Treatment

Lateral epicondylitis is usually a self limiting condition with a typical episode lasting on average about six months to two years (but most (89%) recover within one year) (1). General treatment guidance include (1):

Non operative procedures:

• rest, application of ice
  • the treatment of tennis elbow primarily involves rest
  • the activity that precipitates pain must be avoided so to allow the lesion to heal
• NSAID’s
  • both topical and oral NSAID’s provides short term pain relief, topical preparation may be associated with fewer side effects
• physical therapy
  • stretching and strengthening exercise - specially eccentric (lengthening only) exercises
  • ultrasound therapy - provides modest pain reduction over one to three month (1)
• corticosteroid injections
  • while corticosteroid injections have been shown to improve short-term pain relief (4 to 6 weeks) compared with both placebo and bracing, there is evidence that the long-term outcome following corticosteroid injection for treatment of tennis elbow may be worse than no treatment or physiotherapy alone. (2)
  • hydrocortisone acetate mixed with local anaesthetic may be used, and long acting steroids should be avoided as there is a risk of skin atrophy
  • repeated corticosteroid injections should be avoided (2)
  • care must be taken to avoid both the nerve medially (paralysis) and subcuticular adipose tissue (necrosis) (3)
    
    
• orthotic devices
  • an inelastic, non-articular, proximal forearm strap for lateral epicondylitis may be used. Short-term use of this bracing technique for up to 12 weeks after injury has been shown to be beneficial (4)
• extracorporeal shock wave therapy (ESWT)
  • although one meta-analysis found this was more effective than ultrasound therapy (5) this has not been shown to be effective for treating tennis elbow specifically although it is effective in treating other tendinopathies (6)

Surgery

Systematic reviews have failed to demonstrate the effectiveness of surgical intervention (7) and show no significant differences between arthroscopic and open surgery (such as functional outcomes, failure rate, pain relief) in patients with lateral epicondylitis (8)

• if considered, surgical intervention for lateral epicondylitis should be limited to recalcitrant cases resistant to conservative treatment (1)
• surgical procedures can be broadly grouped into open, percutaneous and arthroscopic options.
• arthroscopic surgery is associated with increased operative time (9)
• post-operative complications are more common following open surgery (8)

Newer treatments

• autologous platelet-rich plasma injections. A sample of the patient's blood is centrifuged and then the heaviest layer of plasma (with a higher concentration of platelets) is injected back into the patient. NICE recommends autologous blood products for the treatment of tendinopathy but their effectiveness remains uncertain (10) and a Cochrane review concluded that autologous blood/platelet-rich plasma injections provide little or no clinically important benefit for pain or function in patients with lateral elbow pain (11)
• hyaluronan gel injection. Efficacy for this has been demonstrated for tennis elbow in clinical trials (12)
• botulinum toxin A injection. Reduced pain following this treatment has been reported in people with lateral epicondylitis, but there is also a high risk of complications, including digital paresis and weakness (13)
  

References

1. Johnson GW, Cadwallader K, Scheffel SB, et al. Treatment of lateral epicondylitis. Am Fam Physician. 2007 Sep 15;76(6):843-8.

2. Gaujoux-Viala C et al. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009 Dec;68(12):1843-9.

3. Coombes BK et al. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20;376(9754):1751-67.

4. Kroslak M, Pirapakaran K, Murrell GAC. Counterforce bracing of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. J Shoulder Elbow Surg. 2019 Feb;28(2):288-295.

5. Yan C et al. A comparative study of the efficacy of ultrasonics and extracorporeal shock wave in the treatment of tennis elbow: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2019 Aug 6;14(1):248

6. Luk JK, Tsang RC et al. Lateral epicondylalgia: midlife crisis of a tendon. Hong Kong Med J. 2014 Apr;20(2):145-51

7. Bateman M, Littlewood C, Rawson B, et al. Surgery for tennis elbow: a systematic review. Shoulder Elbow. 2019 Feb;11(1):35-44.

8. Moradi A, Pasdar P, Mehrad-Majd H, et al. Clinical Outcomes of Open versus Arthroscopic Surgery for Lateral Epicondylitis, Evidence from a Systematic Review. Arch Bone Jt Surg. 2019 Mar;7(2):91-104.

9. Wang W et al. Comparison of arthroscopic debridement and open debridement in the management of lateral epicondylitis: A systematic review and meta-analysis. Medicine (Baltimore). 2019 Nov;98(44)

10. Autologous blood injection for tendinopathy. NICE Interventional procedure guidance, January 2013

11. Karjalainen TV et al. Autologous blood and platelet-rich plasma injection therapy for lateral elbow pain. Cochrane Database Syst Rev. 2021 Sep 30;9

12. Petrella RJ et al. Management of tennis elbow with sodium hyaluronate periarticular injections. Sports Med Arthrosc Rehabilit Ther Technol. 2010 Feb 2;2:4.

13. Lin YC et al. Comparative effectiveness of botulinum toxin versus non-surgical treatments for treating lateral epicondylitis: a systematic review and meta-analysis. Clin Rehabil. 2018 Feb;32(2):131-145.