What are the management options for tennis elbow?

Management of Tennis Elbow (Lateral Epicondylitis)

The most effective approach to managing tennis elbow is to start with conservative first-line treatments including relative rest, activity modification, ice application, NSAIDs, and bracing, followed by progressive eccentric strengthening exercises and stretching. 1

First-Line Conservative Management

• Relative rest prevents ongoing tendon damage while promoting healing, but complete immobilization should be avoided to prevent muscle atrophy 1
• Activity modification is essential - continue activities that don't worsen pain but temporarily stop or modify those that aggravate symptoms 1
• Apply ice (cryotherapy) for 10-minute periods through a wet towel to provide effective short-term pain relief 1
• NSAIDs (oral or topical) effectively relieve pain in the acute phase, though they may not affect long-term outcomes 1
• Counterforce bracing/tennis elbow bands help reinforce, unload, and protect tendons during activity 1
• Eccentric strengthening exercises promote tendon healing by stimulating collagen production and guiding normal alignment of newly formed collagen fibers 1
• Stretching exercises for the wrist extensors are widely accepted and beneficial for recovery 1

Second-Line Treatments

• Corticosteroid injections may provide more effective short-term relief than NSAIDs in the acute phase 1, 2
• However, corticosteroids should be used with caution as they may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1
• No more than 2 corticosteroid injections should be administered due to potential adverse effects 3
• Deep transverse friction massage can help reduce pain 1, 2
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is limited 1
• Extracorporeal shock wave therapy (ESWT) appears safe and may be effective, but requires further research 1

Treatment Algorithm

1. Initial phase (0-4 weeks):

   • Rest, activity modification, ice application, NSAIDs, and bracing 1
   • Avoid activities that aggravate symptoms 1

2. Rehabilitation phase (2-8 weeks):

   • Progressive eccentric strengthening exercises 1
   • Stretching of wrist extensors 1
   • Continue bracing as needed during activities 1

3. For persistent symptoms:

   • Consider corticosteroid injection (with caution) 1, 2
   • Explore other second-line modalities like ESWT or therapeutic ultrasound 1

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

   • Surgical consultation if pain persists despite 6-12 months of well-managed conservative treatment 1
   • Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1

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
• There is wide variability in second-line treatments offered when physiotherapy fails, with many lacking strong evidence to support their use 4
• Corticosteroid injections, while commonly used as second-line treatment (27% of UK practitioners), may be harmful in the long term 4
• Differential diagnosis is important as similar symptoms can be caused by other pathologic processes in the elbow beyond lateral epicondylitis 5