What is the best treatment for tennis elbow?

Treatment of Tennis Elbow

The best treatment for tennis elbow (lateral epicondylitis) involves a stepped approach starting with NSAIDs and physical therapy as first-line treatment, followed by more invasive options only if necessary. This approach prioritizes pain management, functional recovery, and prevention of recurrence.

Initial Management

• Implement the RICE protocol:

  • Rest: Avoid activities that cause pain
  • Ice: Apply for 15-20 minutes every 2-3 hours
  • Compression: Use an elastic bandage to reduce swelling
  • Elevation: Keep the arm elevated when possible 1

• NSAIDs are strongly recommended as first-line medication:

  • Ibuprofen 1.2g daily (safest option)
  • Can be increased to 2.4g daily if needed
  • Can be combined with acetaminophen (up to 4g daily) for inadequate relief 1

Rehabilitation Protocol

The rehabilitation protocol should follow three phases:

Phase 1 (Initial): 0-4 weeks

• Focus on pain control and protected range of motion
• Immediate functional treatment rather than immobilization
• Begin with gentle, pain-free exercises 1

Phase 2 (Intermediate): 4-8 weeks

• Progressive strengthening exercises
• Eccentric training (particularly effective for tendinopathies)
• Gradually increase resistance using weights or resistance bands 1, 2

Phase 3 (Advanced): 8-12 weeks

• Sport-specific or occupation-specific training
• Focus on return to previous activities 1

Physical Therapy Techniques

• Manual therapy: Joint mobilizations, soft tissue massage, and myofascial release 2
• Exercise rehabilitation: Eccentric training and progressive resistance exercises 2
• Therapeutic modalities: Ultrasound, laser therapy, and cryotherapy 2
• Supportive measures: Taping and bracing may provide additional support 2

When to Consider More Invasive Treatment

• Corticosteroid injections should be limited to 2-3 injections with 4-6 weeks between injections 1, 3
• Consider orthopedic referral if:
  • Pain persists despite 3-6 months of conservative treatment
  • Significant functional limitations impact quality of life
  • Suspicion of more serious pathology 1

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates:

• Complete resolution of pain during and after activity
• Full range of motion compared to the uninjured side
• Strength symmetry >90% compared to the uninjured side
• Successful completion of sport-specific functional tests 1

Imaging Considerations

• Plain radiographs (X-rays) should be the initial imaging if symptoms persist beyond 4-6 weeks
• MRI without contrast is indicated if symptoms persist despite conservative management for 6-8 weeks 1

Common Pitfalls to Avoid

• Overreliance on corticosteroid injections (limit to 2-3 injections) 1, 3
• Prolonged immobilization (immediate functional treatment is preferred) 1
• Returning to activities too quickly before adequate healing
• Neglecting eccentric strengthening exercises, which are particularly effective for tendinopathies 2

Tennis elbow is largely a self-limiting condition, with 90% of patients having no further recurrence after appropriate treatment 4. The primary goal should be to provide effective pain management while promoting healing and preventing recurrence through appropriate rehabilitation.