Treatment of Refractory Tennis Elbow
For patients with tennis elbow that has not responded to 6-12 months of conservative treatment, surgical evaluation with arthroscopic or open debridement is warranted, as approximately 80% of cases resolve with conservative measures alone and surgery becomes the definitive option for the remaining refractory cases. 1, 2
Defining Refractory Disease
Refractory lateral epicondylitis is defined as persistent pain despite 6-12 months of well-managed conservative treatment including rest, activity modification, eccentric exercises, NSAIDs, and bracing. 1 Only 20% of patients fail to respond to conservative measures and require escalation of therapy. 2
Treatment Algorithm for Refractory Cases
Step 1: Verify Adequate Conservative Trial
Before proceeding to advanced interventions, confirm the patient has completed:
- Eccentric strengthening exercises for at least 8-12 weeks 1, 3
- Activity modification with relative rest (not complete immobilization) 1, 3
- Counterforce bracing during activities 1, 3
- NSAIDs (oral or topical) for pain control 1, 3
- Cryotherapy for acute symptom management 1, 3
Step 2: Second-Line Interventions (Before Surgery)
If conservative measures have truly failed, consider these options:
Corticosteroid Injection:
- More effective than NSAIDs for acute phase relief but does not alter long-term outcomes 1, 3
- Critical caveat: Use with caution as corticosteroids may inhibit healing, reduce tendon tensile strength, and predispose to spontaneous rupture 4, 1
- Limit to maximum 2 injections—no advantage and considerable disadvantage beyond this 5
Autologous Blood Injection:
- Emerging as an acceptable modality for refractory cases 6
- One study showed sustained improvement at 3-9 year follow-up with mean pain scores dropping from 3.3 to 1.1 6
- Should be considered before surgery as it is cheap, available, and easy 6
Extracorporeal Shock Wave Therapy (ESWT):
- Appears safe and effective but evidence shows mixed benefit 4, 1
- Requires further research to clarify optimal treatment strategies 4, 1
Deep Transverse Friction Massage:
Therapeutic Ultrasound:
- May decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 4, 1
Step 3: Surgical Management
When to refer for surgery:
- Pain persisting despite 6-12 months of well-managed conservative treatment 1, 3
- Significant functional impairment affecting daily activities or work 1
Surgical techniques:
- Arthroscopic debridement with release is a good option and not superior to open or percutaneous techniques 2
- Procedures typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 4, 1
- Recent research shows reduction in MRI signal intensity correlates with pain reduction and functional improvement post-arthroscopy 2
Step 4: Novel Pharmacologic Option
Duloxetine:
- Case reports demonstrate substantial improvement within 4-6 weeks at 60 mg/day in patients who failed conventional medical, physiotherapeutic, and surgical management 7
- Patients were pain-free at 6-month follow-up 7
- Consider this option for truly refractory cases, particularly those with chronic pain syndrome features 7
Critical Pitfalls to Avoid
Overuse of corticosteroid injections: More than 2 injections provides no additional benefit and significantly increases risk of tendon weakening and rupture. 4, 1, 5
Complete immobilization: Avoid this as it leads to muscle atrophy and deconditioning—relative rest means absence of painful activity, not complete cessation of movement. 1, 5
Premature surgical referral: Ensure a full 6-12 month trial of conservative therapy has been completed, as 80% of cases resolve without surgery. 1, 2
Ignoring the self-limiting nature: Tennis elbow has peak incidence between ages 40-50, and 90% of patients have no further recurrence after resolution, so aggressive intervention should be carefully considered. 5