Treatment of Lateral Epicondylitis (Tennis Elbow)
Begin with conservative management including rest, activity modification, NSAIDs, and physical therapy with eccentric strengthening exercises, as this approach successfully resolves symptoms in the majority of patients without requiring invasive interventions.
Initial Management Approach
Activity Modification and Rest
- Immediately advise the patient to avoid or modify activities requiring repetitive wrist extension and forearm supination, particularly screwdriver use and other repetitive occupational tasks that exacerbate symptoms 1.
- This is the cornerstone of initial treatment and should be implemented before any other interventions 1.
Pain Management
- Prescribe NSAIDs for pain relief as first-line pharmacologic therapy 1.
- NSAIDs address both pain and inflammation associated with the degenerative tendinopathy 2.
Physical Therapy
- Initiate eccentric strengthening exercises specifically targeting the wrist extensors to promote tendon healing and improve functional capacity 1.
- Add deep transverse friction massage to reduce pain and improve function 1.
- These exercises are critical for long-term recovery and should be performed consistently over several weeks to months 3.
Diagnostic Imaging Considerations
- Obtain plain radiographs of the elbow to exclude other pathologies such as intra-articular bodies, heterotopic ossification, osteochondral lesions, or occult fractures 1, 4.
- The clinical presentation described (lateral epicondyle tenderness, pain with resisted wrist extension) is diagnostic for lateral epicondylitis, but imaging helps rule out alternative diagnoses 2.
- Advanced imaging (MRI, ultrasound) is not routinely necessary unless symptoms persist despite conservative treatment or if the diagnosis is uncertain 4.
Second-Line Treatment for Persistent Symptoms
Corticosteroid Injections
- Consider corticosteroid injections if symptoms persist after 6-12 weeks of conservative management, as they may provide superior short-term pain relief compared to NSAIDs alone 1, 5.
- However, be aware that corticosteroid injections may provide only temporary relief and do not address underlying biomechanical issues 1.
Platelet-Rich Plasma (PRP)
- PRP injections demonstrate superior functional outcomes compared to both corticosteroids and saline at 3 and 6 months, as measured by DASH and PRTEE scores 6.
- PRP should be considered for patients who fail initial conservative measures and prefer a regenerative approach over corticosteroids 6.
- The most recent high-quality evidence (2025) shows PRP provides better mid-term functional improvement than corticosteroids 6.
Alternative Therapies
- Extracorporeal shock wave therapy (ESWT) may be considered as an alternative, though evidence shows mixed results 1.
Surgical Intervention
- Reserve surgery for patients with debilitating pain persisting after a minimum of 6 months of comprehensive nonoperative treatment 3.
- Surgical options include percutaneous, arthroscopic, or open release of the extensor carpi radialis brevis tendon 2, 3.
- Surgery results in high subjective relief, though objective strength deficits may persist 3.
Common Pitfalls to Avoid
- Do not rely solely on corticosteroid injections without addressing underlying biomechanical factors such as poor ergonomics, improper technique, or inadequate equipment modification 1.
- Ensure the patient understands that symptoms frequently persist or recur even with treatment, and that conservative management typically requires several months 3.
- Do not rush to surgery; most patients (>90%) improve with nonoperative measures 2.
Prognosis and Follow-Up
- Most patients experience significant improvement with conservative treatment within 3-6 months 2, 3.
- For this 40-year-old electrician, workplace ergonomic assessment and tool modification are essential to prevent recurrence once symptoms improve 3.
- Schedule follow-up at 6-8 weeks to assess response to initial conservative measures and determine if escalation to injections is warranted 1.