Management of Tennis Elbow (Lateral Epicondylitis)
Start with conservative management consisting of relative rest with activity modification, eccentric strengthening exercises, and cryotherapy—this approach should be maintained for at least 6-12 months before considering surgical intervention. 1
First-Line Conservative Treatment (0-4 weeks)
Activity Modification and Rest
- Avoid complete immobilization as this leads to muscular atrophy and deconditioning 1
- Continue activities that don't worsen pain, but temporarily stop or modify those that aggravate symptoms 1
- Relative rest prevents ongoing tendon damage while promoting healing 1
Pain Management
- Apply ice for 10-minute periods through a wet towel for effective short-term pain relief 1
- NSAIDs (oral or topical) effectively relieve pain, though they don't alter long-term outcomes 1
- Topical NSAIDs reduce tendon pain while avoiding gastrointestinal risks of oral formulations 1
Bracing
- Counterforce bracing (tennis elbow bands) helps unload and protect tendons during activity 1
- These devices reinforce the damaged tendon and allow continued function 1
Rehabilitation Phase (2-8 weeks)
Exercise Therapy
- Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength 1
- Stretching exercises for wrist extensors are widely accepted and beneficial 1
- Tensile loading stimulates collagen production and guides proper alignment of newly formed collagen fibers 1
- Progressive resistance exercises should target the weakened extensor muscle group 2
Physical Therapy Modalities
- Deep transverse friction massage can reduce pain 1
- Manual techniques including joint mobilizations, soft tissue massage, and myofascial release may improve joint function 2
- Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
Second-Line Treatments (For Persistent Symptoms)
Corticosteroid Injections
- Use corticosteroid injections cautiously—they may be more effective than NSAIDs in the acute phase but don't alter long-term outcomes 1
- Critical caveat: Corticosteroids may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1
- Reserve for cases not responding adequately to first-line conservative measures 3
Emerging Modalities
- Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 1
- Laser therapy and acupuncture have been explored but lack consistent evidence 4
Surgical Management
Indications
- Consider surgical evaluation only if pain persists despite 6-12 months of well-managed conservative treatment 1
- Surgery is reserved for severe or refractory cases 5
Surgical Approach
- Typical procedures include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
Imaging Recommendations
Initial Evaluation
- Plain radiographs of the elbow are the most appropriate initial imaging study to rule out other causes of elbow pain and assess for bony abnormalities 3
- Radiographs may show intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis 5
Advanced Imaging
- MRI may be considered if radiographs are normal or nonspecific and there is suspicion of tendon degeneration or tear 3
- MRI is not routinely needed for initial diagnosis, which remains primarily clinical 3
Critical Pitfalls to Avoid
- Never rely heavily on corticosteroid injections—they may weaken tendons and increase rupture risk 1
- Avoid complete immobilization—this causes muscle atrophy rather than promoting healing 1
- Don't rush to surgery—lateral epicondylitis is a self-limiting condition in most cases 6
- Recognize that over 40 different treatment methods exist, but conservative management with eccentric exercises remains the evidence-based foundation 4