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

Treatment of Tennis Elbow (Lateral Epicondylitis)

Begin with conservative management consisting of relative rest with activity modification, eccentric strengthening exercises, ice application, NSAIDs, and counterforce bracing—this approach should be maintained for at least 6-12 months before considering surgical intervention. 1

First-Line Conservative Treatment (0-4 weeks)

Activity Modification and Rest

• Continue activities that don't worsen pain, but modify or temporarily stop those that aggravate symptoms 1
• Avoid complete immobilization, as this causes muscular atrophy and deconditioning 2, 1
• Relative rest prevents ongoing damage, reduces pain, and promotes tendon healing 2

Pain Control

• Apply ice through a wet towel for 10-minute periods to provide effective short-term pain relief 2, 1
• Use NSAIDs (oral or topical) for pain relief, though they may not affect long-term outcomes 2, 1
• Topical NSAIDs reduce tendon pain while eliminating the gastrointestinal hemorrhage risk associated with oral NSAIDs 2, 1

Bracing

• Apply counterforce bracing (tennis elbow bands) to reinforce, unload, and protect tendons during activity 2, 1
• These devices are safe, widely used, and helpful despite limited definitive data on effectiveness 2

Rehabilitation Phase (2-8 weeks)

Exercise Therapy

• Initiate eccentric strengthening exercises, which are beneficial for promoting tendon healing and increasing strength 1
• Tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers 2
• Perform stretching exercises for the wrist extensors, which are widely accepted and helpful 1
• Continue progressive resistance exercises and eccentric training as tolerated 3

Second-Line Treatments (For Persistent Symptoms After 4-8 Weeks)

Corticosteroid Injections

• Use corticosteroid injections with significant caution, as they may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 2, 1
• Locally injected corticosteroids may be more effective than NSAIDs for acute phase pain relief 2, 1
• However, they do not alter long-term outcomes 2, 1
• Avoid using more than 2 injections, as there is considerable disadvantage beyond this 4

Other Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research on optimal treatment strategies 2, 1
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 2, 1
• Deep transverse friction massage can reduce pain 1

Surgical Management (For Refractory Cases >6-12 Months)

• If pain persists despite 6-12 months of well-managed conservative treatment, refer for surgical evaluation 1
• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 2, 1
• Surgical approaches may be percutaneous, arthroscopic, or open 5

Critical Pitfalls to Avoid

• Never rely on corticosteroid injections as first-line treatment—they may weaken tendons and increase rupture risk 1, 6
• Avoid complete immobilization, which leads to muscle atrophy and deconditioning 2, 1
• Do not rush to surgery—tennis elbow is largely self-limiting, and 90% of patients have no further recurrence after age 50 4
• Start with simple, conservative measures before progressing to more complex and invasive therapies 4