What are the symptoms, diagnosis, and treatment options for tennis elbow (lateral epicondylitis)?

Tennis Elbow: Symptoms, Diagnosis, and Treatment

Conservative treatment including relative rest, eccentric exercises, and NSAIDs is the most effective first-line approach for tennis elbow (lateral epicondylitis). 1

Symptoms and Clinical Presentation

Tennis elbow (lateral epicondylitis) is a common overuse tendinopathy affecting 1-3% of the population, with peak incidence between ages 40-50 years 1. Patients typically present with:

• Activity-related pain at the lateral epicondyle that may become constant in later stages
• Sharp or stabbing pain that worsens with wrist extension activities
• Pain that gradually increases in intensity and duration over time
• Decreased grip strength
• Pain with daily activities such as lifting objects, opening doors, or shaking hands

Diagnosis

Physical Examination

The diagnosis is primarily clinical, based on these key findings:

• Pain directly over the lateral epicondyle, particularly at the origin of the extensor carpi radialis brevis
• Pain with resisted wrist extension with the elbow extended
• Pain with passive wrist flexion with the elbow extended
• Tenderness to palpation at the lateral epicondyle

Imaging

Imaging is typically not necessary for initial diagnosis but may be useful in recalcitrant cases:

• Plain radiography: Usually normal but may show calcification at the epicondyle or rule out other pathology 1
• Ultrasonography: Can demonstrate tendon thickening and heterogeneous echogenicity 1
• MRI: Reserved for cases with unclear diagnosis or planning for surgery; can show degenerative thickening, fibrovascular proliferation, and mucoid degeneration 1

Treatment Algorithm

First-Line Treatment (0-6 weeks)

1. Relative rest: Reduce activities that cause pain, especially repetitive wrist extension 1

   • Complete immobilization should be avoided to prevent muscle atrophy
   • Modify technique in sports or occupational activities

2. Cryotherapy: Apply ice through a wet towel for 10-minute periods to reduce acute pain 1

3. NSAIDs: Effective for short-term pain relief 1

   • Oral NSAIDs for acute pain management
   • Topical NSAIDs may provide relief with fewer systemic side effects

4. Eccentric strengthening exercises: Begin early to promote tendon healing 1, 2

   • Start with gentle wrist extension exercises
   • Progress to eccentric loading as tolerated

5. Counterforce bracing: Tennis elbow strap or brace to reduce tension on the extensor tendon origin 2, 3

Second-Line Treatment (6-12 weeks if no improvement)

1. Physical therapy modalities:

   • Ultrasound therapy may promote healing 4
   • Deep transverse friction massage to reduce pain
   • Progressive strengthening of wrist extensors

2. Corticosteroid injection: Consider for acute pain relief 1

   • More effective than NSAIDs in the acute phase
   • Limit to 1-2 injections as multiple injections may weaken tendon structure
   • Note: Provides short-term relief but does not alter long-term outcomes

Third-Line Treatment (>12 weeks with persistent symptoms)

1. Extracorporeal shock wave therapy (ESWT): May reduce pain and promote healing in chronic cases 1

2. Platelet-rich plasma injections: Consider for recalcitrant cases

3. Surgical referral: Consider if symptoms persist despite 3-6 months of conservative treatment 1

   • Surgical techniques typically involve excision of abnormal tendon tissue
   • Success rates of 85-90% reported

Common Pitfalls and Caveats

1. Misdiagnosis: Rule out other causes of lateral elbow pain:

   • Cervical radiculopathy
   • Posterior interosseous nerve entrapment
   • Radiocapitellar arthritis
   • Osteochondral lesions

2. Overtreatment: Tennis elbow is largely self-limiting in most patients 2

   • Avoid aggressive interventions early in the course
   • Follow the principle of "first do no harm"

3. Corticosteroid injections: While effective for short-term pain relief, limit to 1-2 injections as they may:

   • Inhibit healing
   • Reduce tendon strength
   • Increase risk of recurrence or tendon rupture 1

4. Inadequate rehabilitation: Failure to address underlying biomechanical issues or activity modifications can lead to recurrence

5. Premature return to activities: Gradual return to sports or occupational activities only after pain-free strengthening has been achieved

Tennis elbow management should follow a stepwise approach, beginning with conservative measures and progressing to more invasive options only when necessary. Most patients will respond to first-line treatments within 6-12 weeks.