What is the best treatment approach for a patient with tennis elbow?

Treatment of Tennis Elbow (Lateral Epicondylitis)

Begin with conservative management consisting of activity modification, eccentric strengthening exercises, cryotherapy, and NSAIDs—this approach is effective for the vast majority of patients, and surgery should be reconsidered as tennis elbow is self-limiting with a 50% probability of recovery every 3-4 months regardless of symptom duration. 1, 2, 3

Initial Assessment and Imaging

• Obtain plain radiographs of the elbow as the initial imaging study to rule out intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fracture, or osteoarthritis 4, 1
• MRI is reserved for cases where radiographs are normal or nonspecific and there is suspicion of tendon tear or other soft tissue pathology 5
• Diagnosis is primarily clinical: look for pain at the lateral epicondyle and pain with resisted wrist extension 5

Phase 1: Initial Management (0-4 Weeks) - Pain Control and Protection

The goal is pain relief while avoiding complete immobilization, which causes muscle atrophy and deconditioning. 1, 2

Activity Modification

• Avoid activities that worsen pain, specifically repetitive wrist extension, forceful gripping with simultaneous wrist extension, and activities like shaking hands or opening doors that stress the lateral epicondyle 1
• Continue activities that don't aggravate symptoms—relative rest, not complete rest 4, 2
• Never completely immobilize the elbow 1

Pain Management

• Apply cryotherapy for 10-minute periods through a wet towel for effective short-term pain relief 1, 2
• Use oral NSAIDs for effective pain relief, though they do not affect long-term outcomes 4, 1, 2
• Prefer topical NSAIDs in elderly patients to provide effective pain relief while avoiding gastrointestinal risks 1, 2

Bracing

• Use counterforce bracing (tennis elbow bands) to reinforce, unload, and protect tendons during activity 4, 1, 2

Phase 2: Rehabilitation (2-8 Weeks) - Restore Function

Eccentric strengthening exercises are the cornerstone of rehabilitation and should begin once acute pain subsides. 1, 2

Exercise Program

• Eccentric strengthening exercises are the primary treatment modality—they promote tendon healing and increase strength through tensile loading that stimulates collagen production and guides normal alignment of newly formed collagen fibers 4, 1, 2
• Incorporate stretching exercises for the wrist extensors 1, 2
• Progress to isometric and isotonic exercises as tolerated 6
• Continue bracing as needed during this phase 1

Adjunctive Physical Therapy

• Deep transverse friction massage can reduce pain 5, 2
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 4, 1, 2

Phase 3: Second-Line Treatments for Persistent Symptoms (After 4-8 Weeks)

Corticosteroid Injections - Use With Extreme Caution

• Locally injected corticosteroids may be more effective than NSAIDs for relief in the acute phase, but use with extreme caution 1, 2
• They do not alter long-term outcomes and may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 4, 1, 2
• Limit to no more than 2 injections 7
• This represents a critical pitfall: overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 2

Alternative Modalities

• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 4, 1, 2
• Iontophoresis and phonophoresis are widely used but lack well-designed RCTs to permit reliable recommendations 4

Surgical Management - Reconsider the Indications

Recent evidence challenges the traditional indication for surgery after failed conservative care, as tennis elbow has a 50% probability of recovery every 3-4 months regardless of symptom duration, and there is no evidence that surgery is superior to continued nonoperative care. 3

• If surgery is considered, it should only be after 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 4, 1, 2
• The prognosis of tennis elbow is not influenced by duration of symptoms, which challenges the belief that failed nonoperative care is an indication for surgery 3

Critical Pitfalls to Avoid

• Do not completely immobilize the elbow—this leads to muscle atrophy and deconditioning 1, 2
• Avoid overuse of corticosteroid injections—they may weaken tendons and predispose to rupture 4, 1, 2
• Do not rush to surgery—tennis elbow is largely self-limiting with a benign clinical course 7, 3
• Ensure patients progress through eccentric strengthening exercises, as this is the most evidence-based rehabilitation approach 1, 2