What is the recommended management for a patient with tennis elbow?

Tennis Elbow Management

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

Initial Phase (0-4 Weeks): Pain Control and Protection

Activity Modification

• Avoid activities that worsen pain while continuing those that don't aggravate symptoms 1, 2
• Specifically avoid repetitive wrist extension, forceful gripping with simultaneous wrist extension, and activities like shaking hands or opening doors that stress the lateral epicondyle 2
• Never completely immobilize the elbow, as this leads to muscle atrophy and deconditioning 1, 2

Pain Management

• Topical NSAIDs are preferred in elderly patients to provide effective pain relief while avoiding gastrointestinal risks 2
• Oral NSAIDs effectively relieve pain, though they may not affect long-term outcomes 1
• Apply cryotherapy for 10-minute periods through a wet towel for effective short-term pain relief 1, 2

Bracing

• Use counterforce bracing (tennis elbow bands) to reinforce, unload, and protect tendons during activity 1, 3

Rehabilitation Phase (2-8 Weeks): Restore Function

Exercise Program

• Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength through tensile loading that stimulates collagen production and guides normal alignment of newly formed collagen fibers 1, 2
• Incorporate stretching exercises for the wrist extensors, which are widely accepted as beneficial 1, 2
• Continue bracing as needed during this phase 1

Second-Line Treatments for Persistent Symptoms

Corticosteroid Injections

• Locally injected corticosteroids may be more effective than NSAIDs for relief in the acute phase 1
• Use with extreme caution: corticosteroids do not alter long-term outcomes and may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1
• Limit to no more than 2 injections 4

Alternative Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1, 3
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 1
• Deep transverse friction massage (Cyriax technique) can reduce pain 1, 5

Imaging When Indicated

• 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, 2
• Advanced imaging (MRI) is reserved for cases where radiographs are normal or nonspecific and intra-articular pathology is suspected 6, 2

Surgical Management for Refractory Cases

• Surgical evaluation is warranted only if pain persists despite 6-12 months of well-managed conservative treatment 1, 2
• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1, 2

Critical Pitfalls to Avoid

• Overreliance on corticosteroid injections leads to tendon weakening and potential rupture—limit to 2 injections maximum 1, 4
• Complete immobilization causes muscle atrophy and deconditioning—maintain pain-free activities 1, 2
• Progressing to invasive therapies before adequate conservative management (minimum 6-12 months) 1, 2
• Tennis elbow is largely self-limiting; the prime aim should be "first do no harm" 4