What is the best treatment approach for lateral epicondylitis?

Treatment of Lateral Epicondylitis

Eccentric strengthening exercises combined with relative rest and activity modification are the most effective first-line treatment for lateral epicondylitis, promoting tendon healing while preventing further damage. 1

First-Line Treatment Approach

Conservative Management

• Relative rest and activity modification to reduce repetitive loading of the damaged tendon while avoiding complete immobilization 1
• Eccentric strengthening exercises to promote tendon healing, increase strength, and guide normal alignment of newly formed collagen fibers 1
• Stretching exercises for the wrist extensors to improve flexibility and function 1
• Cryotherapy (ice application) for 10-minute periods through a wet towel for short-term pain relief 1
• NSAIDs (oral or topical) for effective pain relief, though they may not affect long-term outcomes 1, 2
• Counterforce bracing/orthotics (tennis elbow bands) to reinforce, unload, and protect tendons during activity 3, 1

Second-Line Treatment Options

When First-Line Treatments Fail (4-6 weeks)

• Corticosteroid injections provide better short-term relief than NSAIDs in the acute phase but do not improve long-term outcomes 3, 1
• Deep transverse friction massage to reduce pain 3, 1
• Extracorporeal shock wave therapy (ESWT) shows mixed results but may be beneficial for some patients 3, 4

For Persistent Symptoms (2-3 months)

• Biologic injections such as platelet-rich plasma (PRP) or autologous whole-blood may be superior to steroid injections for long-term management 4
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is limited 5

Surgical Management

For Refractory Cases (6-12 months of failed conservative treatment)

• Surgical options include open, arthroscopic, and percutaneous techniques, all of which are highly effective with no method clearly superior 4, 6
• Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work 4
• 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
   • Begin eccentric strengthening exercises and stretching 1

2. Rehabilitation Phase (4-8 weeks)

   • Progressive eccentric strengthening exercises
   • Continued stretching and bracing as needed 1
   • If minimal improvement, consider corticosteroid injection 3, 1

3. For Persistent Symptoms (2-6 months)

   • Consider biologic injections (PRP, autologous whole-blood) 4
   • Deep transverse friction massage 3, 1
   • ESWT or therapeutic ultrasound 4, 5

4. For Refractory Cases (>6-12 months)

   • Surgical consultation 1, 6

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
• NSAIDs provide symptomatic relief but do not address the underlying tendon degeneration 1, 5
• Lateral epicondylitis is primarily a degenerative condition (tendinosis) rather than an inflammatory one (tendinitis), which explains why anti-inflammatory treatments have limited long-term efficacy 7