What are the recommended first-line treatments for a patient diagnosed with lateral epicondylitis?

Recommended first-line treatments for lateral epicondylitis (tennis elbow) focus on pain relief and restoring function. Initial management includes advising the patient to rest the affected arm and avoid activities that aggravate symptoms, such as high-force gripping or use of vibrating tools, for approximately 6 weeks while maintaining as much activity as possible to prevent stiffness ¹.

Patients should be encouraged to apply heat or ice to relieve pain and consider using an orthosis, such as a forearm strap or wrist/elbow brace, which may help offload the common extensor tendon and reduce muscle activity, although evidence for orthoses is limited and somewhat conflicting ¹.

For analgesia, topical nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen gel, are recommended first-line due to moderate-quality evidence supporting short-term pain relief; oral NSAIDs may be considered if topical treatment is insufficient, but their long-term effectiveness is uncertain ¹. Paracetamol is a pragmatic alternative, especially for patients with contraindications to NSAIDs ¹.

If symptoms persist beyond 6 weeks, referral to physiotherapy is advised, focusing on stretching and strengthening exercises, particularly eccentric loading programs, which have shown moderate evidence for short-term benefit in pain and function ¹. Ultrasound therapy and massage may be adjuncts but have less clear evidence ¹.

Corticosteroid injections are generally not recommended routinely due to evidence of short-term pain relief but poorer long-term outcomes and higher recurrence rates compared to physiotherapy or no treatment; if offered, patients should be informed about potential adverse effects and long-term implications ¹.

Recent literature supports these guideline recommendations, emphasizing the limited but potentially beneficial role of NSAIDs in the acute phase and the importance of exercise-based physiotherapy for longer-term recovery (Behrens et al., 2012). The literature also highlights the short-term benefits but long-term drawbacks of corticosteroid injections, aligning with guideline caution (Behrens et al., 2012).