Evidence for the treatment of lateral epicondylitis before 2010 was poor. There were clinical trials addressing many proposed treatments, but the trials were of poor quality. In some cases, severity of<unk>  symptoms mend without any treatment, within six to 24 months.<unk>  left untreated can lead to chronic pain that degrades quality of daily living. Physical therapy There are several recommendations regarding prevention, treatment, and avoidance of recurrence that are largely speculative including stretches and progressive strengthening exercises to prevent re-irritation of the tendon and other exercise measures. One way to help treat minor cases of<unk>  is simply to relax the affected arm. The rest lets stress and tightness within the forearm slowly relax and eventually have the arm in working condition—in a day or two, depending on the case. Eccentric exercise using a rubber bar is highly effective at eliminating pain and increasing strength. The exercise involves grasping a rubber bar, twisting it, then slowly untwisting it. Although it can be considered an evidence-based practice, long-term results have not yet been determined. There are differences in opinions on whether it is okay if pain occurs during these exercises. Some suggest pain of less than 5/10 is okay. Moderate evidence exists demonstrating that joint manipulation directed at the<unk>  and wrist and spinal manipulation directed at the cervical and thoracic spinal regions results in clinical changes to pain and function. There is also moderate evidence for short-term and mid-term effectiveness of cervical and thoracic spine manipulation as an add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. Although not yet conclusive, the short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises, resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis. Low level laser therapy, administered at specific doses and wavelengths directly to the lateral<unk>  tendon insertions, may result in short-term pain relief and less disability. Extracorporeal shockwave therapy, while safe, is of unclear benefit. Orthotic devices Counterforce orthosis reduces the elongation within the musculotendinous fibers Wrist extensor orthosis reduces the overloading strain at the lesion area Orthosis is a device externally used on the limb to improve the function or reduce the pain. Orthotics may be useful in<unk> , however long-term effects are unknown. There are two main types of orthoses prescribed for this problem: counterforce<unk>  orthoses and wrist extension orthoses. Counterforce orthosis has a circumferential structure surrounding the arm. This orthosis usually has a strap which applies a binding force over the origin of the wrist extensors. The applied force by orthosis reduces the elongation within the musculotendinous fibers. Wrist extensor orthosis maintains the wrist in the slight extension. This position reduces the overloading strain at the lesion area. Studies indicated both type of orthoses improve the hand function and reduce the pain in people with<unk> . Medication Although anti-inflammatories are a commonly prescribed treatment for<unk> , the evidence for their effect is usually anecdotal with only limited studies showing a benefit. A systematic review found that topical non-steroidal anti-inflammatory drugs (NSAIDs) may improve pain in the short term (up to 4 weeks) but was unable to draw firm conclusions due to methodological issues. Evidence for oral NSAIDs is mixed. Evidence is poor for long term improvement from injections of any type, whether corticosteroids, botulinum toxin, prolotherapy or other substances. Corticosteroid injection may be effective in the short term however are of little benefit after a year, compared to a wait-and-see approach. A recent randomized control trial comparing the effect of corticosteroid injection, physiotherapy, or a combination of corticosteroid injection and physiotherapy found that patients treated with corticosteroid injection versus placebo had lower complete recovery or improvement at 1 year (Relative risk 0.86). Patients that received corticosteroid injection also had a higher recurrence rate at 1 year versus placebo (54% versus 12%, relative risk 0.23). Complications from repeated steroid injections include skin problems such as hypopigmentation and fat atrophy leading to indentation of the skin around the injection site. Steroid injections against appear to be more effective than shock wave therapy. Botulinum toxin type A to paralyze the forearm extensor muscles in those with chronic<unk>  that has not improved with conservative measures may be viable. Surgery In recalcitrant cases surgery may be an option. Surgical methods include: * Lengthening, release, debridement, or repair of the origin of the extrinsic extensor muscles of the hand at the lateral epicondyle * Rotation of the anconeus muscle * Denervation of the lateral epicondyle * Decompression of the posterior interosseous nerve Surgical techniques for lateral epicondylitis can be done by open surgery, percutaneous surgery or arthroscopic surgery, with no high-quality evidence that any particular type is better or worse than another. Side effects include infection, damage to nerves and inability to straighten the arm. A review of the evidence related to surgery found that published studies were of low quality and did not show that surgery was any more effective than other treatments. A subsequent research trial showed that surgery was no more effective than sham surgery, where patients only received a skin incision, although the trial was limited by a small number of patients.
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