eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
Lateral Epicondylitis: Treatment & Medication
Updated: Jul 24, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
Acutely, the goals of treatment are to reduce pain and inflammation. Anti-inflammatory modalities include ice, ultrasonography, and iontophoresis. Iontophoresis with topical nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to help reduce pain. The use of iontophoresis with corticosteroids is not supported. A wrist splint used during activities can be helpful, because it places the extensor muscles in a position of rest and prevents maximal muscle contraction. Counterforce bracing (tennis elbow strap) is another orthotic alternative that can be used to unload the area of muscle origin at the elbow. A splint or brace should not be used in isolation but should be employed only as an adjunct to modalities and exercise/stretching.10 Deep-tissue and friction massage help to release underlying adhesions and promote improved circulation to the area.
In the subacute stage, emphasis is placed on the restoration of function of the involved muscle group. Flexibility, strength, and endurance of the wrist extensor muscle group can be achieved through a graded program. ROM for wrist flexion/extension and pronation/supination should be achieved prior to proceeding with a strengthening program. Strength and grip training should progress from isometric to concentric to eccentric contractions of the forearm muscles, especially the wrist extensors.11,12
Jafarian et al compared 3 common types of orthoses for their effect on grip strength in patients with lateral epicondylitis.13 In a randomized, controlled laboratory study in 52 patients, maximum and pain-free grip strength were assessed, with patients wearing an elbow strap orthosis, an elbow sleeve orthosis, a wrist splint, or a placebo orthosis. Use of either the elbow strap or sleeve orthosis resulted in an immediate and equivalent increase in pain-free grip strength (p <0.02); consequently, the researchers suggested that either of these types of orthosis may be used. The wrist splint provided no immediate improvement in either pain-free or maximum grip strength.
In chronic refractory cases of lateral epicondylitis, scapular stabilization should be addressed to prevent overuse of the wrist extensors during activities. Sports-specific training should also be included in the rehabilitation program, if appropriate.
Occupational Therapy
As activities are resumed, the patient's vocational and avocational pursuits must be considered. Job and recreational tools and/or equipment may need to be modified, especially if repetitive gripping is required. Gradual resumption of activities is recommended to improve tolerance and prevent recurrence.
Medical Issues/Complications
The so-called radial tunnel syndrome should be considered for refractory cases of lateral epicondylitis. Criteria for diagnosis of radial tunnel syndrome are controversial in the literature.14 There exist cases of posterior interosseous nerve palsy associated with weakness in muscles that are innervated by that nerve. However, syndromes of forearm pain without associated weakness in muscles that are innervated by the posterior interosseous nerve are also seemingly labeled as radial tunnel syndrome.7
Electrodiagnostic studies should be helpful in demonstrating nerve injury in cases of radial tunnel syndrome, thereby differentiating this entity from a forearm pain syndrome. In compression of the posterior interosseous nerve, patients report pain at the lateral aspect of the elbow and weakness in the wrist and hand, but no sensory symptoms. Electrodiagnostic findings in posterior interosseous nerve compression may include denervation in radial-supplied muscles distal to the supinator, and possibly slowing across the area of entrapment. Surgical intervention for radial tunnel syndrome or persistent tennis elbow should be approached with caution and only after a thorough workup and extensive conservative management.
Surgical Intervention
For cases of refractory lateral epicondylitis, surgical resection of the lateral extensor aponeurosis might be considered.15,16
Consultations
An orthopedic hand specialist may be consulted.
Other Treatment
Topical NSAIDs may provide short-term pain relief, but evidence is conflicting on the use of oral NSAIDs.
If a patient does not seem to be responding to conservative care, a steroid injection about the lateral epicondyle using local anesthetic can be performed.9,17,18,19,20,21 However, the role of corticosteroid injection in tendinopathy remains controversial. Most lateral epicondylitis is degenerative rather than inflammatory, and injecting steroid around a tendon can inhibit collagen repair; therefore, steroid injections should be used on a limited basis. Additionally, injecting a corticosteroid directly into a tendon can be deleterious. Nonetheless, steroid injections in some cases can bring about dramatic, albeit short-term, relief. When employing steroid injections, the following steps should be taken:
- Palpate the lateral epicondyle to locate the painful area (usually inferior and radial to the lateral epicondyle).
- Using a 25- or 30-gauge needle, inject 0.5-1 mL of triamcinolone (20 mg/mL) and 1-2 mL of 1% lidocaine. Infiltrate the area, distributing small aliquots of medication in a fanlike fashion. To avoid tissue rupture, take care not to inject directly into the origin of the extensor muscle group.
- Heavy lifting or repetitive activity by the patient should be minimized for 48-72 hours after the injection.
Other substances used for injection include local anesthetics and botulinum toxin. However, studies have provided conflicting evidence as to whether botulinum toxin injection has positive long-term benefits for lateral epicondylitis.22,23,24
Other types of treatment have included acupuncture and extracorporeal shockwave therapy.25,26 However, there is insufficient evidence to support acupuncture as a treatment for epicondylitis. Likewise, reviews of trials using shockwave therapy have found reasons not to support this as a treatment option.
Medication
The goal of drug treatment in cases of lateral epicondylitis is pain control, in order to facilitate the performance of ADL.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Diclofenac (Solaraze)
Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzeneacetic acid, monosodium salt, with an empirical formula of C 14 H 10 Cl 2 NO 2 NA. Diclofenac is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacologic studies. It is believed to inhibit the activity of COX, which is essential in the biosynthesis of prostaglandins.
Adult
Apply topically to affected area(s) bid
Pediatric
Not indicated
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; may cause hypersensitivity, caution in those predisposed (eg, aspirin allergy); may cause contact dermatitis, rash, pruritus, or exfoliation at application sites
Ibuprofen (Motrin, Ibuprin, Advil, Excedrin IB)
DOC for patients with mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-800 mg PO qid
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Naprelan, Anaprox, Aleve)
For relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of COX, which is responsible for prostaglandin synthesis.
Adult
250-500 mg PO bid; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, being induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Pregnancy category D in third trimester of pregnancy; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; caution in severe heart failure and hyponatremia because celecoxib may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
Corticosteroids
The medications have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Triamcinolone (Amcort, Aristospan Intra-articular)
For inflammatory dermatosis responsive to steroids. This agent decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and by reversing capillary permeability.
Adult
0.5-1 mL (20 mg/mL formulation) IM
Pediatric
Not established
Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.
Acetaminophen (Tylenol, Aspirin-Free Anacin, Tempra, Feverall)
DOC for pain in patients who have documented hypersensitivity to aspirin or NSAIDs, who have upper GI disease, or who are taking PO anticoagulants.
Adult
1000 mg PO tid/qid
Pediatric
Not established
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP (acetaminophen) is contained in many OTC products, and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose
More on Lateral Epicondylitis |
| Overview: Lateral Epicondylitis |
| Differential Diagnoses & Workup: Lateral Epicondylitis |
 Treatment & Medication: Lateral Epicondylitis |
| Follow-up: Lateral Epicondylitis |
| References |
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References
Sheon RP. Repetitive strain injury. 1. An overview of the problem and the patients. The Goff Group. Postgrad Med. Oct 1997;102(4):53-6, 62, 68. [Medline].
Sheon RP. Repetitive strain injury. 2. Diagnostic and treatment tips on six common problems. The Goff Group. Postgrad Med. Oct 1997;102(4):72-8, 81, 85 passim. [Medline].
Nadler S, Nadler JM. Cumulative trauma disorders. In: DeLisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998:1661-76.
Khan KM, Cook JL, Taunton JE. Overuse tendinosis, not tendinitis. Phys Sportsmed. 2000;28:38-48.
O'Connor FG, Howard TM, Fieseler CM. Managing overuse injuries. A systematic approach. Phys Sportsmed. 1997;25:88-113.
Yassi A. Repetitive strain injuries. Lancet. Mar 29 1997;349(9056):943-7. [Medline].
Chumbley EM, O'Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. Feb 1 2000;61(3):691-700. [Medline]. [Full Text].
Downs DG. Nonspecific work-related upper extremity disorders. Am Fam Physician. Mar 1997;55(4):1296-302. [Medline].
Torp-Pedersen TE, Torp-Pedersen ST, Qvistgaard E, et al. Effect of glucocorticosteroid injections in tennis elbow verified on colour Doppler ultrasound: evidence of inflammation. Br J Sports Med. Mar 4 2008;[Medline].
Altan L, Kanat E. Conservative treatment of lateral epicondylitis: comparison of two different orthotic devices. Clin Rheumatol. Mar 26 2008;[Medline].
[Best Evidence] Bisset L, Beller E, Jull G, et al. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. BMJ. Nov 4 2006;333(7575):939. [Medline]. [Full Text].
Bisset L, Paungmali A, Vicenzino B, et al. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. Jul 2005;39(7):411-22; discussion 411-22. [Medline].
[Best Evidence] Jafarian FS, Demneh ES, Tyson SF. The immediate effect of orthotic management on grip strength of patients with lateral epicondylosis. J Orthop Sports Phys Ther. Jun 2009;39(6):484-9. [Medline].
Rosenbaum R. Disputed radial tunnel syndrome. Muscle Nerve. Jul 1999;22(7):960-7. [Medline].
Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. Feb 2008;36(2):254-60. [Medline].
Dunn JH, Kim JJ, Davis L, et al. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. Feb 2008;36(2):261-6. [Medline].
Genovese MC. Joint and soft-tissue injection. A useful adjuvant to systemic and local treatment. Postgrad Med. Feb 1998;103(2):125-34. [Medline].
Rifat SF, Moeller JL. Site-specific techniques of joint injection. Useful additions to your treatment repertoire. Postgrad Med. Mar 2001;109(3):123-6, 129-30, 135-6. [Medline].
Tonks JH, Pai SK, Murali SR. Steroid injection therapy is the best conservative treatment for lateral epicondylitis: a prospective randomised controlled trial. Int J Clin Pract. Feb 2007;61(2):240-6. [Medline].
Lewis M, Hay EM, Paterson SM, et al. Local steroid injections for tennis elbow: does the pain get worse before it gets better?: Results from a randomized controlled trial. Clin J Pain. Jul-Aug 2005;21(4):330-4. [Medline].
Roberts WO. Lateral epicondylitis injection. Phys Sportsmed. 2000;28:93-4.
[Best Evidence] Hayton MJ, Santini AJ, Hughes PJ, et al. Botulinum toxin injection in the treatment of tennis elbow. A double-blind, randomized, controlled, pilot study. J Bone Joint Surg Am. Mar 2005;87(3):503-7. [Medline].
[Best Evidence] Wong SM, Hui AC, Tong PY, et al. Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. Dec 6 2005;143(11):793-7. [Medline]. [Full Text].
[Best Evidence] Placzek R, Drescher W, Deuretzbacher G, et al. Treatment of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-controlled, randomized multicenter study. J Bone Joint Surg Am. Feb 2007;89(2):255-60. [Medline].
Haake M, König IR, Decker T, et al. Extracorporeal shock wave therapy in the treatment of lateral epicondylitis: a randomized multicenter trial. J Bone Joint Surg Am. Nov 2002;84-A(11):1982-91. [Medline].
Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. Jun 2005;87(6):1297-304. [Medline].
Further Reading
Keywords
tennis elbow, lateral elbow tendinitis, lateral elbow tendonitis, elbow overuse syndrome
