What is the best treatment approach for lateral epicondylitis?

Treatment of Lateral Epicondylitis

The best treatment approach for lateral epicondylitis is a progressive regimen starting with conservative measures including relative rest, eccentric strengthening exercises, and counterforce bracing, followed by second-line treatments only if symptoms persist. 1

First-Line Conservative Management

• Relative rest and activity modification are essential to prevent ongoing damage while promoting tendon healing, though complete immobilization should be avoided to prevent muscular atrophy 1
• Eccentric strengthening exercises are highly beneficial for promoting tendon healing, increasing strength, and guiding normal alignment of newly formed collagen fibers 1, 2
• Stretching exercises for the wrist extensors should be incorporated into the rehabilitation program 1
• 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 in the short term, though they may not affect long-term outcomes 1, 2
• Counterforce bracing/orthotics (tennis elbow bands) help reinforce, unload, and protect tendons during activity and can improve function during daily activities 1, 3
• Deep transverse friction massage is recommended to reduce pain 2, 1

Second-Line Treatments

• Corticosteroid injections are more effective than NSAIDs in the acute phase of epicondylitis but do not change long-term outcomes of pain 2, 1
  • Caution: Corticosteroids may inhibit healing and reduce tendon tensile strength, potentially predisposing to spontaneous rupture 1
• Extracorporeal shock wave therapy (ESWT) has shown mixed benefits for lateral elbow pain 2, 3
• Biologic injections such as platelet-rich plasma and autologous whole-blood injections may be superior to steroid injections in the long-term management 4
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is limited 1

Surgical Management

• Surgical intervention should be considered only if pain persists despite 6-12 months of well-managed conservative treatment 1, 5
• Open, arthroscopic, and percutaneous techniques are all highly effective for refractory cases, with no method proving clearly superior 4, 5
• Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work 4

Treatment Algorithm

1. Initial phase (0-4 weeks):

   • Rest, activity modification, ice application, NSAIDs, and bracing 1
   • Begin gentle stretching exercises 1

2. Rehabilitation phase (2-8 weeks):

   • Progressive eccentric strengthening exercises 1, 2
   • Deep transverse friction massage 2, 1
   • Continue stretching and bracing as needed 1

3. For persistent symptoms (beyond 8 weeks):

   • Consider corticosteroid injection or other second-line modalities 1, 2
   • Evaluate for biologic injections if corticosteroids fail 4

4. For refractory cases (>6-12 months):

   • Surgical consultation 1, 5

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
• Many treatment options have inconsistent evidence supporting their effectiveness, making a structured, progressive approach most reasonable 6, 3
• Lateral epicondylitis affects men and women equally and is most common after 40 years of age, often occurring in the dominant arm 2