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 (2):

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 (8)
• corticosteroid injections
  • has very good results in short term use (six weeks) but the benefits do not persist beyond six weeks (6)
  • hydrocortisone acetate mixed with local anaesthetic may be used, and of note long acting steroids should be avoided as there is a risk of skin atrophy
  • long term effectiveness when compared to other conservative methods are uncertain and recurrences are more common with long term use
  • repeating and repeated corticosteroid injections
    • has been reported that repeated injections (average 4.3, range 3 to 6 over 18 months) were associated with poorer outcomes - the suggestion is that steroid injections are more effective in acute and subacute tendonitis (duration <12 weeks) (10)
    • if considering repeating corticosteroid injections then "..injections may be repeated 2-3 times at the same site at 3-6 month intervals, if the previous response was positive (11)
  • side effects (12)
    • are usually minor and tend to resolve within six months of starting treatment
    • include persistent pain after injection, loss of skin pigment (5%), and tissue atrophy at injection site (4%)
    • administration of steroids can also induce hyperglycaemia, particularly in patients with diabetes mellitus
      
      
• orthotic devices
  • although commonly used, there is insufficient evidence regarding the effectiveness of orthotic devices
• extracorporeal shock wave therapy (ESWT)
  • except for rare occasions with ectopic calcification in the tendon, randomised trials have not found any benefit of ESWT in regular cases of tennis elbow (6)

Surgery

• useful in resistant cases to conservative treatment
• surgery is still an unproven treatment modality for tennis elbow due to lack of high quality evidence to either support or discourage its use (7)
• should be considered after 1 year of conservative therapy since the condition resolves in around 12 months in most patients (6)
• less than 10% of people undergo surgery (7)
• surgical procedures can be broadly grouped into open, percutaneous and arthroscopic
• majority procedures involves exposure of the extensor carpi radialis brevis tendon and excision of any fibrous mass which is present or release the tendon altogether (8)

Newer treatments

• autologous platelet-rich plasma injections
  • recent high quality randomised controlled trials have shown superior cure rates and pain scores for platelet-rich-plasma (PRP) injections up to two years after treatment when compared to cortisone injections
• hyaluronan gel injection
• topical glyceryl trinitrate patches
  • when applied over the painful area, it improves outcomes in the first six months compared to placebo
• botulinum toxin A injection

Notes:

• a study compared the efficacy of wait and see policy, physiotherapy or corticosteroid injections (3)
  • concluded that physiotherapy or a wait and see policy were the best long term treatment options
  • a subsequent study comparing these treatment options concluded that (4):
    • corticosteroid injection was the most effective strategy in the short term, but symptoms often recurred and long term relief was poorer than with physiotherapy or wait and see
    • physiotherapy provided faster relief from pain than wait and see, but long term results were similar
      
      
• a systematic review and metaanalysis of randomised controlled trials (RCTs) examining the effectiveness and safety of novel treatments for tennis elbow as compared with steroid injections (9)
  • data from 10 RCTs confirmed the lack of effectiveness of steroid injections after 8 weeks
  • data from 4 trials of botulinum toxin showed marginal effectiveness but this was accompanied by temporary weakness of finger extension
  • autologous blood (3 RCTs) and platelet-rich plasma (2 RCTs) were, statistically, more effective than placebo
  • other injections with 1 RCT each were prolotherapy, hyaluronan, glycoaminoglycan and polidocanol
  • in all, 17 RCTs were included in the study
  • only 4 were found to have a low risk of bias. Of these only one (prolotherapy) showed evidence of effectiveness compared with placebo
    

Reference:

• (1) Smidt N, van der Windt DA. Tennis elbow in primary care. BMJ. 2006;333(7575):927-8.
• (2) BMJ (1999); (215): 964-8.
• (3) Smidt N et al. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet (2002); 359: 657-62.
• (4) Bisset L et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. 2006 Nov 4;333(7575):939.
• (5) Paolini JA et al. Topical nitric oxide application in the treatment of chronic extensor tendinosis at the elbow: a randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med 2003;31:915-20.
• (6) Orchard J, Kountouris A. The management of tennis elbow. BMJ. 2011;342:d2687
• (7) Buchbinder R et al. Surgery for lateral elbow pain. Cochrane Database Syst Rev. 2011;(3):CD003525.
• (8) Johnson GW et al. Treatment of lateral epicondylitis. Am Fam Physician. 2007;76(6):843-8.
• (9) Krogh TP, Bartels EM, Ellingsen T et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network metaanalysis of randomized controlled trials. Am J Sports Med 2012 Sep 12.
• (10) Chesterton LS et a. Management of Tennis Elbow. Open Access J Sports Med. 2011; 2: 53-59.
• (11) UK NHS Clinical Knowledge Summaries http://www.cks.nhs.uk/tennis_elbow (accessed May 15th 2023)
• (12) Karbowiak M, Holme T, Thambyrajah J, Di Mascio L. Management of lateral epicondylitis (tennis elbow) BMJ 2023; 381 :e072574 doi:10.1136/bmj-2022-072574