What is the recommended treatment for tennis elbow?

Tennis Elbow Treatment

The recommended treatment for tennis elbow includes NSAIDs as first-line medication, combined with a phased rehabilitation approach of rest, exercise therapy focusing on both hip and knee strengthening, and manual therapy, with surgical consultation if symptoms persist beyond 3-6 months of conservative management. 1

Initial Management (0-4 weeks)

Pain Control and Anti-inflammatory Measures

• NSAIDs are strongly recommended as first-line treatment for tennis elbow pain 1
  • Ibuprofen at 1.2g daily is the safest option
  • Can be increased to 2.4g daily if needed
  • May be combined with acetaminophen (up to 4g daily) for inadequate relief
• Apply the RICE protocol in the acute phase 1:
  • Rest (avoid painful activities)
  • Ice application
  • Compression
  • Elevation

Early Rehabilitation

• Immediate functional treatment rather than immobilization 1
• Begin with pain-free range of motion exercises
• Pool-based exercises may be beneficial for early rehabilitation
• Low-load strengthening exercises starting with seated movements 1

Intermediate Phase (4-8 weeks)

Progressive Strengthening

• Progress to more intensive strengthening exercises 1
• Hip-and-knee-targeted exercise therapy is more effective than knee-targeted exercises alone 1
• Focus on quadriceps strengthening for symptom management 1
• Manual therapy of the lower quadrant is recommended 1
• Consider prefabricated foot orthoses which show primary efficacy compared to wait-and-see approach 1

Additional Interventions

• Corticosteroid injections may be considered, limited to 2-3 injections with 4-6 weeks between injections 1
  • Note: While corticosteroid injections may provide short-term relief, patient-reported outcomes are often less favorable than physician assessments 2

Advanced Phase (8-12 weeks)

Sport-specific or Occupation-specific Training

• Gradually introduce activity-specific exercises 1
• Address technique and equipment modifications that may have contributed to the condition 3
• Focus on eccentric training and progressive resistance exercises 4

Return to Activity Criteria

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

When to Consider Surgical Intervention

• Persistent pain despite 3-6 months of well-managed conservative treatment
• Significant functional limitations impacting quality of life
• Progressive joint degeneration evident on follow-up imaging 1
• Consider bursectomy (open or arthroscopic) for persistent symptoms 1

Common Pitfalls and Caveats

1. Overtreatment: Tennis elbow is largely self-limiting; follow Hippocrates' principle of "first do no harm" 2
2. Excessive corticosteroid use: No advantage and considerable disadvantage in using more than 2 injections 2
3. Neglecting biomechanical factors: Failure to address equipment and technique issues that contribute to the problem may lead to recurrence 3
4. Inadequate differential diagnosis: Ensure proper assessment to distinguish tennis elbow from other similar musculoskeletal conditions 4
5. Premature return to activity: Returning before meeting all criteria can lead to reinjury and chronic problems 1

Tennis elbow affects approximately 50% of tennis players at some point, with one-third experiencing symptoms severe enough to interfere with daily activities 2. The peak incidence occurs between ages 40-50 years, with 90% of players having no further recurrence after recovery 2.