What is the initial approach to treating a patient with lateral epicondylitis?

Initial Approach to Lateral Epicondylitis

Begin with relative rest, activity modification, and eccentric strengthening exercises as the foundation of treatment, since approximately 80% of patients recover completely within 3-6 months with conservative measures alone. 1, 2

Diagnostic Confirmation

• Diagnosis is primarily clinical based on lateral epicondyle pain and pain with resisted wrist extension 1, 2, 3
• Obtain plain radiographs of the elbow as the most appropriate initial imaging study to rule out other causes such as osteochondral lesions, intra-articular bodies, radiocapitellar arthritis, occult fractures, and heterotopic ossification 1, 2
• Reserve MRI or ultrasound only if radiographs are normal but you suspect tendon degeneration, partial/complete tear, or nerve entrapment 1, 2
• Red flags requiring further workup: Night pain or pain at rest suggests inflammatory or neoplastic process; mechanical symptoms like locking suggest intra-articular pathology 2

First-Line Conservative Treatment Algorithm

Immediate Interventions (Start All Simultaneously)

Activity Modification & Rest:

• Reduce repetitive wrist extension, radial deviation, and forearm supination activities that load the damaged extensor carpi radialis brevis tendon 1, 2

Cryotherapy:

• Apply ice for 10-minute periods to provide acute pain relief 1, 2

Oral Analgesia:

• Paracetamol up to 4g/day as first-line oral analgesia 1
• NSAIDs provide short-term pain relief (days to weeks) but do not affect long-term outcomes, so use judiciously 1, 2, 4

Counterforce Bracing:

• Use an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) to reduce tension on the tendon origin and improve function during daily activities 1, 2, 4

Exercise Therapy (Start as Soon as Tolerated)

Eccentric Strengthening Exercises:

• This is the cornerstone of treatment to promote tendon healing and increase strength 1, 2
• Progressive resistance exercises provide modest intermediate-term benefits 4

Stretching Exercises:

• Wrist extensor stretching exercises should be incorporated 1

Manual Therapy:

• Deep transverse friction massage can reduce pain 1
• Manual joint mobilization combined with exercise therapy is more effective than exercise alone 1, 2

Second-Line Options (If No Improvement After 6-8 Weeks)

Corticosteroid Injections:

• More effective than NSAIDs in the acute phase but do not change long-term outcomes 2
• Use judiciously for short-term relief only in patients with significant functional impairment 2, 4

Advanced Physical Therapies:

• Ultrasonography may be beneficial as complementary treatment 1
• Local heat application (paraffin, warm compresses) before exercise 1
• Topical NSAIDs and iontophoresis with NSAIDs provide short-term benefits 4

Surgical Consideration (Refractory Cases After 3-6 Months)

• Surgery should not be first-line despite good clinical outcomes, because most patients respond well to conservative treatment and surgery carries potential complications 1
• Surgical release involves resection of pathologic tissue at the extensor origin with debridement and refixation of healthy tendinous tissue 5
• Consider surgery for patients requiring quick recovery (professional athletes) or those with partial/complete rupture of the extensor origin on imaging 2, 5

Common Pitfalls to Avoid

• Do not rely on corticosteroid injections as primary treatment - they provide only short-term relief without long-term benefit 2, 4
• Do not skip plain radiographs - they are essential to exclude other pathology that would change management 1, 2
• Do not rush to advanced imaging - MRI/ultrasound is only indicated if radiographs are normal and clinical suspicion remains high for tendon tear or nerve entrapment 1, 2
• Avoid extracorporeal shock wave therapy, laser treatment, and electromagnetic field therapy - these do not appear effective 4