What is the best treatment for tennis elbow?

Best Treatment for Tennis Elbow

The best treatment for tennis elbow involves a phased approach starting with NSAIDs as first-line medication, followed by progressive exercise therapy, with surgical intervention reserved for cases that fail conservative management after 3-6 months. 1

Initial Management (0-4 weeks)

First-Line Treatments

• NSAIDs are strongly recommended as first-line treatment 1
  • Ibuprofen 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
• RICE protocol 1
  • Rest (avoiding painful activities)
  • Ice application
  • Compression
  • Elevation
• Immediate functional treatment rather than immobilization 1
  • Pain-free walking as tolerated
  • Low-load strengthening exercises

Physical Modalities

• Manual therapy of the lower quadrant 1
• Prefabricated foot orthoses show primary efficacy compared to wait-and-see approach 1
• Cryotherapy is effective in the acute stage 2

Intermediate Phase (4-8 weeks)

Progressive Exercise Therapy

• Knee-targeted exercises such as quadriceps strengthening 1
• Hip-and-knee-targeted exercise therapy shows better efficacy than knee-targeted exercises alone 1
• Progress to pool-based exercises and bilateral standing heel raises as tolerated 1

Additional Interventions

• Corticosteroid injections may be considered but should be limited to 2-3 injections with 4-6 weeks between injections 1
  • Patient reports are not as favorable as physician assessments 2
  • No advantage and considerable disadvantage in using more than 2 injections 2

Advanced Phase (8-12 weeks)

• Sport-specific or occupation-specific training 1
• Heat therapy in various modalities including ultrasound 2
• Rehabilitative resistance exercise to revitalize unhealthy tissue 3

When to Consider Surgery

• Surgical consultation should be considered if: 1

  • Pain persists despite 3-6 months of well-managed conservative treatment
  • Functional limitations significantly impact quality of life
  • Progressive joint degeneration is evident on follow-up imaging

• Arthroscopic release with debridement is a good surgical option but not superior to open or percutaneous techniques 4

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates: 1

• 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

Important Considerations

• Tennis elbow affects 1-3% of adults annually and is largely self-limiting with approximately 80% of cases resolving with conservative management 4
• The pathoanatomy is noninflammatory "angiofibroblastic tendinosis" rather than true inflammation 3
• About 50% of tennis players can expect to develop tennis elbow during their playing lifetime, with one-third experiencing symptoms severe enough to interfere with daily activities 2
• Peak incidence is between ages 40-50 years, with 90% of players having no further recurrence after this age 2

Common Pitfalls to Avoid

• Overuse of corticosteroid injections - limit to 2-3 injections maximum 1, 2
• Prolonged immobilization - immediate functional treatment is preferred 1
• Neglecting progressive strengthening - rehabilitation should run parallel to pain management 2
• Premature return to activity - ensure complete resolution of pain and restoration of strength before full return 1