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Surgical treatment is considered the last option for chronic tennis elbow. The purpose of this pilot study was to compare treatment with botulinum toxin infiltration of the wrist extensor, a less invasive method, with a surgical wrist extensor release (Hohmann operation). Forty patients were included in the prospective randomized study; one group of patients had surgery (n = 20), the other group of patients was treated with botulinum toxin (n = 20). The results of evaluations after 3, 6, 12, and 24 months are presented. One year after treatment 13 (65%) patients in the botulinum toxin group and 15 (75%) patients in the operative group had good to excellent results. Two years after treatment 15 patients in the botulinum toxin group (75%) had good to excellent results; four patients had been operated on after initial treatment with botulinum toxin Type A. Seventeen patients in the operative group scored good to excellent (85%) at 2 years. When analyzed with an overall scoring system, no differences were found between the two forms of treatment. Botulinum toxin infiltration, a less invasive technique, may be an alternative for surgical treatment of tennis elbow.