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

Treatment of Tennis Elbow (Lateral Epicondylitis)

The first-line treatment for tennis elbow should focus on conservative management including relative rest, activity modification, eccentric strengthening exercises, and NSAIDs, as these approaches effectively reduce pain and promote tendon healing while avoiding the potential complications of more invasive interventions. 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 and increasing strength of the affected area 1, 2
• Stretching exercises for the wrist extensors should be incorporated into the rehabilitation program 1, 3
• Cryotherapy (ice application) for 10-minute periods through a wet towel provides effective short-term pain relief for acute symptoms 1, 4
• NSAIDs (oral or topical) effectively relieve pain in the short term, though they may not affect long-term outcomes 1, 3
• Counterforce bracing/orthotics (tennis elbow bands) help reinforce, unload, and protect tendons during activity 5, 1

Second-Line Treatments

• Corticosteroid injections may provide more effective short-term relief than NSAIDs in the acute phase 1, 3
• However, corticosteroids should be used with caution as they may inhibit healing and reduce tendon tensile strength, potentially predisposing to spontaneous rupture 5, 1
• No more than 2 corticosteroid injections should be administered due to potential negative effects on tendon integrity 4
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is limited 5, 1
• Deep transverse friction massage can reduce pain and improve function 1, 6
• Extracorporeal shock wave therapy (ESWT) appears safe and potentially effective but requires further research to establish optimal protocols 5, 1

Treatment Algorithm

1. Initial phase (0-4 weeks):

   • Rest, activity modification, ice application, NSAIDs, and bracing 1, 7
   • Begin gentle stretching exercises once acute pain subsides 1

2. Rehabilitation phase (2-8 weeks):

   • Progressive eccentric strengthening exercises 1, 2
   • Continue stretching and bracing as needed 1
   • Consider physical therapy modalities such as ultrasound if progress is limited 5, 2

3. For persistent symptoms (beyond 8 weeks):

   • Consider corticosteroid injection (limited to 1-2 injections) 1, 4
   • Evaluate technique and equipment modifications to reduce stress on the affected tendon 7

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

   • Surgical consultation may be warranted 5, 8
   • Arthroscopic or open surgical options typically involve excision of abnormal tendon tissue and release of scarring 5, 8

Common Pitfalls and Caveats

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 5, 1
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 1, 4
• Failing to address biomechanical factors (such as improper technique in sports or occupational activities) may lead to recurrence 7, 2
• Approximately 80% of cases resolve with conservative management, making surgery necessary in only a minority of patients 8
• The condition has its peak incidence between ages 40-50, with 90% of patients experiencing no recurrence after successful treatment 4