Tennis Elbow Treatment

The vast majority—up to 95%—of tennis elbow cases can be successfully treated without surgery. There are a number of nonsurgical treatment options available, ranging from rest and watchful waiting to prescription medications to physical therapy, among other modalities. Severe and/or recurrent cases of tennis elbow sometimes require surgery.¹Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 4 (1992); 11: 851-70. http://www.ncbi.nlm.nih.gov/pubmed/14560549. Abstract accessed December 30, 2014.^,2Kurppa K et al. Tennis elbow: lateral elbow pain syndrome. Scand J Work Environ & Health 5 (1979); suppl. 3, 15-18.^,3Cyriax JH. The pathology and treatment of tennis elbow. J Bone Joint Surg 18 (1936); 921-940.^,4Brattberg G. Acupuncture therapy for tennis elbow. Pain 16 (1983); 285-288.^,5Mills GP. The treatment of tennis elbow. BMJ 1 (1928); 12-13.

Many aspects of tennis elbow treatment remain controversial among physicians, so treatment recommendations may vary greatly depending on which physician(s) or other medical practitioners patients may choose to consult. Patients are therefore advised to seek second or even third professional opinions if their current practitioner’s treatment recommendations are not providing adequate relief. Some patients may find that treatments from non-physician practitioners, such as sports chiropractors, physical therapists, physiatrists, or athletic trainers can also provide relief.

Nonsurgical treatment options for tennis elbow include, but are not limited to:

Rest and watchful waiting. Sometimes taking a break from the activity(ies) that triggered tennis elbow symptoms is sufficient to alleviate the symptoms.⁶American Academy of Orthopedic Surgeons. Tennis elbow (lateral epicondylitis). September 2009: OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=a00068. Accessed December 30, 2014.

RICE protocol, or the combination of Rest, Ice, Compression, and Elevation is often employed as a first-line treatment for tennis elbow. In addition to rest, cloth-covered ice packs can be applied to the affected area for no more than twenty minutes at a time every two to three hours, two to three times per day. ACE bandages, compression sleeves, or other similar devices can be worn on the affected arm, and the arm can be elevated on a cushion, high table, or other type of platform. This protocol can provide pain relief while also reducing swelling and promoting healing.

See The P.R.I.C.E. Protocol Principles

Non-steroidal anti-inflammatory medications, such as aspirin, ibuprofen (Advil, Motrin, Nuprin), or naproxen (Aleve). These drugs help provide pain relief while also combating acute inflammation of injured tissue(s).

Ice massage (cryotherapy), in which ice is applied with circular pressure directly onto the skin over the affected area. Unlike some other types of ice therapy, ice massage does not place a cloth between the ice and the skin. Patients are advised to limit ice massage/cryotherapy to less than five minutes per session, only once or twice per day to reduce the risk of skin damage.⁷Whaley, AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004); 677-691. doi:10.1016/j.csm.2004.006.004.

Deep-tissue massage, instrument-assisted massage, and/or manual manipulation of the elbow by a licensed massage therapist, physical therapist, chiropractor, or other trained professional can provide pain relief and stimulate blood flow to the damaged tissue(s).⁷Whaley, AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004); 677-691. doi:10.1016/j.csm.2004.006.004.

Use of a counterforce brace and/or a wrist extension brace, which can prevent the forearms or wrist extensor muscles from extending, facilitating rest of the affected tissue(s).¹Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 4 (1992); 11: 851-70. http://www.ncbi.nlm.nih.gov/pubmed/14560549. Abstract accessed December 30, 2014.^,2Kurppa K et al. Tennis elbow: lateral elbow pain syndrome. Scand J Work Environ & Health 5 (1979); suppl. 3, 15-18.^,6American Academy of Orthopedic Surgeons. Tennis elbow (lateral epicondylitis). September 2009: OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=a00068. Accessed December 30, 2014.

Acupuncture, an ancient Far Eastern treatment modality that involves inserting tiny sterile needles into the skin at specific pressure points on the body for the purpose of providing pain relief.⁷Whaley, AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004); 677-691. doi:10.1016/j.csm.2004.006.004.

Dry-needling, in which a hollow needle is inserted into the affected tendon under ultrasound guidance, and theoretically stimulates healing.⁸Tyler et al. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg 19 (2010); 917-922.

Activity modification, which includes informing the patient on the causes behind tennis elbow and facilitating behavioral modifications to treat it, such as resting the arm, modifying sports equipment, seeking training from a sports professional to improve improper and damaging play techniques, and so on.⁶American Academy of Orthopedic Surgeons. Tennis elbow (lateral epicondylitis). September 2009: OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=a00068. Accessed December 30, 2014.^,7Whaley, AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004); 677-691. doi:10.1016/j.csm.2004.006.004.

Physical therapy, including exercises that focus on flexing and extending the elbows and wrists, exercises that stretch the wrists and forearms, and grip-strengthening eccentric exercises, such as using a rubber twisting baton.⁸Tyler et al. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg 19 (2010); 917-922.^,9Reynolds, G. Phys ed: an easy fix for tennis elbow? August 25, 2009: The New York Times, WELL Blog. http://well.blogs.nytimes.com/2009/08/25/phys-ed-an-easy-fix-for-tennis-elbow/?_r=0. Accessed December 29, 2014.

Extracorporeal shock wave therapy (ESWT), in which sound waves are applied to the body from an external source as a means for providing pain relief, though this treatment remains controversial among many medical professionals.⁶American Academy of Orthopedic Surgeons. Tennis elbow (lateral epicondylitis). September 2009: OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=a00068. Accessed December 30, 2014.^,7Whaley, AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004); 677-691. doi:10.1016/j.csm.2004.006.004.

Topical steroid and/or cortisone creams or gels, which are applied directly to the skin over the affected area, to help reduce inflammation and provide pain relief.⁷Whaley, AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004); 677-691. doi:10.1016/j.csm.2004.006.004.

Corticosteroid injections, in which one or more types of these anti-inflammatory medications are injected directly into the affected tendon(s)⁶American Academy of Orthopedic Surgeons. Tennis elbow (lateral epicondylitis). September 2009: OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=a00068. Accessed December 30, 2014.^,7Whaley, AL, Baker CL. Lateral epicondylitis. Clin Sports Med 23 (2004); 677-691. doi:10.1016/j.csm.2004.006.004.. There is currently little consensus in the medical literature as to how many injections should be given, or on the dosage or frequency.

In addition to the above options, following are some emergent and/or experimental nonsurgical treatments for tennis elbow:

Autologous blood injections. In this injection procedure, small amounts of the patient’s own blood is injected into the affected tendon, which theoretically helps accelerate the body’s natural healing process.

Phonophoresis, electrical stimulation, ultrasound, and/or iontophoresis. These treatments use electrical and/or sonic stimulation of the affected tissue, which theoretically stimulates the body’s own natural healing processes. Phonophoresis and iontophoresis often combine this stimulative treatment with the application of topical medications, such as corticosteroids. These treatments may be administered separately or in combination with one or more other therapies.¹⁰Klaiman MD et al. Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exerc 30 (1998) 1349-1355.^,11Nirschl RP et al. Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. A randomized, double-blinded, placebo-controlled study. Am J Sports Med 31 (2003); (2): 189-195.

Platelet-rich plasma (PRP) injections, an emerging treatment in which the patient’s own blood is withdrawn, then run through a centrifuge to first separate the platelets and other solid components (red and white blood cells) from the plasma (liquid) component of blood. The centrifuge then re-mixes the platelets with the plasma at a higher concentration than occurs naturally. This new platelet-rich solution is then injected into the affected tissues, which some experts believe accelerates the body’s own natural healing process.¹²American Academy of Orthopedic Surgeons. Platelet rich plasma (PRP). September 2011: OrthoInfo. http://orthoinfo.aaos.org/topic.cfm?topic=A00648. Accessed January 5, 2015.

See PRP Therapy for Chronic Tendon Injuries

Percutaneous needle tenotomy. In this procedure, a needle is inserted into the elbow under ultrasonic guidance, and the injured tendon and surrounding bone is scraped or cut using the needle to help remove scar tissue. Then a corticosteroid mixed with a longer-acting local anesthetic is injected into the same area to provide ongoing pain relief and stimulate healing.¹³McShane J et al. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. Journal of Ultrasound in Medicine 25 (2006); (10) 1281-1289.

With many different nonsurgical treatment options to consider, most tennis elbow patients can find relief without having to undergo surgery. However, in rare cases, surgery may be the only option.