What is the initial treatment for lateral epicondylitis?

Initial Treatment for Lateral Epicondylitis

The initial treatment for lateral epicondylitis should include NSAIDs for pain relief combined with eccentric strengthening exercises and functional support with a brace, while avoiding immobilization and limiting corticosteroid injections. 1

Non-Pharmacological Management

Physical Therapy and Exercise

• Eccentric strengthening exercises are the cornerstone of rehabilitation for lateral epicondylitis
• A phased rehabilitation approach is recommended:
  • Initial phase (0-4 weeks): Pain control and protected range of motion
  • Intermediate phase (4-8 weeks): Progressive strengthening exercises and eccentric training
  • Advanced phase (8-12 weeks): Occupation-specific training and functional exercises 1

Bracing/Support

• Functional support with a counterforce brace or tennis elbow strap can help reduce pain during daily activities
• Bracing provides better outcomes compared to immobilization 1
• The brace should be worn during activities that provoke pain, not continuously

Pharmacological Management

NSAIDs

• First-line medication for pain and discomfort
• Options include:
  • Ibuprofen 1.2g daily (can be increased to 2.4g daily if needed)
  • Naproxen 500mg twice daily
  • Can be combined with paracetamol (up to 4g daily) for enhanced pain relief 1
• NSAIDs should be used for short-term pain management, typically 1-2 weeks 2
• Consider gastroprotective agents in patients with increased GI risk 3

Corticosteroid Injections

• Should be limited in use (no more than 2-3 injections, with 4-6 weeks between injections)
• May provide short-term relief but do not improve long-term outcomes 1, 4
• Not recommended as first-line treatment due to the non-inflammatory nature of the condition 4

Activity Modification

• Avoid or modify activities that exacerbate symptoms, particularly repetitive gripping or wrist extension
• Complete rest is not recommended; instead, focus on modifying activities to reduce pain 2
• Gradual return to activities as symptoms improve

Treatment Progression and Follow-up

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement 1
• Consider referral to a specialist if no improvement occurs after 6-8 weeks of conservative treatment
• Surgical options should only be considered when conservative measures fail after 3-6 months of well-managed treatment 1, 2

Common Pitfalls to Avoid

1. Overreliance on corticosteroid injections, which may provide short-term relief but can lead to tendon weakening with repeated use
2. Complete immobilization, which can lead to stiffness and muscle atrophy
3. Returning to aggravating activities too quickly before adequate healing
4. Focusing solely on pain relief without addressing the underlying tendon degeneration through appropriate exercises
5. Neglecting proper technique modification to prevent recurrence

Remember that lateral epicondylitis is primarily a degenerative tendinopathy rather than an inflammatory condition, which explains why anti-inflammatory treatments alone may not be sufficient for long-term management 2, 4.