What is the initial treatment for lateral epicondylitis?

Initial Treatment for Lateral Epicondylitis

The initial treatment for lateral epicondylitis should include rest, activity modification, NSAIDs for pain relief, and a progressive exercise program focusing on eccentric strengthening of the wrist extensors. 1, 2, 3

Conservative Management Approach

First-Line Interventions:

• Rest and Activity Modification

  • Avoid aggravating activities that involve repetitive gripping or wrist extension
  • Modify technique in sports or occupational activities to reduce stress on the extensor tendons

• Pain Management

  • NSAIDs (e.g., naproxen 500mg twice daily or ibuprofen 1.2g daily) for short-term pain relief 2
  • Acetaminophen as an alternative if NSAIDs are contraindicated

• Physical Support

  • Counterforce bracing with an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) to improve function during daily activities 2
  • The brace should support rather than replace active rehabilitation 1

Exercise Therapy:

• Begin with low-load exercises that don't exacerbate symptoms
• Gradually progress to eccentric strengthening exercises of the wrist extensors
• Implement a phased rehabilitation approach:
  1. Initial phase (0-4 weeks): Pain control and protected range of motion
  2. Intermediate phase (4-8 weeks): Progressive strengthening exercises and eccentric training
  3. Advanced phase (8-12 weeks): Occupation-specific training and functional exercises

Additional Treatment Options

Physical Therapy Modalities:

• Soft tissue mobilization techniques
• Neural tension techniques
• Friction massage
• Stretching exercises for forearm extensors

Injection Therapies (if conservative measures fail after 6-8 weeks):

• Corticosteroid injections provide good short-term relief but may have diminished long-term efficacy 2, 3
• Biologics such as platelet-rich plasma (PRP) or autologous whole-blood injections may be superior for long-term management 1, 3

Treatment Timeline and Follow-up

• Most cases are self-limiting over time, but proper management can accelerate recovery 1
• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement
• Consider referral to a specialist if no improvement occurs after 6-8 weeks of conservative treatment

Common Pitfalls and Caveats

• Avoid prolonged immobilization as it can lead to stiffness and muscle atrophy
• Corticosteroid injections, while providing short-term relief, may have adverse effects on tendon healing and increase risk of recurrence
• Extracorporeal shock wave therapy, laser treatment, and electromagnetic field therapy have limited evidence supporting their effectiveness 2
• Surgical intervention should only be considered after failure of conservative management for at least 6 months 3

Special Considerations

• Proper diagnosis is crucial as lateral epicondylitis can be confused with other conditions such as radial tunnel syndrome, cervical radiculopathy, or intra-articular pathology
• The condition affects men and women equally and is more common in persons 40 years or older 2
• Progressive resistance exercises may provide modest intermediate-term results 2