What is the treatment for tennis elbow?

Treatment of Tennis Elbow (Lateral Epicondylitis)

Start with conservative management including relative rest, eccentric strengthening exercises, ice application, and NSAIDs, as this approach successfully resolves symptoms in 80-90% of cases without the risks associated with corticosteroid injections or surgery. 1, 2

First-Line Conservative Treatment (0-12 weeks)

Activity Modification and Rest

• Relative rest is essential—avoid complete immobilization which causes muscle atrophy, but stop activities that aggravate symptoms while continuing pain-free activities 1
• Modify repetitive wrist extension activities that perpetuate the tendon damage 3

Pain Control

• Apply ice for 10-minute periods through a wet towel for effective short-term pain relief in the acute phase 1
• NSAIDs (oral or topical) effectively relieve pain, though they don't alter long-term outcomes 1
• Topical NSAIDs reduce pain while avoiding gastrointestinal side effects of oral formulations 1

Rehabilitation Exercises

• Eccentric strengthening exercises promote tendon healing by stimulating collagen production and guiding proper alignment of newly formed collagen fibers 1
• Stretching exercises for wrist extensors are widely accepted and beneficial 1
• Tensile loading of the tendon is crucial for proper healing 1

Bracing

• Tennis elbow bands (counterforce bracing) help unload and protect the tendon during activity 1
• These are safe adjuncts though definitive evidence for effectiveness is limited 3

Second-Line Treatments (If Conservative Fails After 4-8 Weeks)

Corticosteroid Injections - Use With Caution

• Corticosteroid injections provide short-term pain relief and may be more effective than NSAIDs in the acute phase, but do not alter long-term outcomes 4, 1
• Critical caveat: Corticosteroids may inhibit healing, reduce tendon tensile strength, and predispose to spontaneous rupture 3, 1
• Limit to no more than 2 injections 5
• Avoid injecting directly into tendon substance—peritendinous injection is safer 3

Additional Physical Therapy Modalities

• Deep transverse friction massage can reduce pain 4, 1
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 3, 1
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 3, 1

Surgical Management (For Refractory Cases)

Indications

• Reserve surgery only for patients with persistent pain despite 6-12 months of well-managed conservative treatment 1
• Approximately 10-20% of cases require surgical intervention 2

Surgical Techniques

• Both open and arthroscopic methods are acceptable with excellent results 6
• Procedures typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 3, 1
• Arthroscopic debridement is a good option but not superior to open or percutaneous techniques 2

Treatment Algorithm Summary

Weeks 0-4: Rest, activity modification, ice, NSAIDs, and counterforce bracing 1

Weeks 2-8: Add progressive eccentric strengthening and stretching exercises 1

Weeks 8-12: If symptoms persist, consider corticosteroid injection (maximum 2) or other second-line modalities like ESWT 4, 1

Beyond 6-12 months: Surgical consultation for refractory cases 1

Critical Pitfalls to Avoid

• Never rely heavily on corticosteroid injections—they may weaken tendons and cause rupture 3, 1
• Avoid complete immobilization—it leads to muscle atrophy and deconditioning 1
• Don't rush to surgery—tennis elbow is largely self-limiting and 80-90% resolve with conservative care 5, 2
• Remember the Hippocratic principle: first do no harm—start simple and conservative before progressing to invasive therapies 5