What is the recommended treatment for a patient with lateral epicondylitis?

Treatment of Lateral Epicondylitis

Begin with relative rest, activity modification, and eccentric strengthening exercises—this conservative approach resolves symptoms in 80% of patients within 3-6 months and should be the first-line treatment for all patients with lateral epicondylitis. 1, 2

Initial Conservative Management (First-Line Treatment)

Core Treatment Components

• Relative rest and activity modification to reduce repetitive wrist extension and supination that loads the damaged extensor carpi radialis brevis tendon 1, 2
• Eccentric strengthening exercises are the cornerstone of treatment, promoting tendon healing and increasing strength 1, 2
• Progressive stretching exercises for wrist extensors should be incorporated into the rehabilitation program 1, 2

Adjunctive Pain Management

• Cryotherapy (ice application) for 10-minute periods provides acute pain relief 1, 2
• NSAIDs offer short-term pain relief but do not change long-term outcomes—use them for symptomatic relief only 1, 2
• Paracetamol up to 4g/day can be used as first-line oral analgesia 1
• Counterforce bracing (tennis elbow brace) may improve function during daily activities, though evidence is limited 2

Enhanced Physical Therapy Approaches

• Manual joint mobilization combined with exercise therapy is more effective than exercise therapy alone and should be considered when available 1, 2
• Deep transverse friction massage can reduce pain 1, 2
• Ultrasonography and local heat application (paraffin, warm compresses) may be beneficial as complementary treatments, especially before exercise 1

Second-Line Interventions for Persistent Cases

Corticosteroid Injections

• Use corticosteroid injections judiciously for short-term relief only—they are more effective than NSAIDs in the acute phase but do not change long-term outcomes 2
• Reserve injections for patients who have failed initial conservative measures and need temporary relief to participate in physical therapy 2, 3

Other Injection Therapies

• Emerging options include autologous blood, platelet-rich plasma, botulinum toxin, bone marrow aspirate concentrate, and autologous tenocyte injectates for refractory cases 4
• These should be considered investigational and reserved for cases failing standard conservative treatment 4

Surgical Treatment (Reserved for Refractory Cases)

Indications for Surgery

• Persistent debilitating pain for more than 6 months despite comprehensive conservative treatment 5, 4
• Partial or complete rupture of the extensor origin identified on imaging 5

Surgical Approach

• Resection of pathologic tissue at the extensor origin with debridement and refixation of healthy tendinous tissue yields good results 5
• Surgical options include open, percutaneous, and arthroscopic approaches 4, 6

Diagnostic Workup Before Treatment

Clinical Diagnosis

• Pain at the lateral epicondyle with resisted wrist extension is diagnostic 1, 2
• Assess for repetitive occupational or athletic activities involving wrist extension and supination 2, 6

Imaging Studies

• Plain radiographs of the elbow are the most appropriate initial imaging study to rule out other causes of elbow pain (osteochondral lesions, intra-articular bodies, radiocapitellar arthritis) 1, 2
• MRI or ultrasound should be considered only if radiographs are normal and there is clinical suspicion for tendon degeneration or tear 1, 2

Common Pitfalls to Avoid

• Do not rush to corticosteroid injections—while they provide short-term relief, they do not improve long-term outcomes and may delay implementation of effective eccentric exercise programs 2
• Do not skip plain radiographs—they are essential to rule out other pathology before committing to a treatment plan for lateral epicondylitis 1, 2
• Do not consider surgery before 6 months of comprehensive conservative treatment, as most patients recover without operative intervention 5, 4