What is the treatment for tennis elbow?

Treatment of Tennis Elbow (Lateral Epicondylitis)

The first-line treatment for tennis elbow should include relative rest, activity modification, ice application, NSAIDs, and counterforce bracing, followed by progressive eccentric strengthening exercises and stretching. 1

Conservative Management (First-Line)

• Relative rest prevents ongoing damage while promoting healing, but complete immobilization should be avoided to prevent muscular atrophy 1
• Activities that aggravate symptoms should be modified or temporarily stopped, while pain-free activities may be continued 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 acute phase, though they may not affect long-term outcomes 1
• Topical NSAIDs can reduce tendon pain while avoiding gastrointestinal risks associated with oral NSAIDs 1
• Counterforce bracing/orthotics (tennis elbow bands) help reinforce, unload, and protect tendons during activity 1, 2
• Eccentric strengthening exercises are beneficial for promoting tendon healing and increasing strength 1
• Stretching exercises for the wrist extensors are widely accepted and helpful for rehabilitation 1

Second-Line Treatments

• Corticosteroid injections may provide better short-term relief than NSAIDs in the acute phase 1, 3
• However, caution is warranted with corticosteroid injections as they may inhibit healing and reduce tendon tensile strength, potentially predisposing to spontaneous rupture 2, 1
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 2, 1
• Extracorporeal shock wave therapy (ESWT) appears safe and potentially effective but requires further research 2, 1
• Deep transverse friction massage can reduce pain and may be incorporated into physical therapy 1, 3

Surgical Management

• If pain persists despite 6-12 months of well-managed conservative treatment, surgical evaluation may be warranted 1
• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 2, 1
• Surgery is effective in carefully selected patients who have failed conservative management 2

Treatment Algorithm

1. Initial phase (0-4 weeks):

   • Rest and activity modification 1
   • Ice application for 10 minutes through a wet towel 1
   • NSAIDs (oral or topical) 1
   • Counterforce bracing 2, 1

2. Rehabilitation phase (2-8 weeks):

   • Continue initial treatments as needed 1
   • Begin progressive eccentric strengthening exercises 1
   • Incorporate stretching exercises for wrist extensors 1

3. For persistent symptoms:

   • Consider second-line treatments such as corticosteroid injection (with caution) 1, 3
   • Consider therapeutic ultrasound or ESWT 2, 1

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

   • Surgical consultation 2, 1

Common Pitfalls and Caveats

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 2, 1
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 1
• Tennis elbow is often self-limiting, but improper management can lead to chronic pain and dysfunction 4
• The condition affects not only tennis players but anyone engaged in repetitive gripping or wrist extension activities 5
• Failure to address biomechanical issues or technique problems may lead to recurrence 4