What is the treatment for elbow tendonitis?

Treatment for Elbow Tendonitis

Begin with relative rest, ice therapy, NSAIDs (oral or topical), and eccentric strengthening exercises for 3-6 months before considering any invasive interventions. 1

First-Line Conservative Treatment (0-6 Months)

Activity Modification

• Implement relative rest by reducing activities that worsen pain while maintaining some level of activity to prevent muscle atrophy and deconditioning 2, 1
• Complete immobilization must be avoided as it leads to muscular atrophy 2
• For athletes and manual laborers, modify technique to minimize repetitive stresses on the affected tendon 2, 1

Pain Control and Anti-Inflammatory Measures

• Topical NSAIDs are preferred over oral formulations because they provide equivalent pain relief while eliminating the risk of gastrointestinal hemorrhage 2, 1
• If using oral NSAIDs, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours is appropriate for acute tendonitis 3
• Apply ice through a wet towel for 10-minute periods for short-term pain relief and to reduce swelling 2, 1
• NSAIDs are effective for short-term pain relief but do not alter long-term outcomes 2, 4

Rehabilitation Exercises

• Eccentric strengthening exercises are the cornerstone of treatment as they stimulate collagen production and guide normal alignment of newly formed collagen fibers 2, 1
• Stretching exercises are widely accepted and generally helpful 2, 1
• Tensile loading of the tendon through controlled exercise promotes healing 2

Bracing

• Tennis elbow bands (counterforce braces) help reinforce, unload, and protect tendons during activity and are safe adjuncts to therapy 2, 1
• While definitive data on effectiveness is limited, these devices are widely used and often helpful 2

Second-Line Treatments (If First-Line Fails After 6-12 Weeks)

Corticosteroid Injections - Use With Caution

• Corticosteroid injections may provide short-term pain relief (more effective than oral NSAIDs in the acute phase) but do not improve long-term outcomes 2, 1, 4
• Critical pitfall: Never inject directly into the tendon substance as this inhibits healing, reduces tensile strength, and may predispose to spontaneous rupture 2, 1
• Peritendinous injections should be used cautiously because corticosteroids may inhibit healing in what is primarily a degenerative (not inflammatory) condition 2, 4

Advanced Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective for chronic tendinopathies, though it is expensive and optimal treatment strategies require further research 2, 1
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, but evidence for consistent benefit is weak 2, 1
• Iontophoresis and phonophoresis are widely used but lack well-designed randomized controlled trials to support definitive recommendations 2

Surgical Management (After 3-6 Months of Failed Conservative Treatment)

• Surgery is indicated only after 3-6 months of well-managed conservative treatment has failed 2, 1, 5
• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
• Surgery is required in less than 10% of cases and has a similarly long recovery period of 3-6 months 5
• Most patients (approximately 80%) fully recover within 3-6 months with appropriate conservative treatment alone 1, 5

Important Clinical Pearls

Diagnosis Confirmation

• Physical examination typically reveals well-localized tenderness that reproduces the pain experienced during activity 1
• Lateral epicondylosis is 7-10 times more common than medial epicondylosis and involves the dominant arm 75% of the time 1
• Plain radiography may show osteophyte formation at the epicondyles but usually cannot demonstrate soft-tissue changes 1
• MRI or ultrasound may be helpful if diagnosis remains unclear after thorough history and physical examination, or for preoperative evaluation 2, 1

Pathophysiology Understanding

• The underlying pathology is angiofibroblastic degeneration (tendinosis), not inflammation (tendinitis), which explains why anti-inflammatory treatments have limited long-term benefit 6, 4
• Most patients have prolonged symptoms before presentation, by which time acute inflammation has subsided and been replaced by collagen fiber degeneration 2

Common Pitfalls to Avoid

• Do not use multiple corticosteroid injections as they may weaken tendon structure despite providing short-term symptom relief 1
• Do not proceed to surgery without an adequate conservative trial of at least 3-6 months 2, 1
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 2
• Avoid combining naproxen with aspirin as this increases naproxen excretion rates and may result in higher frequency of adverse events 3