What is the management of lateral epicondylitis?

Management of Lateral Epicondylitis

Start with conservative treatment including relative rest, activity modification, counterforce bracing, and eccentric strengthening exercises, as approximately 80% of patients recover completely within 3-6 months with this approach. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Reduce repetitive wrist extension, forearm pronation/supination, and forceful gripping activities that stress the lateral epicondyle 1, 2
• Avoid sustained wrist extension during computer work and activities requiring wrist stabilization with the elbow straight 2
• Modify gripping techniques to reduce stress on the common extensor origin 2

Bracing and Support

• Apply a counterforce orthosis (tennis elbow brace) proximally on the forearm to reduce tension on the tendon origin 1
• This inelastic, nonarticular, proximal forearm strap improves function during daily activities 3

Exercise Therapy

• Begin eccentric strengthening exercises as soon as tolerated to promote tendon healing and increase strength 1
• Include stretching exercises for wrist extensors 1
• Progress to a strengthening program focused on the affected extensor muscle groups 1

Pain Management

• Apply ice (cryotherapy) for 10-minute periods to relieve acute pain 1
• Use NSAIDs for short-term pain relief (days to weeks), though they do not affect long-term outcomes 1, 3
• Topical NSAIDs provide short-term benefits and may be preferred over systemic options for localized pain 3

Advanced Physical Therapy Modalities

Manual Therapy

• Deep transverse friction massage can reduce pain 1
• Manual joint mobilization combined with exercise therapy is more effective than exercise alone 1

Adjunctive Therapies

• Ultrasonography may provide complementary benefit 1
• Local heat application (paraffin, warm compresses) before exercise can be beneficial 1
• Iontophoresis with NSAIDs appears to provide short-term benefits 3

Therapies with Limited or No Evidence

• Extracorporeal shock wave therapy does not appear effective 3
• Laser treatment and electromagnetic field therapy lack evidence of effectiveness 3
• Acupuncture has mixed evidence 3

Injection Therapies

Corticosteroid Injections

• Provide short-term pain relief (weeks to months) 3
• May be used for acute symptom control but do not improve long-term outcomes 4

Biologic Injections (For Chronic Cases)

• Platelet-rich plasma (PRP) and autologous whole-blood injections may be superior to corticosteroid injections for long-term management 4
• Consider biologics for patients with chronic symptoms not responding to conservative treatment 4

Surgical Management

Indications

• Reserve surgery for refractory cases that fail conservative treatment after 3-6 months 1, 4
• Surgery should not be first-line despite good clinical outcomes, as many patients respond well to conservative treatment 1

Surgical Options

• Open, arthroscopic, and percutaneous techniques are all highly effective with no clear superiority of one method 4
• Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work 4

Treatment Algorithm

1. Weeks 0-6: Activity modification, counterforce bracing, ice, NSAIDs (topical or oral), eccentric exercises
2. Weeks 6-12: Add manual mobilization, continue progressive strengthening, consider ultrasonography or iontophoresis
3. Months 3-6: If persistent symptoms, consider corticosteroid injection for acute relief OR biologic injections (PRP, autologous blood) for chronic management
4. After 6 months: If refractory to all conservative measures, refer for surgical evaluation

Important Caveats

• The condition is self-limiting over several years in most cases, making watchful waiting a reasonable option 3
• Tailor treatment according to severity of structural change, level of pain, and presence of inflammation 1
• Patients primarily affected are adults aged 40 and older with dominant arm involvement 2
• Initial radiographs are appropriate to rule out other causes of elbow pain; consider ultrasound or MRI if radiographs are normal but tendon injury is suspected 1