treatment

Last edited 05/2023 and last reviewed 05/2023

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:

Related pages:

steroid injection in tennis elbow

autologous blood injection for tennis elbow