling methods. Manual acupuncture reduced pain with a moderate standardised mean difference (SMD) of −0.66, a gap expressed in units of the spread of scores; electroacupuncture, which passes a small current through the needles, showed no significant effect (SMD −0.08, 95% CI −0.99 to 0.83). Most effects were short term. The same group’s [2020 review of trigger point dry needling](https://doi.org/10.1177/0269215520937468) reported large short-term effects on pain (SMD −1.13) and disability, with heterogeneity, meaning trials that disagreed more than chance explains, lowering the evidence level. [Ma and colleagues](https://doi.org/10.1016/j.apmr.2024.02.713) at the First Rehabilitation Hospital of Shanghai reported pain scores 0.95 points lower within a week of dry needling, and better elbow disability and grip strength both within a week and later. [Yin and colleagues](https://doi.org/10.3389/fmed.2026.1892618) in Beijing pooled 14 trials of acupuncture combined with manipulation, found better response rates than either alone, and rated the certainty low because of risk of bias, heterogeneity and possible publication bias. [Dry needling](/wiki/techniques/dry-needling) describes how the method differs from acupuncture.

## Trials against sham

- **Deep against superficial needling, 1990.** [Haker and Lundeberg](https://doi.org/10.1097/00002508-199009000-00009) at the Karolinska Institutet in Stockholm gave 82 people 10 sessions at five points: [`LI10`](/points/LI10) (Shousanli), [`LI11`](/points/LI11) (Quchi), [`LI12`](/points/LI12) (Zhouliao), [`LU05`](/points/LU05) (Chize) and [`TB05`](/points/TB05) (Waiguan), which the paper writes as SJ 5. Deep needling did better than superficial insertion at the end of treatment and no better at 3 months and 1 year. A [second trial by the same authors](https://doi.org/10.1016/0304-3959(90)91078-W), of laser applied to acupuncture points, is the one the Cochrane review found no different from placebo.
- **One treatment, 1994.** [Molsberger and Hille](https://doi.org/10.1093/rheumatology/33.12.1162) at the University of Düsseldorf gave 48 people with chronic tennis elbow a single acupuncture treatment at a point on the leg of the same side, which the 2014 review lists as [`GB34`](/points/GB34) (Yanglingquan), or a placebo that did not pierce the skin. Pain fell by 55.8% against 15%, 19 of 24 people against 6 of 24 reported relief of at least half, and the relief lasted an average 20.2 hours against 1.4.
- **Ten sessions with long follow-up, 2002.** [Fink and colleagues](https://doi.org/10.1093/rheumatology/41.2.205) at Hannover Medical School randomised 45 people to 10 sessions of real acupuncture or of needling at non-acupuncture points; the 2014 review lists the real points as a tender point, `LI10`, `LI11`, `LU05`, [`LI04`](/points/LI04) (Hegu) and `TB05`. Two weeks after treatment pain, arm function and strength were better with real acupuncture. At 2 months only function still differed, and in a [one-year follow-up](https://doi.org/10.1159/000066030) the pain differences had gone by 2 months and stayed gone at 12.
- **Four countries, 2020.** In a [trial](https://doi.org/10.1002/ejp.1574) led by Gadau at centres in Australia, mainland China, Hong Kong and Italy, 96 people with lateral elbow pain for at least three months received manual acupuncture at `LI10` and `LI11` on the painful side, or sham laser at the same points. Three weeks after treatment the DASH, a 0 to 100 disability score for the arm, shoulder and hand, had fallen by a median 11.7 points against 7.5, an effect size of 0.47, and pain scores also favoured acupuncture. No severe adverse event occurred.

[Sham acupuncture](/wiki/research/sham-acupuncture) sets out why superficial needling, needling away from points and non-penetrating shams each control for different things.

## Dry needling against injection

At İstanbul Medeniyet University, [Uygur and colleagues](https://doi.org/10.1016/j.jse.2020.08.044) randomised 108 people whose pain had not settled after three weeks of first-line treatment to dry needling around the epicondyle or a corticosteroid injection, and analysed 101. Both groups improved on the Patient-Rated Tennis Elbow Evaluation over 6 months, and the needled group improved more. Four people given the injection developed thinning and whitening of the skin, and one person withdrew from needling because of the pain of the procedure.

## Safety

The Cochrane review found that no trial assessed adverse effects, and in the 2014 review 4 of 19 trials reported on them. Two of those, both Chinese, used scarring ginger moxibustion, which is burned until the skin blisters, and both reported permanent scars. [Burns from moxibustion and cupping](/wiki/safety/burns-from-moxibustion-and-cupping) covers the method and its injuries.

## What guidelines say

The [clinical practice guideline](https://www.orthopt.org/uploads/content_files/files/jospt.2022.0302.pdf) on lateral elbow pain from two academies of the American Physical Therapy Association, by Lucado and colleagues and published in December 2022, states that clinicians should use tendon or trigger point dry needling for pain and loss of function, a grade B recommendation, meaning one supported by moderate evidence. It drew on the 2020 dry needling review and the injection trial above, and lists optimal dose, technique and depth among the gaps in knowledge. It also allows TENS, electrical stimulation through skin pads, applied to acupuncture points for short-term pain relief, at grade C. It makes no recommendation on acupuncture itself. The guideline is due to be considered for review in 2027.

The British Elbow and Shoulder Society’s [patient care pathway](https://doi.org/10.1177/17585732231170793), published in August 2023 by Singh and Watts using GRADE, reaches a different verdict on dry needling. It found eight comparative trials and none against placebo, and rates its recommendation conditional neutral: patients offered dry needling should be told there is no evidence of benefit over placebo, and the authors conclude that dry needling cannot currently be recommended. Its review of physiotherapy excluded acupuncture. [Clinical guidelines](/wiki/evidence/clinical-guidelines) compares how guideline bodies treat acupuncture across conditions.

## What the reviews could not settle

Every sham-controlled trial of needle acupuncture found a difference at the end of treatment or within days of it, and the two that followed people for months found the difference in pain gone by 2 to 3 months. The reviews did not settle whether acupuncture changes the course of the condition or only relieves pain while treatment lasts. The two pooled sham comparisons disagree: Tang and colleagues found a significant difference in function, and Zhou and colleagues found none in response rate or pain. The trials against injections and drugs, mostly from China, were rated low quality in the reviews that assessed them. For dry needling, the reviews found large short-term effects against other treatments, no trial against placebo, and two guidelines read that evidence in opposite directions. The largest sham-controlled acupuncture trial enrolled 96 people.

AcuiQ’s symptom pages for [tennis elbow](/symptoms/tennis-elbow), [lateral epicondylitis](/symptoms/lateral-epicondylitis) and [lateral elbow pain](/symptoms/elbow-lateral-pain) list the protocols individual studies prescribed, each with its citation.

### Sources

1. Green S, Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W, Acupuncture for lateral elbow pain, Cochrane Database of Systematic Reviews 2002, CD003527 — https://doi.org/10.1002/14651858.CD003527
2. Trinh KV, Phillips SD, Ho E, Damsma K, Acupuncture for the alleviation of lateral epicondyle pain: a systematic review, Rheumatology 2004 — https://doi.org/10.1093/rheumatology/keh247
3. Chang WD, Lai PT, Tsou YA, Analgesic effect of manual acupuncture and laser acupuncture for lateral epicondylalgia: a systematic review and meta-analysis, American Journal of Chinese Medicine 2014 — https://doi.org/10.1142/S0192415X14500815
4. Gadau M, Yeung WF, Liu H, et al., Acupuncture and moxibustion for lateral elbow pain: a systematic review of randomized controlled trials, BMC Complementary and Alternative Medicine 2014 — https://doi.org/10.1186/1472-6882-14-136
5. Tang H, Fan H, Chen J, et al., Acupuncture for lateral epicondylitis: a systematic review, Evidence-Based Complementary and Alternative Medicine 2015 — https://doi.org/10.1155/2015/861849
6. Zhou Y, Guo Y, Zhou R, Wu P, Liang F, Yang Z, Effectiveness of acupuncture for lateral epicondylitis: a systematic review and meta-analysis of randomized controlled trials, Pain Research and Management 2020 — https://doi.org/10.1155/2020/8506591
7. Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF, Cummings M, Fernández-de-las-Peñas C, Plaza-Manzano G, Effects of manual acupuncture and electroacupuncture for lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis, Acupuncture in Medicine 2021 — https://doi.org/10.1177/0964528420967364
8. Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF, et al., Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis, Clinical Rehabilitation 2020 — https://doi.org/10.1177/0269215520937468
9. Ma X, Qiao Y, Wang J, Xu A, Rong J, Therapeutic effects of dry needling on lateral epicondylitis: an updated systematic review and meta-analysis, Archives of Physical Medicine and Rehabilitation 2024 — https://doi.org/10.1016/j.apmr.2024.02.713
10. Yin J, Tang G, Zhao B, et al., Efficacy evaluation of acupuncture combined with manipulation for lateral epicondylitis: a meta-analysis, Frontiers in Medicine 2026 — https://doi.org/10.3389/fmed.2026.1892618
11. Haker E, Lundeberg T, Acupuncture treatment in epicondylalgia: a comparative study of two acupuncture techniques, Clinical Journal of Pain 1990 — https://doi.org/10.1097/00002508-199009000-00009
12. Haker E, Lundeberg T, Laser treatment applied to acupuncture points in lateral humeral epicondylalgia: a double-blind study, Pain 1990 — https://doi.org/10.1016/0304-3959(90)91078-W
13. Molsberger A, Hille E, The analgesic effect of acupuncture in chronic tennis elbow pain, British Journal of Rheumatology 1994 — https://doi.org/10.1093/rheumatology/33.12.1162
14. Fink M, Wolkenstein E, Karst M, Gehrke A, Acupuncture in chronic epicondylitis: a randomized controlled trial, Rheumatology 2002 — https://doi.org/10.1093/rheumatology/41.2.205
15. Fink M, Wolkenstein E, Luennemann M, et al., Chronic epicondylitis: effects of real and sham acupuncture treatment: a randomised controlled patient- and examiner-blinded long-term trial, Forschende Komplementärmedizin 2002 — https://doi.org/10.1159/000066030
16. Gadau M, Zhang SP, Wang FC, et al., A multi-center international study of acupuncture for lateral elbow pain: results of a randomized controlled trial, European Journal of Pain 2020 — https://doi.org/10.1002/ejp.1574
17. Uygur E, Aktaş B, Yilmazoglu EG, The use of dry needling vs. corticosteroid injection to treat lateral epicondylitis: a prospective, randomized, controlled study, Journal of Shoulder and Elbow Surgery 2021 — https://doi.org/10.1016/j.jse.2020.08.044
18. Lucado AM, Day JM, Vincent JI, et al., Lateral elbow pain and muscle function impairments: clinical practice guidelines, Journal of Orthopaedic and Sports Physical Therapy 2022 — https://www.orthopt.org/uploads/content_files/files/jospt.2022.0302.pdf
19. Singh HP, Watts AC, BESS patient care pathway: tennis elbow, Shoulder and Elbow 2023 — https://doi.org/10.1177/17585732231170793