What is the recommended treatment for tennis elbow?

Treatment of Tennis Elbow

Start with conservative management including relative rest, eccentric strengthening exercises, ice application, NSAIDs, and counterforce bracing—this approach should be maintained for at least 6-12 months before considering surgery, as tennis elbow is largely self-limiting with a 50% probability of recovery every 3-4 months regardless of symptom duration. 1, 2

First-Line Conservative Treatment

Immediate Management (0-4 weeks)

• Relative rest by modifying or temporarily stopping activities that aggravate symptoms while continuing pain-free activities to prevent muscular atrophy 1
• Cryotherapy applied for 10-minute periods through a wet towel for effective short-term pain relief 1
• NSAIDs (oral or topical) for pain relief—topical formulations avoid gastrointestinal risks while maintaining efficacy 1
• Counterforce bracing (tennis elbow bands) to unload and protect the tendon during activity 1

Rehabilitation Phase (2-8 weeks onward)

• Eccentric strengthening exercises are the cornerstone of treatment, promoting tendon healing and increasing strength by stimulating collagen production and guiding proper collagen fiber alignment 1
• Wrist extensor stretching exercises should be incorporated as they are widely accepted and beneficial 1
• Continue bracing as needed during this phase 1

Second-Line Treatments for Persistent Symptoms

Corticosteroid Injections

• Use with significant caution—while locally injected corticosteroids may provide better acute phase relief than NSAIDs, they do not alter long-term outcomes 1
• Corticosteroids may inhibit healing and reduce tendon tensile strength, predisposing to spontaneous rupture 3, 1
• Limit to no more than 2 injections to avoid these complications 4

Additional Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 1
• Deep transverse friction massage can reduce pain 1

Surgical Management

Surgery should only be considered after 6-12 months of well-managed conservative treatment 1

Critical Evidence on Surgery Timing

• Recent evidence challenges traditional surgical indications: tennis elbow prognosis is not influenced by symptom duration, with a 50% probability of recovery every 3-4 months regardless of how long symptoms have been present 2
• No evidence supports the superiority of surgery over continued nonoperative care or no treatment 2
• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1

Common Pitfalls to Avoid

• Never rely heavily on corticosteroid injections—they may weaken tendons and increase rupture risk 3, 1
• Avoid complete immobilization—this leads to muscle atrophy and deconditioning; relative rest with continued pain-free activity is preferred 1
• Do not rush to surgery—the self-limiting nature of tennis elbow means most patients will recover with continued conservative care, even after prolonged symptoms 2
• Recognize that failed conservative treatment is not necessarily an indication for surgery—the natural history shows ongoing recovery potential regardless of duration 2