What is the treatment for tennis elbow?

Treatment for Tennis Elbow

The treatment for tennis elbow should begin with conservative measures including rest, activity modification, NSAIDs, physical therapy with eccentric strengthening exercises, and cryotherapy, progressing to corticosteroid injections for acute pain relief if initial treatments fail. 1

Understanding Tennis Elbow

Tennis elbow (lateral epicondylitis or lateral epicondylosis) is a common overuse tendinopathy affecting the common extensor tendon at the lateral epicondyle of the humerus. It:

• Affects 1-3% of the general population 1
• Is 7-10 times more common than medial epicondylosis 1
• Affects men and women equally, most commonly after age 40 1
• Results from repetitive wrist extension activities, including racquet sports and occupational activities 1

Diagnostic Approach

Before initiating treatment, confirm the diagnosis through:

• Pain localized to the lateral epicondyle
• Pain exacerbated by resisted wrist extension
• Tenderness at the lateral epicondyle
• Pain with gripping activities

Radiographs are beneficial as initial imaging to rule out other causes of elbow pain such as osteoarthritis, fractures, or osteochondral lesions 1.

Treatment Algorithm

First-Line Treatment

1. Relative Rest and Activity Modification

   • Reduce activities that cause pain
   • Avoid complete immobilization to prevent muscle atrophy 1

2. Cryotherapy (Ice)

   • Apply ice through a wet towel for 10-minute periods
   • Most effective for acute pain relief 1

3. NSAIDs

   • Effective for short-term pain relief
   • Can be oral or topical (topical may have fewer systemic side effects) 1
   • Do not alter long-term outcomes 1

4. Physical Therapy

   • Eccentric strengthening exercises are particularly effective
   • Help reverse degenerative changes in the tendon 1
   • Promote proper collagen fiber alignment during healing

Second-Line Treatment

1. Corticosteroid Injections

   • More effective than NSAIDs for acute pain relief 1
   • Do not change long-term outcomes 1
   • May cause increased pain for the first 24 hours after injection 2
   • Therapeutic benefits become evident 3-4 days after injection 2
   • Limit to no more than 2 injections 3

2. Orthotics/Braces

   • Commonly used but evidence for effectiveness is limited 1
   • Consider based on patient preference

Third-Line Treatment

1. Other Modalities

   • Extracorporeal shock wave therapy has shown mixed benefits 1
   • Therapeutic ultrasound, iontophoresis - uncertain benefit 1

2. Surgery

   • Consider only after 3-6 months of failed conservative therapy 1
   • Recent evidence questions the need for surgery as tennis elbow is largely self-limiting with a 50% probability of recovery every 3-4 months regardless of treatment 4

Important Clinical Considerations

• Tennis elbow is largely self-limiting, with 90% of players experiencing no recurrence after recovery 3
• The peak incidence is between ages 40-50 3
• Avoid aggressive interventions early as they may cause more harm than benefit
• Corticosteroid injections provide good short-term relief but may cause initial pain increase for 24 hours 2

Common Pitfalls to Avoid

1. Rushing to invasive treatments before adequate trial of conservative measures
2. Using more than two corticosteroid injections, which can lead to tendon weakening
3. Recommending complete rest/immobilization, which can lead to muscle atrophy
4. Failing to address biomechanical factors that may contribute to the condition
5. Not warning patients about potential temporary pain increase after steroid injection

The evidence strongly supports starting with conservative measures and progressing to more invasive options only when necessary, recognizing that most cases will resolve with time and appropriate management of symptoms.