Treatment of Tennis Elbow (Lateral Epicondylitis)
Start with conservative management including relative rest, activity modification, ice application, NSAIDs, and counterforce bracing, followed by eccentric strengthening exercises beginning at 2-8 weeks. 1
Initial Phase (0-4 weeks)
Relative rest is the cornerstone of early treatment – continue activities that don't worsen pain but modify or temporarily stop those that aggravate symptoms. 1 Complete immobilization should be avoided as it leads to muscular atrophy and deconditioning. 1
Pain Control Measures:
- Cryotherapy: Apply ice for 10-minute periods through a wet towel for effective short-term pain relief 1
- NSAIDs: Both oral and topical formulations effectively relieve pain, though they don't alter long-term outcomes 1
- Topical NSAIDs reduce tendon pain while avoiding gastrointestinal risks of oral formulations 1
- Counterforce bracing: Tennis elbow bands help reinforce, unload, and protect the tendon during activity 1
- While evidence for effectiveness is limited, these devices are safe and widely used 2
Rehabilitation Phase (2-8 weeks)
Eccentric strengthening exercises are beneficial for promoting tendon healing and increasing strength by stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 1
- Stretching exercises for the wrist extensors are widely accepted and helpful 1
- Progressive loading of the tendon should be implemented as tolerated 1
- Continue bracing as needed during this phase 1
Second-Line Treatments for Persistent Symptoms
Corticosteroid injections may be more effective than NSAIDs for acute phase relief but should be used with significant caution. 1
Critical Caveat About Corticosteroids:
- They do not alter long-term outcomes 1
- May inhibit healing and reduce tendon tensile strength, potentially predisposing to spontaneous rupture 1
- No evidence-based guidelines support their use in tendinopathy 2
- Avoid injecting directly into tendon substance due to deleterious effects 2
Alternative Second-Line 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 1
- Deep transverse friction massage: Can reduce pain 1
Surgical Management
If pain persists despite 6-12 months of well-managed conservative treatment, refer for surgical evaluation. 1
- Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
- The mechanism of surgical healing promotion is not entirely understood, but surgery is effective in carefully selected patients 2
Key Pitfalls to Avoid
Overreliance on corticosteroid injections is the most significant pitfall – they may lead to tendon weakening and potential rupture. 1 The role of inflammation in tendinopathies is unclear, and corticosteroids may serve only to inhibit healing. 2
Complete immobilization must be avoided as it causes muscle atrophy rather than promoting healing. 1