What is the best approach for managing refractory tendinitis of the elbow in an adult patient with a history of overuse or repetitive strain injuries?

Management of Refractory Elbow Tendinitis

For refractory elbow tendinitis that has failed initial conservative treatment, you should intensify rehabilitation with eccentric strengthening exercises while considering corticosteroid injection for short-term relief, and refer for surgical evaluation if symptoms persist beyond 6-12 months of well-managed conservative therapy. 1

Initial Assessment of "Refractory" Status

Before escalating treatment, confirm the patient has completed an adequate trial of first-line conservative management:

• Minimum 3-6 months of properly executed conservative treatment is required before considering a case truly refractory 2, 1
• Verify the patient has performed eccentric strengthening exercises correctly, as these are highly effective and can reverse degenerative tendon changes 2, 1
• Ensure relative rest (not complete immobilization) has been maintained, as complete immobilization causes muscle atrophy and worsens outcomes 1, 3

Escalation Strategy for Refractory Cases

Phase 1: Optimize Conservative Management (Months 3-6)

• Intensify eccentric strengthening exercises under supervised physical therapy, as these promote tendon healing and increase collagen production with proper fiber alignment 1
• Add counterforce bracing (tennis elbow band) to reinforce and unload the tendon during activities 1
• Continue topical NSAIDs for pain control without gastrointestinal risks 1, 3
• Apply cryotherapy for 10-minute periods through a wet towel for acute pain flares 1, 3

Phase 2: Second-Line Interventions (Months 4-8)

• Consider corticosteroid injection for short-term pain relief, particularly if pain is limiting rehabilitation participation 1, 3
• Critical caveat: Corticosteroids provide acute phase relief but do not improve long-term outcomes and may inhibit healing, reduce tendon tensile strength, and predispose to spontaneous rupture 1, 3
• Use corticosteroids sparingly and avoid repeated injections 1
• Alternative modalities with emerging evidence include extracorporeal shock wave therapy (ESWT), which appears safe and effective but requires further research 1, 3
• Deep transverse friction massage may reduce pain 1

Phase 3: Surgical Referral (After 6-12 Months)

• Refer for surgical evaluation if pain persists despite 6-12 months of well-managed conservative treatment 1, 4
• Surgery typically involves excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1
• Surgical intervention is required in less than 10% of cases and has a 3-6 month recovery period 5
• The natural history shows lateral epicondylitis is generally self-limiting over 12-18 months, though some cases remain persistent 6

Critical Pitfalls to Avoid

• Do not over-rely on corticosteroid injections, as this leads to tendon weakening and potential rupture 1
• Never prescribe complete immobilization, which causes muscle atrophy and deconditioning 1, 3
• Do not proceed to surgery prematurely—approximately 80% of tendinopathy patients recover completely with conservative management within 3-6 months 2
• Ensure underlying biomechanical issues are addressed to prevent recurrence 2

Evidence Quality Note

The strongest guideline evidence consistently supports eccentric exercises as the cornerstone of treatment 2, 1, with surgery reserved only after documented failure of 6-12 months of proper conservative care 1, 4. While older research from 2007 suggests watchful waiting is reasonable 7, more recent guidelines emphasize active rehabilitation over passive observation 1.