From the Guidelines
Lateral epicondylitis should be initially managed with relative rest, reduced activity, and cryotherapy to prevent further damage and promote healing and pain relief. This approach is based on the evidence rating of C, which represents a consensus of disease-oriented evidence, usual practice, expert opinion, or case series 1. The condition, also known as tennis elbow, is a painful condition affecting the outer part of the elbow caused by overuse of forearm muscles and tendons.
Key Recommendations for Practice
- Relative rest and reduced activity are crucial to prevent further damage and promote healing and pain relief 1.
- Cryotherapy, such as repeated applications of melting ice water through a wet towel for 10-minute periods, provides acute relief of tendinopathy pain and its use is widely accepted, with a evidence rating of B 1.
- Eccentric strengthening is an effective treatment of tendinopathy and may reverse degenerative changes, also with a evidence rating of B 1.
- NSAIDs, such as ibuprofen or naproxen, are recommended for short-term pain relief but have no effect on long-term outcomes, with a evidence rating of B 1.
- Locally injected corticosteroids may be more effective than oral NSAIDs in acute-phase pain relief but do not alter long-term outcomes, with a evidence rating of B 1.
Treatment Approach
Treatment begins with rest from aggravating activities and ice application for 15-20 minutes several times daily to reduce inflammation. Over-the-counter NSAIDs like ibuprofen (400-600mg three times daily with food) or naproxen (220-440mg twice daily) can help manage pain and inflammation for 1-2 weeks. A counterforce brace worn just below the elbow can reduce tendon strain during activities. Physical therapy focusing on eccentric strengthening exercises is crucial for recovery, with the wrist extension exercise (holding a light weight, slowly lowering the wrist for 3 seconds, 3 sets of 15 repetitions daily) being particularly effective. Most cases resolve within 6-12 months with conservative treatment. If pain persists beyond 6-12 weeks despite these measures, consider seeking medical evaluation for possible corticosteroid injections or other interventions. This condition results from repetitive microtrauma to the extensor carpi radialis brevis tendon where it attaches to the lateral epicondyle, causing inflammation and degeneration of the tendon fibers rather than true inflammation, which explains why recovery often requires time and proper rehabilitation rather than just anti-inflammatory treatment.
Additional Considerations
It is essential to note that extracorporeal shock wave therapy appears to be a safe, noninvasive, effective but expensive means of pain relief for a number of chronic tendinopathies, with a evidence rating of B 1. Surgery is an effective option in carefully selected patients who have failed three to six months of conservative therapy, also with a evidence rating of B 1. However, these options should be considered only after conservative management has been exhausted.
From the Research
Definition and Prevalence of Lateral Epicondylitis
- Lateral epicondylitis is a common problem among physically active individuals, affecting approximately 1 to 3 percent of the population 2.
- It is also known as tennis elbow, although this name is somewhat of a misnomer as the condition is often work-related and occurs in athletes and nonathletes alike 3.
Treatment Options for Lateral Epicondylitis
- Initially, lateral epicondylitis can be treated with rest, ice, tennis brace and/or injections 4.
- Physical therapy is initiated when the condition is chronic or not responding to initial treatment, with common rehabilitation modalities including ultrasound, phonophoresis, electrical stimulation, manipulation, soft tissue mobilisation, and stretching and strengthening exercise 4.
- Electrophysiotherapy and physical therapy have been shown to be effective in improving pain and function compared to placebo 2.
- Injections, such as corticosteroid injections, may provide short-term pain relief but have not been shown to provide long-term benefits 5.
- Non-invasive treatment methods such as bracing, physical therapy, and extracorporeal shockwave therapy do not appear to provide definitive benefit regarding pain relief 5.
- Surgery may be considered as a last resort for chronic or resistant cases 4, 6.
Efficacy of Treatment Options
- A systematic review and meta-analysis found that electrophysiotherapy and physical therapy were effective in improving pain and function, while injections did not improve any outcome measures 2.
- Another systematic review found that there was no conclusive evidence to support one preferred method of non-surgical treatment for lateral epicondylitis 5.
- A review of current concepts in the management of lateral epicondylitis highlighted the need for a standard protocol for treatment, given the numerous options available 6.