What is the best treatment for lateral epicondylitis (tennis elbow) with a burning sensation that has lasted three months?

Best Treatment for Lateral Epicondylitis (Tennis Elbow) with Burning Sensation for 3 Months

NSAIDs are strongly recommended as the first-line treatment for tennis elbow pain, with ibuprofen at 1.2g daily being the safest option, which can be increased to 2.4g daily or combined with paracetamol (up to 4g daily) if inadequate relief is achieved. 1

Initial Management (0-4 weeks)

Pain Control

• First-line medications:
  • NSAIDs (ibuprofen 1.2g daily, can increase to 2.4g daily)
  • Acetaminophen (up to 4g daily) if NSAIDs provide inadequate relief 1
• RICE protocol:
  • Rest (avoid painful activities)
  • Ice (15-20 minutes several times daily)
  • Compression
  • Elevation 1

Early Rehabilitation

• Begin immediate functional treatment rather than immobilization
• Progress to pain-free walking as soon as tolerated
• Start with low-load strengthening exercises 1
• Consider bracing to reduce tension on the extensor tendons 2

Intermediate Management (4-8 weeks)

Physical Therapy

• Progressive strengthening exercises focusing on:
  • Eccentric strengthening of wrist extensors
  • Gradual resistance training 1, 3
• Manual therapy of the lower quadrant 1
• Consider prefabricated foot orthoses 1
• Ultrasound therapy has shown effectiveness in controlled trials 4

Injection Therapy (if conservative measures fail)

• Corticosteroid injections (limited to 2-3 injections with 4-6 weeks between injections) 1
• Consider other injection options:
  • Platelet-rich plasma
  • Autologous blood
  • Dextrose 2

Advanced Management (8-12 weeks and beyond)

Continued Rehabilitation

• Sport-specific or occupation-specific training 1
• Daily exercise with weekly load increase has shown superior outcomes compared to wait-and-see approaches 3

Surgical Consideration

• If pain persists despite 3-6 months of well-managed conservative treatment
• Options include arthroscopic debridement, which has shown good results in refractory cases 2
• Approximately 80% of cases resolve without surgery 2

Important Considerations

Pathophysiology

• Tennis elbow is primarily an enthesopathy (pathological lesion at the insertion of tendon into bone) 5
• The condition involves "angiofibroblastic tendinosis" rather than inflammation 6
• Specific areas affected include the extensor carpi radialis brevis-extensor digitorum communis complex 6

Common Pitfalls

1. Overreliance on injections: Limit corticosteroid injections to 2-3, as there is "considerable disadvantage" in using more 5
2. Inadequate rehabilitation: The primary goal should be to revitalize unhealthy tissue through rehabilitative resistance exercise 6
3. Premature return to aggravating activities: Return to full activity should only occur after complete resolution of pain, full range of motion, and strength symmetry >90% compared to the uninjured side 1
4. Ignoring the self-limiting nature: Tennis elbow is largely self-limiting, with approximately 80% of cases resolving with proper conservative management 5, 2

Progression 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

The evidence strongly supports a progressive approach starting with NSAIDs and rehabilitation exercises, with most cases resolving within 3-6 months with proper management.