Treatment of Lateral Epicondylitis
Begin with relative rest, activity modification, and eccentric strengthening exercises as first-line treatment, as approximately 80% of patients recover completely within 3-6 months with conservative management alone. 1, 2
Initial Conservative Management (First-Line)
The foundation of treatment consists of:
- Relative rest and activity modification to reduce repetitive strain on the damaged extensor carpi radialis brevis tendon, avoiding movements that involve wrist extension, radial deviation, and forearm supination 1, 2
- Eccentric strengthening exercises are essential as they promote tendon healing and increase strength—these should be initiated early 1, 2
- Cryotherapy (ice application) for 10-minute periods provides acute pain relief 1, 2
- Counterforce bracing (tennis elbow brace) reduces tension on the tendon origin and may improve function during daily activities 1, 2
- Progressive stretching exercises for wrist extensors should be incorporated 1
Pharmacologic Management
- NSAIDs provide short-term pain relief (days to weeks) but do not affect long-term outcomes or healing, so use them judiciously for symptomatic relief only 1, 2
- Corticosteroid injections are more effective than NSAIDs in the acute phase for short-term relief but similarly do not change long-term outcomes—reserve these for patients requiring rapid symptom control 2
Important caveat: While injections have historically been popular with high initial success rates 3, recent evidence shows they carry higher adverse effects compared to physical therapy and electrophysiotherapy 4, and the 2021 meta-analysis found injections did not improve any outcome measures compared to placebo 4.
Advanced Physical Therapy Interventions
When initial conservative measures are insufficient:
- Manual joint mobilization combined with exercise therapy is more effective than exercise alone and should be prioritized 1, 2
- Deep transverse friction massage can reduce pain 1, 2
- Electrophysiotherapy (including ultrasound, electrical stimulation) improves pain scores (mean difference -10.0), Patient-Rated Tennis Elbow Evaluation scores (mean difference -10.7), and Disabilities of the Arm, Shoulder and Hand scores (mean difference -11.9) compared to placebo 4
- Local heat application (paraffin, warm compresses) before exercise can be beneficial 1
Treatment Algorithm Priority
Prioritize electrophysiotherapy and physical therapy before injections, as the 2021 meta-analysis demonstrated these modalities produce statistically and clinically improved scores in pain and function compared to placebo, while injections put patients at higher risk for adverse effects 4.
Surgical Consideration
- Surgery should not be first-line despite good clinical outcomes, as it carries potential complications and most patients respond well to conservative treatment 1
- Reserve surgical release of the extensor carpi radialis brevis tendon for the small percentage of patients who fail 3-6 months of optimal conservative management 5
Diagnostic Workup Before Treatment
- Plain radiographs are the most appropriate initial imaging to rule out other causes including osteochondral lesions, intra-articular bodies, radiocapitellar arthritis, and occult fractures 1, 2
- MRI or ultrasound should only be considered if radiographs are normal but there is clinical suspicion for tendon degeneration or tear 1, 2