Treatment of Tennis Elbow (Lateral Epicondylitis)
The recommended first-line treatment for tennis elbow is conservative management including relative rest, activity modification, ice application, NSAIDs, bracing, and eccentric strengthening exercises. 1
First-Line Treatment (0-4 weeks)
- Relative rest to prevent ongoing damage while promoting healing, but complete immobilization should be avoided to prevent muscular atrophy 1
- Activity modification by continuing activities that don't worsen pain while temporarily stopping those that aggravate symptoms 1
- Cryotherapy (ice application) for 10-minute periods through a wet towel for effective short-term pain relief 1
- NSAIDs (oral or topical) for pain relief, with topical options providing the benefit of avoiding gastrointestinal risks 1
- Counterforce bracing/orthotics (tennis elbow bands) to reinforce, unload, and protect tendons during activity 1
Rehabilitation Phase (2-8 weeks)
- Eccentric strengthening exercises to promote tendon healing and increase strength 1, 2
- Stretching exercises for the wrist extensors to improve flexibility 1
- Tensile loading of the tendon to stimulate collagen production and guide normal alignment of newly formed collagen fibers 1
- Continued bracing as needed during activities 1
Second-Line Treatments (for persistent symptoms)
- Corticosteroid injections may provide better short-term relief than NSAIDs in the acute phase 1, 3
- However, corticosteroids should be used with caution as they may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1
- Limit corticosteroid injections to no more than 2, as additional injections can cause considerable disadvantage 4
- Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
- Extracorporeal shock wave therapy (ESWT) appears safe and potentially effective 1, 5
- Deep transverse friction massage can help reduce pain 1, 3
Surgical Management
- Consider surgical evaluation if pain persists despite 6-12 months of well-managed conservative treatment 1, 5
- Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
- Arthroscopic debridement is a good surgical option for refractory cases, though it's not necessarily superior to open or percutaneous techniques 5
Common Pitfalls and Caveats
- Overreliance on corticosteroid injections can lead to tendon weakening and potential rupture 1
- Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 1
- Tennis elbow is largely self-limiting with approximately 80% of cases resolving with appropriate conservative management 5
- The pathoanatomy of tennis elbow is noninflammatory "angiofibroblastic tendinosis" rather than true inflammation, which should guide treatment approaches 2
- Proper diagnosis is essential as other conditions can mimic tennis elbow symptoms 6