What is the treatment for lateral epicondylitis?

Treatment for Lateral Epicondylitis

Conservative treatment with eccentric strengthening exercises and activity modification is the first-line approach for lateral epicondylitis, with approximately 80% of patients recovering completely within 3-6 months. 1

Initial Conservative Management (First-Line Treatment)

The following interventions should be implemented as primary therapy:

Activity Modification and Rest

• Relative rest with modification of repetitive wrist extension and supination activities is essential 1, 2
• Avoid movements requiring sustained wrist extension with the elbow straight, such as forceful gripping, computer mouse use, and activities involving repetitive forearm pronation/supination 3
• This does not mean complete immobilization—controlled loading is preferred 1

Exercise Therapy (Most Important Component)

• Eccentric strengthening exercises of the wrist extensors are the cornerstone of treatment, promoting tendon healing and increasing strength 1, 2, 4
• Progressive strengthening program focused on the extensor muscle groups 1
• Stretching exercises for the wrist extensors should be incorporated 1, 2
• Range of motion exercises to maintain joint mobility 1

Pain Management

• Cryotherapy (ice application) for 10-minute periods provides acute pain relief 1, 2
• NSAIDs offer short-term pain relief but do not affect long-term outcomes 1, 2
• Paracetamol up to 4g/day can be used as first-line oral analgesia based on extrapolation from musculoskeletal guidelines 5

Supportive Devices

• Counterforce braces/orthoses reduce tension on the tendon origin 1, 2
• These should be used during activities that stress the lateral epicondyle 1

Physical Therapy Modalities

When basic conservative measures are insufficient:

• Deep transverse friction massage can reduce pain 1, 2
• Local heat application (paraffin wax, warm compresses) before exercise may be beneficial 1
• Ultrasound therapy may provide complementary benefit 1

Second-Line Interventions

For patients not responding to initial conservative treatment after 6-12 weeks:

Corticosteroid Injections

• Intra-articular or peritendinous corticosteroid injections provide short-term pain relief (especially during acute flares) but do not change long-term outcomes 2
• More effective than NSAIDs in the acute phase 2
• Should be used judiciously given lack of long-term benefit 2

Surgical Treatment

Reserved for therapy-resistant cases after comprehensive conservative treatment failure:

• Surgery is indicated when conservative treatment fails after 3-6 months and in cases of partial or complete rupture of the extensor origin 4, 6
• Resection of pathologic tissue at the extensor origin with debridement and refixation of healthy tendinous tissue yields good results 4
• Surgical approaches include open, arthroscopic, or percutaneous release of the extensor carpi radialis brevis tendon 6, 7
• Only a small percentage of patients require surgery, as most respond to conservative measures 6

Diagnostic Imaging Considerations

• Plain radiographs are the most appropriate initial imaging study to rule out other causes of elbow pain 1, 2
• MRI should be considered if radiographs are normal and there is suspicion of tendon degeneration or tear 1, 2
• Diagnosis remains primarily clinical based on lateral elbow pain and pain with resisted wrist extension 1, 2

Common Pitfalls to Avoid

• Do not rely solely on NSAIDs or corticosteroid injections—these provide only temporary relief without addressing the underlying tendinopathy 1, 2
• Avoid complete rest or immobilization—controlled loading through eccentric exercises is therapeutic 1
• Do not rush to surgery—80% of patients recover with conservative treatment within 3-6 months 1
• Ensure proper technique with eccentric exercises, as this is the most evidence-based conservative intervention 1, 4