First-Line Treatment for Lateral Epicondylitis
Begin with activity modification, NSAIDs for pain relief, and a structured eccentric strengthening exercise program—this conservative approach provides superior long-term outcomes compared to corticosteroid injections or passive treatments. 1
Initial Conservative Management
The cornerstone of first-line treatment involves three key components that should be implemented simultaneously:
Activity Modification
- Avoid repetitive wrist extension, radial deviation, and forearm supination movements that aggravate the condition 1
- Modify gripping techniques during daily activities to reduce stress on the lateral epicondyle 2
- This is particularly important since the condition affects the dominant arm 75% of the time in adults over 40 years old 3
Pain Control
- Use NSAIDs for acute pain relief as a short-term measure 1, 3
- Apply cryotherapy during the acute phase 3
- These provide symptomatic relief while allowing patients to engage in therapeutic exercises 4
Eccentric Strengthening Exercises
- Implement eccentric strengthening exercises for wrist extensors as the primary therapeutic intervention 1
- Begin these exercises once acute symptoms settle 3
- Perform exercises 4 sessions per week for maximum benefit 3
- Add deep transverse friction massage to reduce pain and improve function 1
- Physical therapy achieves 91% success rates at 52 weeks compared to only 69% for corticosteroid injections 1
What to Avoid Initially
Do not use corticosteroid injections as first-line treatment—reserve these only for persistent symptoms despite 6-12 weeks of conservative management 1. While one older study suggested steroid injections provide quick symptom relief 5, more recent guideline evidence demonstrates that corticosteroids are more effective than NSAIDs only in the acute phase but do not improve long-term outcomes and are inferior to exercise therapy 1. Additionally, corticosteroids may inhibit healing and reduce tensile strength of tissue, predisposing to spontaneous rupture 1.
Diagnostic Imaging Considerations
- Obtain plain radiographs first to exclude fractures, intra-articular bodies, heterotopic ossification, osteochondral lesions, or soft tissue calcification 1
- Look specifically for avulsion fractures at tendon attachment sites and joint effusions 1
- Reserve ultrasound or MRI for cases where radiographs are normal but significant tendon or ligament injury is suspected 1
Clinical Pitfalls
- Avoid relying on bracing alone as evidence supporting its effectiveness is weak, though it remains a safe adjunct to active therapies 1
- Do not use extracorporeal shock wave therapy (ESWT) as first-line treatment—evidence demonstrates limited benefit overall and it should be reserved for refractory cases 1
- Recognize that lateral epicondylitis is a self-limiting condition over several years, but proper treatment accelerates recovery 6, 7
When to Escalate Treatment
If symptoms persist despite 6-12 weeks of well-managed conservative treatment, consider: