What are the management options for tennis elbow?

Management of Tennis Elbow

The most effective management of tennis elbow involves a phased approach starting with conservative measures including rest, NSAIDs, and physical therapy, with surgery reserved only for cases that fail to respond after 3-6 months of well-managed treatment. 1, 2

Initial Management (0-4 weeks)

Pain Control and Rest

• Implement relative rest (absence of painful activity) to prevent further microtrauma 1
• Apply cryotherapy (ice) in the acute phase to reduce inflammation and pain 1
• Prescribe NSAIDs such as naproxen 500mg twice daily or ibuprofen 1.2g daily for short-term pain relief 1, 3
  • Diflunisal may provide better patient-reported pain relief compared to naproxen according to some studies 3
• Consider a counterforce brace to reduce overload forces on the affected tendon 4

Early Rehabilitation

• Begin with gentle range of motion exercises once acute pain subsides
• High-voltage galvanic stimulation may help promote the healing process 4
• Patient education about activity modification and proper equipment (for tennis players)

Intermediate Phase (4-8 weeks)

Progressive Strengthening

• Implement eccentric strengthening exercises for the wrist extensors
• Gradually increase intensity as tolerated
• Include flexibility exercises for the forearm muscles
• Continue with the counterforce brace during activities that stress the elbow 4

Additional Interventions

• Consider corticosteroid injections if pain persists despite initial management
  • Limit to no more than 2 injections due to potential long-term tissue damage 1
• Heat therapy and ultrasound may be beneficial during this phase 1
• Alternative therapies such as acupuncture may be considered, though evidence is limited 1

Advanced Phase (8-12 weeks)

Functional Rehabilitation

• Progress to occupation-specific or sport-specific training
• Focus on strength, endurance, and flexibility in the arm and forearm 4
• Gradual return to previous activities with modified technique to prevent recurrence
• Equipment modification for tennis players (grip size, string tension, etc.)

When to Consider Surgery

• Surgery should only be considered when conservative measures fail after 3-6 months of well-managed treatment 2
• Recent evidence suggests tennis elbow is largely self-limiting with a 50% probability of recovery every 3-4 months regardless of symptom duration 2
• This challenges the traditional belief that failed nonoperative care automatically indicates surgery 2

Important Considerations

• Tennis elbow affects approximately 50% of tennis players at some point, with one-third experiencing symptoms severe enough to interfere with daily activities 1
• Peak incidence occurs between ages 40-50 years, with 90% of patients having no recurrence after recovery 1
• The primary pathology is an enthesopathy (pathological lesion at the tendon-bone insertion) 1
• Lateral epicondylitis is three times more common than medial epicondylitis 1

Common Pitfalls to Avoid

1. Rushing to invasive treatments before adequate trial of conservative care
2. Overuse of corticosteroid injections (more than 2) which can lead to tendon weakening
3. Failing to address biomechanical factors contributing to the condition
4. Returning to full activity too quickly before adequate healing and rehabilitation
5. Neglecting to modify equipment or technique in sports-related cases

Remember that tennis elbow is primarily a self-limiting condition, and management should follow Hippocrates' principle of "first do no harm," starting with simple, conservative approaches before considering more invasive options 1, 2.