What are the causes and treatment options for lateral epicondylitis?

Lateral Epicondylitis: Causes and Treatment

Etiology

Lateral epicondylitis results from repetitive wrist extension, radial deviation, and forearm supination that causes degenerative tendinopathy (not inflammation) of the common extensor origin, particularly affecting the extensor carpi radialis brevis tendon. 1

• Affects men and women equally, most commonly after age 40 1, 2
• Involves the dominant arm in 75% of cases 1
• Seven to 10 times more common than medial epicondylitis 1
• Occurs in racquet sports players ("tennis elbow") and occupations requiring repetitive wrist flexion/extension 1, 3
• The underlying pathology is degenerative tendinopathy, not inflammatory tendinitis 3, 4

Diagnosis

Diagnosis is primarily clinical based on pain at the lateral epicondyle and pain with resisted wrist extension. 5

• Plain radiographs are the most appropriate initial imaging to rule out other causes of elbow pain 6, 5
• MRI or ultrasound may be considered if radiographs are normal but tendon degeneration or tear is suspected 6, 5

Treatment Algorithm

First-Line Conservative Management (80% recover within 3-6 months) 5

Begin with relative rest, activity modification, and eccentric strengthening exercises as these form the foundation of treatment. 6, 5

• Relative rest and activity modification to reduce repetitive loading of the damaged tendon 6, 5
• Eccentric strengthening exercises to promote tendon healing and increase strength 6, 5
• Cryotherapy (ice application) for 10-minute periods for acute pain relief 6, 5
• NSAIDs provide short-term pain relief but do not affect long-term outcomes 1, 6, 5, 2
• Counterforce bracing (tennis elbow brace) may improve function during daily activities, though evidence is limited 6, 5, 2
• Deep transverse friction massage to reduce pain 6, 5
• Progressive stretching exercises for wrist extensors 6, 5

Second-Line Treatment (If Conservative Fails After 6-12 Weeks)

Corticosteroid injections are more effective than NSAIDs in the acute phase but do not change long-term outcomes, so use them judiciously for short-term relief only. 1, 6

• Corticosteroid injections provide short-term pain relief superior to NSAIDs in acute phase 1, 6
• Platelet-rich plasma (PRP) and autologous whole-blood injections may be superior to steroid injections for long-term management 3, 4
• Extracorporeal shock wave therapy has demonstrated mixed benefit 1, 2

Surgical Management (For Refractory Cases >6 Months)

For persistent debilitating pain after 6 months of conservative treatment, surgical intervention (open, arthroscopic, or percutaneous) is highly effective with no single technique clearly superior. 3, 4

• Open, arthroscopic, and percutaneous techniques are all highly effective 3
• Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work 3
• Surgery should not be first-line due to potential complications and high success rates with conservative treatment 5

Common Pitfalls

• Avoid labeling this as an inflammatory condition—it is a degenerative tendinopathy, which explains why anti-inflammatory treatments have limited long-term benefit 3, 4
• Do not rely solely on corticosteroid injections—while effective short-term, they do not improve long-term outcomes and may be inferior to biologics for chronic cases 1, 6, 3
• Watchful waiting is reasonable given the self-limiting nature in most cases 2
• Manual joint mobilization combined with exercise therapy is more effective than exercise alone 5