Background: Lateral epicondylitis or tennis elbow is a common cause of elbow pain. Resistant cases may lead to disability. Patients and methods: Fifty five cases with unilateral resistant lateral epicondylitis in king Fahd hospital in Madinah Muunawarah were subjected to treatment by either extracorporeal shock wave therapy (ESWT) (n=32) or arthroscopic release of common extensor origin (n=23). Results: In the first group (ESWT group), the average follow-up period was 36.7 months. The average VAS was 3.1 and the average DASH score was 50. The outcome was successful in 23 cases (18 excellent and 5 good) and non-successful in 9 cases (6 fair and 3 poor). In the second group (treated by arthroscopy), the average follow-up period was 39.2 months. The average VAS was 1.8, the average DASH score was 44. The outcome was successful in 21 cases (19 excellent and 2 good) and non-successful in 2 cases (1 fair and 1 poor). Conclusions: When compared to ESWT, arthroscopic release gave better outcome for resistant lateral epicondylitis.