Conservative Management of Tennis Elbow

Initial Phase (0-4 Weeks): Pain Control and Protection

The American College of Radiology recommends plain radiographs of the elbow as the initial imaging study if structural pathology is suspected, to rule out intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fracture, or osteoarthritis 3, 2
Avoid activities that worsen pain while continuing those that don't aggravate symptoms, and specifically avoid repetitive wrist extension, forceful gripping with simultaneous wrist extension, and activities like shaking hands or opening doors that stress the lateral epicondyle 1, 2
Never completely immobilize the elbow, as this leads to muscle atrophy and deconditioning 1, 2
Topical NSAIDs are preferred in elderly patients to provide effective pain relief while avoiding gastrointestinal risks 2
Oral NSAIDs effectively relieve pain, though they may not affect long-term outcomes 1
Apply cryotherapy for 10-minute periods through a wet towel for effective short-term pain relief 1, 2
Use counterforce bracing (tennis elbow bands) to reinforce, unload, and protect tendons during activity 1

Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength through tensile loading that stimulates collagen production and guides normal alignment of newly formed collagen fibers 1, 2
Incorporate stretching exercises for the wrist extensors, which are widely accepted as beneficial 1, 2
Continue bracing as needed during this phase 1

Locally injected corticosteroids may be more effective than NSAIDs for relief in the acute phase, but use with extreme caution: corticosteroids do not alter long-term outcomes and may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 1
Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 1

Surgical evaluation is warranted only if pain persists despite 6-12 months of well-managed conservative treatment 1, 2
Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1, 2