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Refractory Epicondylitis — SCE Rheumatology MCQ

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ModerateSoft Tissue RheumatologyRefractory EpicondylitisSCE Rheumatology

A 48-year-old woman has medial epicondylitis that continues to limit gripping and lifting after 6 months of activity modification, topical NSAID treatment and use of a counterforce brace. Previous physiotherapy consisted only of passive modalities, without a progressive tendon-loading programme. There are no symptoms or signs of ulnar neuropathy. Which is the most appropriate evidence-supported next treatment?

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Correct answer: C — Physiotherapist-supervised progressive wrist-flexor loading, including eccentric exercise

Explanation lettering: D = shown as A · C = shown as B · E = shown as C · B = shown as D · A = shown as E

E is correct. Her previous treatment did not include progressive loading, so an important component of conservative rehabilitation has not been adequately tried. Evidence specific to medial epicondylitis suggests that eccentric wrist-flexor exercise can improve pain and function when incorporated into a multimodal programme, although study certainty remains limited. Serial corticosteroid injections are inappropriate: elbow tendinopathy data show short-term benefit but worse intermediate- and long-term outcomes. Prolonged immobilisation and systemic corticosteroids are unsupported and risk weakness or other harms. Surgery is reserved for persistent, substantially disabling symptoms after a comprehensive non-operative programme. PRP should not be routinely bundled with exercise as established treatment because NICE considers the efficacy evidence for autologous blood and PRP injections inadequate and requires special governance, consent and audit or research arrangements.

Reference: See ZH, Loo CE, Jaafar Z. Eccentric exercise therapy for medial epicondylitis: A systematic review of clinical outcomes. Complementary Therapies in Medicine. 2026;98:103364. https://pubmed.ncbi.nlm.nih.gov/41887339/