What is the recommended treatment for lateral epicondylitis (tennis elbow)?

Treatment of Tennis Elbow (Lateral Epicondylitis)

Start with 3-6 months of conservative management including relative rest, ice therapy, NSAIDs, and eccentric strengthening exercises before considering any invasive interventions. 1

First-Line Conservative Treatment (0-6 months)

Activity Modification and Rest

• Implement relative rest by avoiding activities that worsen pain while maintaining some activity to prevent muscle atrophy and deconditioning. 1
• Modify technique for athletes and manual laborers to minimize repetitive stresses on the extensor tendons. 1
• Complete immobilization should be avoided as it leads to muscle atrophy. 1

Pain Control and Anti-Inflammatory Measures

• Use topical NSAIDs as the preferred option over oral NSAIDs because they eliminate the risk of gastrointestinal hemorrhage while providing effective acute pain relief. 1
• Apply ice therapy through a wet towel for 10-minute periods to provide short-term pain relief, reduce swelling, and blunt inflammatory response. 1
• Oral NSAIDs (such as diflunisal or naproxen) are effective alternatives if topical preparations are insufficient. 2

Exercise Rehabilitation

• Prescribe eccentric strengthening exercises as the cornerstone of rehabilitation because they stimulate collagen production and guide normal alignment of newly formed collagen fibers. 1
• Include stretching exercises, which are widely accepted and generally helpful for tendon rehabilitation. 1
• Progress to sport or activity-specific exercises once pain improves. 1

Adjunctive Physical Therapy Modalities

• Deep transverse friction massage can be incorporated to reduce pain when combined with eccentric exercises. 1
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak. 1

Second-Line Interventions (If Conservative Treatment Insufficient)

Orthotics and Bracing

• Tennis elbow bands (counterforce bracing) can help reinforce, unload, and protect tendons during activity, although limited data supports their effectiveness. 1

Corticosteroid Injections

• Use corticosteroid injections cautiously and only for acute phase relief, as they are more effective than NSAIDs short-term but do not alter long-term outcomes. 3, 1
• Limit to a maximum of 2 injections because corticosteroids may inhibit healing, reduce tensile strength of tissue, and potentially predispose to rupture. 1
• Avoid direct injection into the tendon substance due to rupture risk. 1

Emerging Therapies

• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research, with studies showing mixed benefit for lateral elbow pain. 3, 1

Surgical Management

Indications for Surgery

• Refer to an orthopedic surgeon for surgical evaluation if pain persists despite 3-6 months of well-managed conservative treatment. 3, 1

Surgical Technique

• Surgical procedures typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 3, 1
• Common surgical approaches include percutaneous, arthroscopic, or open techniques. 4

Important Clinical Considerations

Prognosis

• Approximately 80% of patients with lateral epicondylitis fully recover within 3-6 months with appropriate conservative treatment. 1
• Tennis elbow is largely a self-limiting condition. 5

Epidemiology and Risk Factors

• Lateral epicondylosis is 7-10 times more common than medial epicondylosis and involves the dominant arm 75% of the time. 3, 1
• The condition affects men and women equally and is most common after 40 years of age. 3
• Activities requiring repetitive wrist extension and supination contribute to development. 3, 4

Common Pitfalls to Avoid

• Do not use more than 2 corticosteroid injections, as there is no advantage and considerable disadvantage to additional injections. 5
• Avoid complete immobilization, which causes muscle atrophy and deconditioning. 1
• Do not rush to surgery without an adequate trial of conservative management (minimum 3-6 months). 1
• Ensure proper diagnosis through physical examination showing well-localized tenderness that reproduces the pain experienced during activity. 1