What are the next steps for a patient with lateral epicondylitis and persistent pain in the forearm and triceps, who has not responded to treatment with a band or brace?

Management of Refractory Lateral Epicondylitis

For a patient with lateral epicondylitis who has failed bracing, initiate a structured eccentric strengthening exercise program combined with activity modification, as this provides superior long-term outcomes compared to passive treatments or injections. 1

Immediate Next Steps

First-Line Conservative Management

• Begin eccentric strengthening exercises for wrist extensors as the cornerstone of treatment, which demonstrates superior long-term outcomes over passive modalities 1
• Add deep transverse friction massage to reduce pain and improve function 1
• Prescribe NSAIDs for acute pain relief, though recognize they provide limited long-term benefit 1, 2
• Strictly avoid activities requiring repetitive wrist extension, radial deviation, and forearm supination 1

Physical Therapy Referral

• Refer to physical therapy for supervised exercise program, as physiotherapy achieves 91% success rates at 52 weeks compared to 69% for corticosteroid injections 3
• Physical therapy should incorporate eccentric strengthening, stretching, and potentially manipulation techniques 4, 5
• Consider augmented soft tissue mobilization (ASTM) as it allows detection of soft tissue texture changes during rehabilitation 6

Second-Line Interventions (After 6-12 Weeks of Failed Conservative Care)

Corticosteroid Injections

• Reserve corticosteroid injections only for persistent symptoms despite 6-12 weeks of conservative management 1
• Understand that while injections show 92% success at 6 weeks, they have high recurrence rates and only 69% success at 52 weeks 3
• Corticosteroids may inhibit healing and reduce tensile strength of tissue, predisposing to spontaneous rupture 4
• Physiotherapy demonstrates significantly better long-term outcomes than injections (91% vs 69% success at 52 weeks) 3

Biologic Injections

• Consider platelet-rich plasma (PRP) or autologous whole-blood injections as they may be superior to steroid injections for long-term management 2
• These biologics show promise but require larger comparative studies for definitive recommendations 2

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT appears safe and may reduce pain through structural and neurochemical alterations 4
• However, evidence demonstrates limited overall benefit, making this a conditional recommendation for refractory cases 1, 2

Diagnostic Imaging Considerations

When to Image

• Order imaging only when clinical tests are inconclusive, symptoms persist despite appropriate treatment, or surgical planning is being considered 7
• Obtain plain radiographs first to exclude fractures, intra-articular bodies, heterotopic ossification, or soft tissue calcification 1

Advanced Imaging

• Use ultrasound as the preferred advanced imaging modality when radiographs are normal but significant tendon pathology is suspected 7
• Ultrasound demonstrates 72.73% overall accuracy for diagnosing common extensor tendon tears 7
• Advanced ultrasound techniques (sonoelastography, superb microvascular imaging) achieve 93.5-96% accuracy 7
• Reserve MRI for surgical planning or when ultrasound is inconclusive 7

Surgical Referral

Indications

• Refer to orthopedic surgery if pain persists despite well-managed conservative treatment trial of at least 6-12 months 4
• Open, arthroscopic, and percutaneous techniques are all highly effective with no method clearly superior 2
• Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work 2
• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 4

Critical Pitfalls to Avoid

• Do not rely on bracing alone as evidence supporting its effectiveness is weak, though it remains a safe adjunct to active therapies 4
• Avoid early corticosteroid injection as it provides inferior long-term outcomes compared to exercise therapy despite short-term pain relief 1, 3
• Do not order CT imaging as it provides no useful information about tendon pathology 7
• Recognize that 70% of cases affect the dominant arm and occur most commonly after age 40, requiring realistic expectations about recovery timeline 1
• Understand that most cases are self-limiting over several years, so aggressive early intervention may not be necessary 2

Pain Extending to Forearm and Triceps

• The described pain pattern extending to the forearm and triceps suggests more extensive involvement than typical lateral epicondylitis 5
• This presentation warrants thorough physical examination to rule out radial tunnel syndrome, posterior interosseous nerve entrapment, or cervical radiculopathy
• Consider imaging to evaluate for alternative diagnoses if the pain distribution is atypical 1