What are the management options for a patient with tennis elbow?

Tennis Elbow Management

Start with activity modification, topical or oral NSAIDs, ice application, and counterforce bracing, then progress to eccentric strengthening exercises beginning at 2 weeks—this conservative approach resolves approximately 80% of cases without surgery. 1, 2, 3

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

Activity Modification

• Avoid 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 worsen pain while modifying those that aggravate symptoms 1, 2
• Never completely immobilize the elbow—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 1, 2
• Oral NSAIDs effectively relieve pain, though they don't affect long-term outcomes 1, 2
• 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, 2

Imaging (If Structural Pathology Suspected)

• Plain radiographs of the elbow are the initial imaging study to rule out intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fracture, or osteoarthritis 4, 1

Rehabilitation Phase (2-8 Weeks): Restore Function

Exercise Program

• Eccentric strengthening exercises are the cornerstone of rehabilitation—they promote tendon healing and increase 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 1, 2
• Continue bracing as needed during this phase 1, 2

Second-Line Treatments for Persistent Symptoms

Corticosteroid Injections

• Use with extreme caution: locally injected corticosteroids may be more effective than NSAIDs for acute phase relief, but they don't alter long-term outcomes and may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1, 2
• Limit to no more than 2 injections 5

Alternative Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1, 2
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 1, 2, 3
• Deep transverse friction massage (Cyriax technique) can reduce pain 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, 3

• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1, 2
• Arthroscopic release with debridement is a good surgical option but is not superior to open or percutaneous techniques 3
• Management for refractory cases may also be indicated for collateral ligament injury, biceps injury, cubital tunnel syndrome, or osteochondral abnormalities 4

Critical Pitfalls to Avoid

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 1, 2
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 1, 2
• Progressing to surgery before completing 6-12 months of conservative treatment 1, 2