What is the treatment for common extensor tendinopathy?

Treatment of Common Extensor Tendinopathy

Begin with relative rest, ice applications, and eccentric strengthening exercises as the foundation of treatment, reserving corticosteroid injections for acute pain relief only and avoiding them in chronic cases due to potential tendon weakening. 1

Initial Conservative Management (First 3-6 Months)

Activity Modification and Rest

• Continue activities that do not worsen pain while avoiding complete immobilization, which leads to muscle atrophy and deconditioning 1
• Reduce or eliminate repetitive gripping, wrist extension, and forearm supination activities that reproduce symptoms 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods repeatedly for acute pain relief 1
• This provides short-term pain control by reducing tissue metabolism and slowing vascular protein release 1

Eccentric Strengthening (Most Important)

• Eccentric strengthening exercises are the most effective treatment and may reverse degenerative tendon changes 1, 2, 3
• These exercises stimulate collagen production and guide proper alignment of newly formed collagen fibers 1
• Begin once acute pain subsides and continue for at least 12 weeks 1

Pharmacological Options

NSAIDs

• Topical NSAIDs are preferred over oral formulations for short-term pain relief (less than 10 days) due to fewer systemic side effects, particularly reduced gastrointestinal hemorrhage risk 1, 3, 4
• Oral NSAIDs (such as naproxen 375-750 mg twice daily) provide acute pain relief but show no long-term benefit and carry cardiovascular and gastrointestinal risks 1, 4
• NSAIDs cannot be recommended over other analgesics as evidence does not demonstrate superiority 1

Corticosteroid Injections

• Use with extreme caution and only for acute-phase pain relief, as they do not alter long-term outcomes 1, 3
• May be more effective than oral NSAIDs for acute pain but can inhibit healing, reduce tendon tensile strength, and predispose to spontaneous rupture 1, 3
• Avoid injecting directly into tendon substance; peritendinous injections are safer but still carry risks 1
• Never inject within 6 weeks of planned minimally invasive procedures 5

Adjunctive Therapies

Bracing

• Tennis elbow bands (counterforce braces) can unload and protect the tendon during activity 1, 3
• Evidence for effectiveness is limited, but they are safe and may help correct biomechanical problems 1

Physical Therapy Modalities

• Therapeutic ultrasound, iontophoresis, and phonophoresis have uncertain benefit with weak supporting evidence 1
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but is expensive, with inconsistent results across studies 1, 6

Advanced Interventions for Refractory Cases

Minimally Invasive Procedures (After 3-6 Months of Failed Conservative Treatment)

• Ultrasound-guided percutaneous ultrasonic tenotomy (TenJet) is safe and effective for refractory cases, with significant improvement in Oxford Elbow Scores at 1 year and zero progression to open surgery in case series 5
• This can be performed in outpatient settings and is successful even after failed open surgical release 7
• Sclerotherapy and nitric oxide patches show promise but require larger trials for confirmation 6

Emerging Biological Treatments

• Microfragmented adipose tissue transfer has demonstrated complete bridging and remodeling of full-thickness tears at 15 weeks, offering a surgical alternative 8
• Platelet-rich plasma and growth factors show preliminary promise but require further study 6, 8

Surgery

• Reserve for patients who fail 3-6 months of consistent conservative therapy 1, 2, 3
• Surgery carries significant morbidity and inconsistent outcomes, making it the last resort 6
• Approximately 80% of patients recover fully with conservative management alone within 3-6 months 2, 3

Critical Pitfalls to Avoid

• Do not misdiagnose this as an inflammatory condition ("tendinitis") – it is a degenerative process ("tendinosis") with minimal inflammation, making anti-inflammatory focused treatment suboptimal 1, 3, 6
• Avoid complete immobilization, which worsens outcomes through muscle atrophy 1
• Do not rely solely on corticosteroid injections, especially in chronic cases, as they may cause tendon rupture and do not improve long-term outcomes 1, 3
• Address underlying biomechanical issues and technique problems in athletes and manual laborers to prevent recurrence 1, 2