What is the recommended management for an elderly female patient with tennis elbow (lateral epicondylitis)?

Management of Tennis Elbow in an Elderly Female

Begin with conservative management consisting of relative rest with activity modification, cryotherapy, NSAIDs (preferably topical to avoid GI risks in elderly patients), and a counterforce brace, followed by progressive eccentric strengthening exercises starting at 2-4 weeks. 1

Initial Phase (0-4 Weeks)

Activity Modification and Rest

• Relative rest is essential – the patient should avoid activities that worsen pain (such as gripping, wrist extension against resistance, or twisting motions) while continuing activities that don't aggravate symptoms 1
• Complete immobilization must be avoided as it leads to muscle atrophy and deconditioning 1
• Specific movements to avoid include repetitive wrist extension, forceful gripping with simultaneous wrist extension, and activities like shaking hands or opening doors that stress the lateral epicondyle 2

Pain Management

• Topical NSAIDs are preferred in elderly patients to provide effective pain relief while avoiding gastrointestinal risks associated with oral NSAIDs 1
• Cryotherapy applied for 10-minute periods through a wet towel provides effective short-term pain relief 1, 3
• Oral NSAIDs can be used if topical agents are insufficient, though they may not affect long-term outcomes 1

Bracing

• A counterforce brace (tennis elbow band) should be applied to reinforce, unload, and protect the tendon during necessary activities 1, 4

Rehabilitation Phase (2-8 Weeks)

Exercise Program

• Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength through tensile loading that stimulates collagen production 1
• Stretching exercises for the wrist extensors should be incorporated and are widely accepted as beneficial 1
• These exercises guide normal alignment of newly formed collagen fibers 1

Continued Support

• Continue bracing as needed during activities 1
• Progress exercises gradually based on pain tolerance 1

Second-Line Treatments (If Initial Management Fails)

Corticosteroid Injections

• Use with significant caution in elderly patients – locally injected corticosteroids may be more effective than NSAIDs for acute phase relief but do not alter long-term outcomes 1
• Critical warning: Corticosteroids may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1
• Limit to no more than 2 injections maximum 3

Alternative Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 1
• Deep transverse friction massage (Cyriax technique) can reduce pain and may be beneficial when combined with conventional therapy 1, 5

Imaging Considerations

• Plain radiographs of the elbow are the initial imaging study if structural pathology is suspected, to rule out intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fracture, or osteoarthritis 6
• Advanced imaging (MRI) is reserved for cases where radiographs are normal or nonspecific and intra-articular pathology is suspected 6

Surgical Referral

• Surgical evaluation is warranted only if pain persists despite 6-12 months of well-managed conservative treatment 1
• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1

Critical Pitfalls to Avoid in Elderly Patients

• Never overrely on corticosteroid injections – this is particularly dangerous in elderly patients with potentially compromised tendon integrity 1
• Avoid complete immobilization – elderly patients are especially vulnerable to rapid muscle atrophy and deconditioning 1
• Consider polypharmacy – topical NSAIDs are safer than oral in elderly patients who may be on multiple medications 1
• Tennis elbow is largely self-limiting, and the prime aim should be "first do no harm" – start simple and conservative before progressing to invasive therapies 3