What is the recommended treatment for lateral elbow pain?

Recommended Treatment for Lateral Elbow Pain

For lateral elbow pain (lateral epicondylitis), begin with rest, activity modification, NSAIDs for pain relief, and a structured exercise program focusing on eccentric strengthening and stretching, as this approach provides superior long-term outcomes compared to passive treatments or corticosteroid injections. 1, 2

Initial Diagnostic Approach

• Obtain plain radiographs first to exclude fractures, intra-articular bodies, heterotopic ossification, osteochondral lesions, or soft tissue calcification 1, 3
• Look specifically for avulsion fractures at tendon attachment sites and joint effusions (anterior/posterior fat pad elevation) that may indicate occult fractures 1
• Reserve ultrasound or MRI without contrast for cases where radiographs are normal but significant tendon or ligament injury is suspected 4

First-Line Conservative Management

Activity Modification and Rest

• Avoid activities requiring repetitive wrist extension, radial deviation, and forearm supination 1, 5
• This is particularly important for occupations involving desktop use, weight training, forceful forearm movements, or repetitive vibratory movements 5

Exercise Therapy (Primary Treatment)

• Implement eccentric strengthening exercises for wrist extensors as the cornerstone of treatment 1, 2
• Exercise therapy demonstrates superior outcomes compared to corticosteroid injections at mid-term (clinically significant difference in pain-free grip strength: MD 22.45,95% CI 3.63 to 41.3) and long-term follow-up (MD 18,95% CI 11.17 to 24.84) 2
• Add deep transverse friction massage to reduce pain and improve function 1
• Structure the program with 4-6 therapy visits spaced over 12 weeks, focusing on patient education and self-management 6
• Note that stretching alone without strengthening is equally effective according to one trial, but the weight of evidence favors including strengthening 6, 2

Pain Management

• Use NSAIDs for acute pain relief 1, 7
• NSAIDs are more effective than passive interventions but provide limited long-term benefit 7
• Ice and rest as adjunctive pain management techniques 6

Orthotics/Bracing

• Consider counterforce bracing, though evidence for effectiveness remains inconclusive 1, 7

Second-Line Interventions

Corticosteroid Injections

• Reserve corticosteroid injections for persistent symptoms despite 6-12 weeks of conservative management 1, 3
• Corticosteroids are more effective than NSAIDs in the acute phase but do not improve long-term outcomes and are inferior to exercise therapy 1, 2
• Exercise outperforms corticosteroid injections at all time points except short-term pain reduction (low certainty evidence) 2

Biologic Injections

• Platelet-rich plasma (PRP) and autologous whole-blood injections may be superior to corticosteroid injections for long-term management of chronic, refractory cases 7

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT shows mixed results and may be considered as an alternative therapy for refractory cases 1, 3
• Evidence demonstrates limited benefit overall 7

Surgical Management

• For chronic, refractory lateral epicondylitis unresponsive to 6-12 months of conservative treatment, open, arthroscopic, or percutaneous surgical techniques are all highly effective with no clear superiority of one method over another 7
• Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work 7

Expected Timeline and Outcomes

• Most cases are self-limiting over several years, but structured treatment accelerates recovery 7
• With exercise-based therapy, expect statistically significant improvements in pain and disability at 6,12, and 24 weeks 6
• Pain continues to decrease through 52 weeks, though functional scores may plateau or slightly worsen between 24-52 weeks 6
• Manual therapy combined with exercise provides only slight additional benefit (MD -0.53 points for pain, MD -5.00 points for disability on 0-100 scales) that may not be clinically worthwhile 8

Critical Pitfalls to Avoid

• Do not rely on corticosteroid injections without addressing underlying biomechanical issues and implementing exercise therapy 3, 2
• Avoid passive treatments alone (ultrasound, electrical stimulation) as they provide minimal benefit compared to active exercise 7, 8
• Do not order advanced imaging (MRI, CT) as initial studies unless radiographs suggest significant structural pathology 1, 4
• Recognize that 70% of cases affect the dominant arm and occur most commonly after age 40, requiring realistic expectations about recovery timeline 1