Latest Treatment for Tennis Elbow (Lateral Epicondylitis)
Start with a structured 3-6 month conservative treatment program combining relative rest, eccentric strengthening exercises, and NSAIDs before considering any invasive interventions, as approximately 80% of patients fully recover with this approach alone. 1
First-Line Conservative Management (3-6 Months)
Core Treatment Components
Relative rest: Avoid activities that reproduce pain while maintaining general arm activity to prevent muscle atrophy—this is not complete immobilization but strategic activity modification 1
Eccentric strengthening exercises: These are the cornerstone of rehabilitation, stimulating collagen production and guiding proper alignment of newly formed collagen fibers in the damaged extensor carpi radialis brevis tendon 1
NSAIDs for pain control: Both oral and topical formulations effectively relieve acute pain, though topical NSAIDs are preferable as they eliminate the gastrointestinal bleeding risk associated with systemic NSAIDs 1
Ice therapy: Apply for 10-minute periods to provide short-term pain relief and reduce swelling in the acute phase 1
Stretching exercises: Incorporate wrist extensor stretches as part of the rehabilitation program 1
Important Clinical Context
Tennis elbow is largely self-limiting with a 50% probability of recovery every 3-4 months regardless of symptom duration 2. This benign natural history challenges the traditional rush to invasive treatments and supports patience with conservative care 2.
Second-Line Treatment Options (If Conservative Care Insufficient)
Tennis Elbow Braces
Counterforce bracing can help unload and protect the tendon during activity, though definitive evidence for effectiveness is limited 1
These are safe adjuncts worth trying before more invasive options 3
Corticosteroid Injections (Use With Caution)
Corticosteroid injections provide superior short-term pain relief compared to NSAIDs in the acute phase but do not alter long-term outcomes 3, 1
Critical caveat: Use with significant caution as corticosteroids may inhibit tendon healing and reduce tensile strength, potentially predisposing to spontaneous rupture 3, 1
Limit to no more than 2 injections maximum 4
The short-term benefit must be weighed against potential long-term harm to tendon integrity 3
Emerging Physical Modalities
Extracorporeal shock wave therapy (ESWT): Appears safe and effective for reducing pain and promoting tendon healing, though studies show mixed results and optimal protocols remain unclear 3
Therapeutic ultrasound: May decrease pain and increase collagen synthesis, but evidence for consistent benefit remains weak 3
Deep transverse friction massage can reduce pain when combined with eccentric exercises 1
Surgical Intervention (Last Resort)
Refer for surgical evaluation only if pain persists despite 3-6 months of well-managed conservative treatment. 1
Surgical techniques typically involve excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 3, 1
Surgery can be effective in carefully selected patients who have truly failed comprehensive conservative care 3
Critical Pitfall to Avoid
Do not rush to surgery based solely on symptom duration. New evidence demonstrates that tennis elbow prognosis is not influenced by how long symptoms have been present, and spontaneous recovery continues to occur even after prolonged symptoms 2. The traditional belief that "failed conservative care" after a certain timeframe mandates surgery is not evidence-based 2.
Key Clinical Pearls
Lateral epicondylosis is 7-10 times more common than medial epicondylosis and affects the dominant arm 75% of the time 3, 1
Peak incidence occurs between ages 40-50 years, with 90% of patients having no recurrence after resolution 4
Activities requiring repetitive wrist extension are the primary causative factor 3
The underlying pathology is angiofibroblastic tendinosis (degenerative tendon changes), not inflammation, which explains why anti-inflammatory treatments have limited long-term benefit 5