What is the best treatment for tennis elbow?

Tennis Elbow Treatment

The best treatment for tennis elbow involves a phased approach starting with conservative management including rest, NSAIDs, and physical therapy, with corticosteroid injections providing short-term relief only, and surgery considered after 3-6 months of failed conservative treatment. 1

Initial Management (0-4 weeks)

• Rest and activity modification: Avoid activities that aggravate symptoms
• NSAIDs: First-line treatment for pain relief
  • Ibuprofen 1.2g daily (can be increased to 2.4g daily if needed)
  • Can be combined with paracetamol (up to 4g daily) for inadequate relief
• Ice application: Apply for 15-20 minutes several times daily
• Counterforce bracing: Use a tennis elbow strap to reduce load on the tendon 2
• Gentle range of motion exercises: To prevent stiffness

Intermediate Phase (4-8 weeks)

• Physical therapy: Progressive strengthening exercises
  • Eccentric exercises have shown benefit despite earlier recommendations to avoid them
  • Stretching exercises for wrist extensors
• Modalities:
  • Ultrasound therapy has shown effectiveness in controlled trials 3
  • Low-energy laser therapy may reduce objective symptoms
  • High-voltage galvanic stimulation to promote healing 2

Advanced Treatment (8-12 weeks)

• Sport/occupation-specific training: Gradually return to normal activities
• Technique modification: For tennis players, evaluate and modify playing technique
• Equipment assessment: Consider grip size, string tension, and racquet weight 2

For Persistent Symptoms

• Corticosteroid injections: Provide short-term relief but do not improve long-term outcomes
  • Limit to 2-3 injections with 4-6 weeks between injections
  • Note: While effective for short-term pain relief, there is risk of long-term recurrence 1
• Imaging: Consider MRI or ultrasound if symptoms persist beyond 12 weeks

Surgical Considerations

• Indications for surgical referral:
  • Persistent pain despite 3-6 months of well-managed conservative treatment
  • Significant functional limitations affecting quality of life
• Surgical options:
  • Percutaneous, arthroscopic, or open release of the extensor carpi radialis brevis tendon 4

Important Considerations

• Tennis elbow (lateral epicondylitis) involves degenerative changes in the extensor carpi radialis brevis tendon rather than simple inflammation 4
• Most cases (80-95%) resolve with conservative management within 1 year 1
• "Wait and see" approach with advice is recommended as first-line treatment in primary care 1
• Rule out alternative diagnoses such as radial nerve entrapment, cervical radiculopathy, or intra-articular pathology

Follow-up

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement
• Consider referral if no improvement after 12 months of conservative management 1