What is the best treatment approach for a patient with chronic lateral epicondylitis (tennis elbow) that has persisted for 3 months?

Treatment for Tennis Elbow Persisting for 3 Months

For tennis elbow (lateral epicondylitis) that has persisted for 3 months, the most effective treatment approach is a comprehensive rehabilitation program including NSAIDs for pain relief, eccentric strengthening exercises, and functional support with a brace, while avoiding immobilization and limiting corticosteroid injections. 1, 2

Initial Assessment and Imaging

• Radiographs should be the first imaging study for chronic elbow pain to rule out intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis 1
• If radiographs are normal or nonspecific and symptoms persist, MRI may be considered to evaluate for tendinosis of the common extensor tendon and rule out other pathologies 1
• Clinical diagnosis is usually sufficient, with pain at the lateral epicondyle that worsens with wrist extension and gripping activities 3

Treatment Algorithm

First-Line Treatments

1. Pain Management:

   • NSAIDs such as ibuprofen (up to 2.4g daily) or naproxen (500mg twice daily) for short-term pain relief 2
   • Can be combined with paracetamol for enhanced pain relief 2
   • Ice application to reduce inflammation 4

2. Activity Modification:

   • Relative rest without complete immobilization 2
   • Avoid activities that exacerbate symptoms 2
   • Use of a counterforce brace for 4-6 weeks to reduce tension on the extensor tendons 2, 4

3. Rehabilitation Exercises:

   • Progressive eccentric strengthening exercises of the wrist extensors 2, 5
   • Flexibility exercises for the forearm muscles 4
   • Gradual progression to endurance training 2

Second-Line Treatments

If no improvement after 6-8 weeks of first-line treatment:

1. Physical Therapy Modalities:

   • High-voltage galvanic stimulation to promote healing 4
   • Ultrasound therapy, which has shown effectiveness in placebo-controlled trials 6
   • Manual therapy including mobilization with movement techniques 5

2. Corticosteroid Injections:

   • May provide short-term relief but do not improve long-term outcomes 2, 5
   • Limited use recommended (2-3 injections, with 4-6 weeks between injections) 2
   • Caution: High recurrence rates after 6 weeks with potential for poorer long-term outcomes compared to physical therapy 5

Third-Line Treatment

If no improvement after 3-6 months of well-managed conservative treatment:

• Surgical Intervention should be considered 2, 7
• Surgical release of the extensor carpi radialis brevis tendon may be performed via percutaneous, arthroscopic, or open approaches 3
• Required in less than 10% of cases 7
• Recovery period after surgery typically requires 3-6 months 7

Expected Timeline and Follow-up

• Tennis elbow typically requires a minimum of 3-6 months to resolve even with optimal management 7
• Regular assessment at 2,6, and 12 weeks to evaluate pain levels, range of motion, and functional improvement 2
• Return to full activity is permitted when the patient demonstrates complete resolution of pain, full range of motion, and strength symmetry >90% compared to the uninjured side 2

Common Pitfalls to Avoid

1. Premature return to aggravating activities before adequate healing
2. Overreliance on corticosteroid injections, which may provide short-term relief but can lead to poorer long-term outcomes 5
3. Complete immobilization, which can lead to stiffness and muscle atrophy 2
4. Neglecting eccentric strengthening exercises, which are crucial for tendon healing and rehabilitation 2, 5
5. Inadequate rehabilitation, which increases risk of chronic problems and recurrence 2

For a patient with tennis elbow that has persisted for 3 months, a structured rehabilitation program with progressive strengthening exercises combined with appropriate pain management and activity modification offers the best chance for recovery, with physiotherapy showing superior outcomes to corticosteroid injections in the mid to long term 5.