What is the recommended treatment for tennis elbow (lateral epicondylitis)?

Treatment of Tennis Elbow (Lateral Epicondylitis)

The recommended first-line treatment for tennis elbow includes relative rest, activity modification, eccentric strengthening exercises, cryotherapy, and NSAIDs, with bracing as a helpful adjunct. 1, 2

Conservative Management (First-Line)

Rest and Activity Modification

• Relative rest prevents ongoing damage, reduces pain, and promotes tendon healing, though complete immobilization should be avoided to prevent muscular atrophy 1
• Activities that don't worsen pain may be continued, but those that aggravate symptoms should be modified or temporarily stopped 1, 2

Physical Interventions

• Eccentric strengthening exercises are beneficial for promoting tendon healing and increasing strength 2
• Stretching exercises for the wrist extensors are widely accepted and helpful 1, 2
• Tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers 1

Pain Management

• Cryotherapy (ice application) for 10-minute periods through a wet towel provides effective short-term pain relief 1
• NSAIDs (oral or topical) effectively relieve pain, though they may not affect long-term outcomes 1, 2
• Topical NSAIDs can reduce tendon pain while avoiding the gastrointestinal risks associated with oral NSAIDs 1

Bracing

• Counterforce bracing/orthotics (tennis elbow bands) help reinforce, unload, and protect tendons during activity 1, 2
• While evidence for their effectiveness is limited, they are safe and often helpful in correcting biomechanical problems 1

Second-Line Treatments

Corticosteroid Injections

• Locally injected corticosteroids may be more effective than NSAIDs for relief in the acute phase 1
• However, they do not tend to alter long-term outcomes and should be used with caution 1, 2
• Corticosteroids may inhibit healing and reduce tendon tensile strength, potentially predisposing to spontaneous rupture 1

Other Therapeutic Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 1
• Deep transverse friction massage can reduce pain 2
• Iontophoresis and phonophoresis are widely used but lack well-designed RCTs to permit reliable recommendations 1

Surgical Management

• If pain persists despite 6-12 months of well-managed conservative treatment, surgical evaluation may be warranted 1, 3
• Arthroscopic release with debridement is a good surgical option for refractory cases, though it's not superior to open or percutaneous techniques 3
• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1

Treatment Algorithm

1. Initial phase (0-4 weeks): Rest, activity modification, ice application, NSAIDs, and bracing 1, 2
2. Rehabilitation phase (2-8 weeks): Progressive eccentric strengthening exercises, stretching, and continued bracing as needed 2, 4
3. Advanced rehabilitation (6-12 weeks): Sport or activity-specific exercises, technique modification 5, 4
4. For persistent symptoms: Consider corticosteroid injection or other second-line modalities 1, 2
5. For refractory cases (>6-12 months): Surgical consultation 1, 3

Common Pitfalls and Caveats

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 1
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 1
• Tennis elbow is often self-limiting, with approximately 80% of cases resolving with conservative management 3
• Failure to correct underlying biomechanical issues or technique problems may lead to recurrence 5, 4