Comparative Effectiveness of Focused Versus Radial Extracorporeal Shockwave Therapy and Leukocyte-Poor Versus Leukocyte-Rich Platelet-Rich Plasma for Lateral Epicondylitis: A Network Meta-Analysis.

Background/

Objectives

Lateral elbow tendinopathy (LET) causes chronic pain and functional limitation, and the evidence base is confounded by the "lumping" of biologically and physically distinct interventions. We conducted a systematic review and network meta-analysis (NMA) distinguishing focused (fESWT) from radial (rESWT) extracorporeal shockwave therapy (ESWT) and leukocyte-rich (LrPRP) from leukocyte-poor (LpPRP) platelet-rich plasma (PRP) to establish a precise hierarchy of treatment efficacy.

Methods

We searched PubMed, EMBASE, Cochrane, Scopus, and Web of Science from inception to 8 December 2025, with the search updated on 12 August 2026. Twenty-three randomized controlled trials (1484 participants) evaluating fESWT, rESWT, LrPRP and LpPRP were included. Standardized mean differences (SMDs) were calculated using a random-effects model, and treatments were ranked by the surface under the cumulative ranking curve (SUCRA).

Results

fESWT ranked highest for grip strength overall (SUCRA: 82.6) and in the short term (≤3 months; 78.4). For upper-limb disability (Disabilities of the Arm, Shoulder and Hand), rESWT ranked highest overall (92.9) and in the long term (≥6 months; 94.0), while fESWT ranked lowest (19.9). rESWT was also most effective for pain at rest (Visual Analogue Scale; 86.6) and fESWT for disease-specific function (Patient-Rated Tennis Elbow Evaluation; 81.9), both significantly superior to placebo. The LrPRP advantage did not persist when trials at high risk of bias were excluded.

Conclusions

Clinical outcomes in LET are influenced by the specific subtypes of ESWT and PRP. rESWT was most effective for pain at rest and long-term upper-limb function, whereas fESWT was superior for short-term grip strength and disease-specific function. The apparent benefit of LrPRP was less robust and should be regarded as preliminary, and treatment selection should be tailored to a patient's recovery priorities.