What is the initial treatment for bilateral epicondylitis?

Initial Treatment for Bilateral Epicondylitis

Begin with relative rest, activity modification, eccentric strengthening exercises, and cryotherapy, as 80-90% of patients recover with conservative management within 3-6 months. 1

Critical First Step: Rule Out Systemic Disease

The presence of bilateral symptomatic tendons should prompt evaluation for rheumatic disease or rheumatologic referral. 1 Bilateral involvement is atypical for mechanical overuse and raises concern for inflammatory arthropathy, seronegative spondyloarthropathy, or other systemic conditions. 1

First-Line Conservative Management

Activity Modification

• Reduce repetitive wrist flexion/extension and forearm pronation/supination activities that load the damaged common flexor or extensor tendons. 1
• Avoid complete immobilization to prevent muscle atrophy—continue activities that do not reproduce pain, as tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers. 1

Eccentric Exercise Program

• Eccentric exercise is the cornerstone of rehabilitation and may reverse degenerative changes in the tendon. 1
• This should be initiated early and forms the foundation of your treatment plan. 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for acute pain relief. 1

NSAIDs

• NSAIDs provide short-term pain relief but do not alter long-term outcomes. 1
• Use for symptomatic relief during the acute phase. 1

Second-Line Interventions (If Conservative Measures Fail After 4-6 Weeks)

Corticosteroid Injections

• Local corticosteroid injections are more effective than oral NSAIDs for acute-phase pain relief but do not change long-term outcomes. 1
• Consider for patients with persistent symptoms despite appropriate conservative therapy. 1, 2

Counterforce Bracing

• Tennis elbow braces can be incorporated into the rehabilitation program. 2

Uncertain Benefit Modalities

• Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis are of uncertain benefit. 1
• Dry needling shows promise in recent studies but requires further validation. 3

Surgical Consideration

• Surgery should only be considered after failure of 6-12 months of appropriate conservative treatment. 1, 2
• Surgical intervention involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin to the epicondyle. 2

Common Pitfalls to Avoid

• Do not overlook bilateral presentation—this is your red flag for systemic disease requiring rheumatologic workup. 1
• Do not immobilize completely—controlled loading through eccentric exercises is therapeutic, not harmful. 1
• Do not rely solely on injections—they provide short-term relief but must be combined with rehabilitation for lasting benefit. 1
• Do not rush to surgery—the natural history favors conservative management in the vast majority of cases. 1, 2