What's the best treatment for lateral epicondylitis (elbow pain on the lateral epicondyle) in an adult, possibly due to tricep movement and repetitive forearm strain?

Treatment of Lateral Epicondylitis

Start with conservative management including rest, activity modification, NSAIDs, and physical therapy with eccentric strengthening exercises, as this condition is typically self-limiting and most patients improve without invasive interventions. 1, 2

Initial Diagnostic Approach

• Obtain plain radiographs of the elbow to exclude fractures, dislocations, heterotopic ossification, or osteoarthritis that may mimic lateral epicondylitis 1, 3, 4
• The diagnosis is primarily clinical, based on lateral elbow pain, pain with wrist extension, and weakened grip strength 5
• Lateral epicondylitis affects the dominant arm 75% of the time and is most common after age 40, with equal incidence in men and women 1

First-Line Conservative Treatment (0-12 weeks)

Activity Modification and Rest

• Avoid repetitive wrist extension, radial deviation, and forearm supination activities that perpetuate the condition 1, 2
• Relative rest and modification of aggravating activities are essential in the initial 0-4 weeks 3

Pain Management

• Use oral or topical NSAIDs for pain control, though they provide limited long-term benefit 1, 3, 2
• Apply ice for 10 minutes through a wet towel for short-term pain relief 3

Physical Therapy

• Implement eccentric strengthening exercises for wrist extensors to reduce pain and promote tendon healing 1, 4
• Deep transverse friction massage can help reduce pain 1, 4
• Supportive forearm bracing may be used, though evidence for orthotics is inconclusive 1, 6

Second-Line Treatment (4-12 weeks if symptoms persist)

Corticosteroid Injections

• Consider corticosteroid injections for persistent symptoms, as they are more effective than NSAIDs in the acute phase 1, 4
• Important caveat: Corticosteroids provide only short-term relief and do not change long-term outcomes 1
• Use with caution due to potential complications including skin atrophy, infection, and tendon weakening 3

Alternative Therapies

• Extracorporeal shock wave therapy (ESWT) has shown mixed results but may be considered 1, 4, 2
• Biologic injections (platelet-rich plasma or autologous whole blood) may be superior to corticosteroids for long-term management 2

Surgical Management (After 6-12 months of failed conservative treatment)

• Reserve surgery only for refractory cases after 6-12 months of appropriate conservative management 3, 2
• Open, arthroscopic, and percutaneous techniques are all highly effective with no clear superiority of one method over another 2
• Arthroscopic and percutaneous approaches may result in faster recovery and earlier return to work 2
• Denervation of the posterior branch of the posterior cutaneous nerve of the forearm is highly efficacious for long-term pain control in refractory cases, with low incidence of sensory deficits 7

Critical Pitfalls to Avoid

• Early intervention is crucial: Longer symptom duration before starting treatment is associated with treatment failure 3
• Do not overrely on corticosteroid injections without addressing underlying biomechanical issues and activity modification 4
• Most cases are self-limiting over several years, so avoid premature surgical intervention 2, 5
• Ensure proper diagnosis, as the underlying collateral ligamentous complex and joint capsule may also be involved 6