Successful results have been described with physical therapy regimens utilizing a combination of stretches, targeted massage, strengthening, and hot-cold modalities [15, 26–28]. Eccentric muscle training has demonstrated excellent results with subjective improvement in both pain and strength [29]; resistance physiotherapy is the authors’ preferred modality. Newer treatments such as extracorporeal shock wave therapy and topical glyceryl trinitrate patches do not have long-term data to support their routine use at this time [28, 30].

Physiotherapy may also include sport-specific technique and equipment modifications. When compared with professionals, amateur players experience tennis elbow symptoms more frequently which suggests that poor technique is contributory [2, 13, 14, 31]. A tennis coach can teach the player to concentrate the core muscles into the forehand swing by striking the ball while it is still in front of the player. Additionally, in a one-handed backstroke, the coach should focus on making sure the player extends the wrist during ball contact; striking the ball while the wrist falls in flexion creates a greater eccentric load on the wrist extensors. Alternatively, a 2-handed backstroke can also help unload the tension across the dominant wrist. Equipment should also be inspected. Lighter rackets made of low-vibration materials (graphite or epoxies) and rackets that are less tightly strung and/or have more strings per unit area can also reduce the work of the wrist extensors during active play [32]. A proper grip size is also recommended; a good estimate of the racket handle circumference is to measure the distance from the players proximal wrist crease to the tip of the ring finger. Last, playing on “slower” surfaces, such as a clay court, may also reduce the forces experienced across the wrist.

Orthoses can be an adjunctive therapy for tennis elbow but are not usually prescribed as a monotherapy. Counterforce straps are wrapped tightly around the upper forearm in an attempt to move the mechanical origin of the wrist extensors more distal; thus the player, in theory, can still move the wrist while resting the proximal portion of the muscles [28, 33]. Cock-up wrist splints are another option, which restrict wrist extension. Currently, no orthosis has been proven superior [34].

A recent Cochrane review examined 13 trials that reported on the efficacy topical and oral NSAIDs for symptom relief in lateral epicondylitis and could not recommend for or against their use. Symptom alleviation in some patients was offset by the side effects of stomach pain and diarrhea with oral tablets and skin rash with topical applications [35].

Steroid injections alleviate elbow pain and assist with early return to athletic or work activity, although no long-term benefit has been established [28, 36]. Comparative studies have not found a superior steroid preparation, although universal risks for all steroid injections are skin depigmentation, fat atrophy, tendon rupture, and transient hyperglycemia in diabetics [37, 38].

Platelet-rich plasma (PRP) and whole blood injections are an alternative to steroids and have been used with more frequency in recent years. A prospective study by Mishra et al. with 230 participants demonstrated clinical improvements at 24 months compared with controls [39]. Gosens et al. also showed greater clinical improvement with PRP compared to corticosteroids at 2 years [40]. Thanasas et al. was unable to demonstrate better outcomes with PRP compared to whole blood injections at 6 months [41]. Currently, the optimal timing, concentration, and number of doses of these biologic injectables are not known, and the cost can be prohibitive for some patients.