Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

initial presentation

1st line – rest + ice + NSAID + brace/strap

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ACUTE
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initial presentation
1st line – 

rest + ice + NSAID + brace/strap

The mainstay of initial treatment for medial and lateral epicondylitis is rest, ice, and activity modification of the wrist, elbow, and forearm for 6 weeks.[1][4][24][59]

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended during the initial 10-21 days following injury. Short-term studies have demonstrated that oral diclofenac for 28 days for lateral epicondylitis is associated with improved pain but not statistically improved grip strength.[60][61]

In addition to NSAIDs, an inelastic, nonarticular, proximal forearm strap for lateral epicondylitis may be utilized. Short-term use of this bracing technique for up to 12 weeks following injury has been shown to be beneficial in lateral epicondylitis.[62] There is no difference in symptom improvement using a brace confined to a forearm compared with a brace with a strap above the elbow.[63]

Conservative treatment should be continued for about 6 weeks.

The use of transcutaneous electrical nerve stimulation (TENS) devices does not appear to provide additional benefit.[64]

Primary options

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

OR

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 500 mg orally twice daily when required

OR

meloxicam: 15 mg once orally daily when required

OR

celecoxib: 200 mg orally once daily when required

ONGOING

no response to initial treatment at 6 weeks

1st line – physical therapy ± local anesthetic injection

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ONGOING
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no response to initial treatment at 6 weeks
1st line – 

physical therapy ± local anesthetic injection

The physical exam should be repeated to re-evaluate for other etiologic processes. Radiographic and/or electrophysiological studies may also be indicated to further evaluate the patient.

Formal physical therapy procedures, with or without local injections of local anesthetic, may be beneficial and should include an eccentric loading program.[65][66][67][68][69][70]​ Radial nerve mobilization techniques have also been found to provide effective short-term pain relief in a small randomized controlled trial.[71]

Some physicians inject both lidocaine and bupivacaine. They do this on the basis that lidocaine has a rapid onset, allowing the injection to have good diagnostic value, whereas bupivacaine is longer-acting with a longer onset.

Patients should be monitored every 6-8 weeks for 6 months to assess progress, such as whether they have returned to work or are participating in any sport.

lateral epicondylitis refractory to treatment 6-12 months after initial presentation

1st line – surgery

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ONGOING
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lateral epicondylitis refractory to treatment 6-12 months after initial presentation
1st line – 

surgery

Surgical intervention for both medial and lateral epicondylitis is limited to refractory cases.[4][24][59] All patients should be informed preoperatively of possible decreased grip strength after surgery.[4]

Systematic reviews have suggested that the current evidence is insufficient to support or refute the effectiveness of surgical intervention.[79][80]​ 

Systematic reviews and one randomized controlled trial (published subsequent to systematic review searches) report no significant differences between arthroscopic and open surgery (e.g., functional outcomes, failure rate, pain relief) in patients with lateral epicondylitis.[81][82][83] One review found that postoperative complications (such as mild flexion-extension limitation, hematoma, wound infection, revision requirement, forearm paresthesias for 2 weeks after surgery) were significantly more common following open surgery.[81] Arthroscopic surgery was associated with increased operative time.[82][83] 

Long-term follow up data are limited. Single-surgeon series (with mean follow-up >9.8 years) report subjective overall improvement in >90% of patients who underwent an open surgical procedure for lateral epicondylitis.[84][85] In one series, patient satisfaction averaged 8.9/10.[84]

2nd line – ultrasound-guided minimally invasive tenotomy

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ONGOING
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lateral epicondylitis refractory to treatment 6-12 months after initial presentation
2nd line – 

ultrasound-guided minimally invasive tenotomy

Ultrasound-guided minimally invasive tenotomy has shown symptomatic improvement in nonrandomized studies.[87]

It is a safe and effective treatment option for chronic refractory lateral and medial elbow tendinopathy, showing significant pain and function improvements over one year. Further research is required to assess its effectiveness in diverse patient populations using controlled study designs.[88]

2nd line – dry needling

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ONGOING
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lateral epicondylitis refractory to treatment 6-12 months after initial presentation
2nd line – 

dry needling

Dry needling is a low-cost, minimally invasive, and low-risk therapy for refractory lateral epicondylitis. It involves multiple needle insertions into the extensor carpi radialis brevis tendon and is usually performed percutaneously under local anesthetic. Dry needling has been shown to provide symptomatic improvement in a few small studies.[89][90]

2nd line – extracorporeal shock wave therapy

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ONGOING
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lateral epicondylitis refractory to treatment 6-12 months after initial presentation
2nd line – 

extracorporeal shock wave therapy

Extracorporeal shock wave therapy may be effective in patients with risk factors precluding surgery, or who wish to avoid surgery.[91]

Systematic reviews suggest that extracorporeal shock wave therapy may be of modest benefit in the management of lateral epicondylitis, but high-quality RCTs are required.[92][93]

2nd line – injection with nonanesthetic agents

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ONGOING
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lateral epicondylitis refractory to treatment 6-12 months after initial presentation
2nd line – 

injection with nonanesthetic agents

Injection modalities, including autologous blood, platelet-rich plasma, hyaluronic acid, and botulinum toxin, have been proposed as treatments for recalcitrant lateral and medial epicondylitis.

Autologous blood or platelet-rich plasma is injected into the tendons and is thought to stimulate a local inflammatory response. The use of injections with autologous blood/platelet-rich plasma may be considered as alternate treatments to surgical intervention, but the evidence for these therapies is currently limited.[94]​​ [ Cochrane Clinical Answers logo ] The UK National Institute for Health and Care Excellence (NICE) recommends autologous blood products for the treatment of tendinopathy; however, their effectiveness is uncertain.[96]

Two systematic reviews in patients with lateral epicondylitis reported that autologous blood or platelet-rich plasma significantly improved pain and elbow function in the intermediate term (12-26 weeks), and that platelet-rich plasma injection improved function and pain at 24 weeks, compared with corticosteroid injections.[97][98] 

However, a subsequent 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.[99] It also reported that it is uncertain whether the injections improve treatment success or pain relief (>50%).[99] [ Cochrane Clinical Answers logo ]  

Reduced pain following botulinum toxin injection has been reported in people with lateral epicondylitis, but there is also a high risk of complications, including digital paresis and weakness.[100][101][102][103]

Hyaluronic acid injections have been shown to improve pain and grip strength in patients with chronic lateral epicondylitis when compared with placebo. No serious adverse effects were reported and improvement persisted after 1 year.[104] However, few high-quality studies are available.

2nd line – low-level laser therapy

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ONGOING
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lateral epicondylitis refractory to treatment 6-12 months after initial presentation
2nd line – 

low-level laser therapy

Optimally dosed low-level laser therapy administered directly to the lateral elbow tendon insertions seems to offer short-term pain relief and less disability in lateral epicondylitis, both alone and in conjunction with an exercise regimen. There is conflicting evidence for the efficacy of this intervention.[105][106][107][108][109]

medial epicondylitis refractory to treatment 6-12 months after initial presentation

1st line – surgery

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ONGOING
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medial epicondylitis refractory to treatment 6-12 months after initial presentation
1st line – 

surgery

Surgical intervention for both medial and lateral epicondylitis is limited to refractory cases.[4][24][59]​​[Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: probe placed on area of degenerative tendon showing loss of normal tendon appearanceFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends].com.bmj.content.model.Caption@170c7e61[Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: pickups lifting off area of degenerative tendon after elliptical incision to excise this areaFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends].com.bmj.content.model.Caption@2d775540[Figure caption and citation for the preceding image starts]: Markings for swing incision location for patient with chronic refractory medial epicondylitisFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends].com.bmj.content.model.Caption@44e954c6[Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: degenerative tendon removedFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends].com.bmj.content.model.Caption@3a626311[Figure caption and citation for the preceding image starts]: Surgery for refractory medial epicondylitis: medial epicondyle exposedFrom the collection of Dr Brian Fitzgerald, Naval Medical Center San Diego, CA; used with permission [Citation ends].com.bmj.content.model.Caption@658d40bb

Surgical intervention for medial epicondylitis involves the open debridement and excision of the undersurface of the flexor pronator mass. Mean subjective estimate of elbow function has been found to improve from 38% to 98% of normal after surgery for medial epicondylitis.[86]

Possible adverse effects of surgery include injury to ulnar nerve and/or weakness with wrist flexion.

2nd line – ultrasound-guided minimally invasive tenotomy

Back
ONGOING
|
medial epicondylitis refractory to treatment 6-12 months after initial presentation
2nd line – 

ultrasound-guided minimally invasive tenotomy

Ultrasound-guided minimally invasive tenotomy has shown symptomatic improvement in nonrandomized studies.[87]

It is a safe and effective treatment option for chronic refractory lateral and medial elbow tendinopathy, showing significant pain and function improvements over one year. Further research is required to assess its effectiveness in diverse patient populations using controlled study designs.[88]

2nd line – injection with nonanesthetic agents

Back
ONGOING
|
medial epicondylitis refractory to treatment 6-12 months after initial presentation
2nd line – 

injection with nonanesthetic agents

Injection modalities, including autologous blood, platelet-rich plasma, hyaluronic acid, and botulinum toxin, have been proposed as treatments for recalcitrant lateral and medial epicondylitis.

Autologous blood or platelet-rich plasma injected into the tendons and is thought to stimulate a local inflammatory response. The use of injections with autologous blood/platelet-rich plasma may be considered as alternate treatments to surgical intervention, but the evidence for these therapies is currently limited.[94][95] The UK National Institute for Health and Care Excellence (NICE) recommends autologous blood products for the treatment of tendinopathy; however, their effectiveness is uncertain.[96]

Two systematic reviews in patients with lateral epicondylitis reported that autologous blood or platelet-rich plasma significantly improved pain and elbow function in the intermediate term (12-26 weeks), and that platelet-rich plasma injection improved function and pain at 24 weeks, compared with corticosteroid injections.[97][98] 

However, a subsequent 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.[99] It also reported that it is uncertain whether the injections improve treatment success or pain relief (>50%).[99] [ Cochrane Clinical Answers logo ]  

Reduced pain following botulinum toxin injection has been reported in people with lateral epicondylitis, but there was also a high risk of complications, including digital paresis and weakness.[100][101][102][103]

Hyaluronic acid injections have been shown to improve pain and grip strength in patients with chronic lateral epicondylitis when compared with placebo. No serious adverse effects were reported and improvement persisted after 1 year.[104] However, few high-quality studies are available.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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