What is the treatment for lateral epicondylitis (tennis elbow)?

Treatment of Tennis Elbow (Lateral Epicondylitis)

Start with 3-6 months of conservative management including relative rest, ice, NSAIDs, and eccentric strengthening exercises before considering any invasive interventions. 1

Initial Conservative Treatment (First-Line for 3-6 Months)

Core Conservative Therapies

• Relative rest is essential—avoid activities that worsen pain while maintaining some activity to prevent muscle atrophy and deconditioning 1
• Ice therapy provides short-term pain relief, reduces swelling, and blunts the inflammatory response 1
• NSAIDs effectively relieve acute pain, with topical formulations preferred over oral to eliminate gastrointestinal bleeding risk 1
• Eccentric strengthening exercises are critical as they stimulate collagen production and guide proper alignment of newly formed collagen fibers 1
• Stretching exercises are widely accepted and helpful for tendon rehabilitation 1

Important Success Rate

Approximately 80% of patients fully recover within 3-6 months with appropriate conservative treatment, making this the most important phase of management 1, 2

Second-Line Conservative Options

Adjunctive Therapies

• Tennis elbow bands can reinforce, unload, and protect tendons during activity, though supporting data is limited 3, 1
• Technique modification for athletes and manual laborers minimizes repetitive stresses on tendons 3, 1

Therapeutic Modalities

• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 3, 1
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 3, 1

Corticosteroid Injections: Use With Caution

Corticosteroid injections may provide better acute pain relief than NSAIDs but do not alter long-term outcomes and carry significant risks. 1

Critical Caveats

• No evidence-based guidelines support their use in tendinopathy 3
• They may inhibit healing and reduce tensile strength of tissue, predisposing to spontaneous rupture 3, 1
• Limit to no more than 2 injections if used at all 4
• The role of inflammation in tendinopathies is unclear, so corticosteroids may only serve to inhibit healing 3

Surgical Management

Refer for surgical evaluation only if pain persists despite 3-6 months of well-managed conservative treatment. 1

Surgical Techniques

• Arthroscopic, open, or percutaneous release with debridement are all effective options (no technique is superior) 2
• Procedures typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 3, 1
• Recent evidence shows that reduction in MRI signal intensity correlates with pain reduction and functional improvement after arthroscopic treatment 2

Common Pitfalls to Avoid

• Do not rush to corticosteroid injections—they provide only short-term relief and may harm long-term healing 3, 1
• Do not inject corticosteroids into the tendon substance—peritendinous injections are safer if used at all 3
• Do not proceed to surgery before completing a full 3-6 month conservative trial—most cases resolve without surgery 1, 2
• Do not neglect eccentric exercises—they are the cornerstone of tendon rehabilitation 1

Clinical Context

Lateral epicondylosis is 7-10 times more common than medial epicondylosis and involves the dominant arm 75% of the time 1. Activities requiring repetitive wrist extension are the primary contributing factor 1. The condition is self-limited in the vast majority of cases, making aggressive early intervention unnecessary and potentially harmful 2, 4.