Introduction

Tennis elbow was originally characterised in 1873 by Runge, and Henry Morris subsequently named it "Lawn Tennis Arm" in a Lancet article published in 1882.¹ However, it is also known by many different names, such as angiofibroblastic hyperplasia, lateral epicondylitis (LE), and tendonosis.² Tennis elbow is a common overuse injury that causes pain and tenderness on the outer part of the elbow.³ 

It is a typical middle-aged condition that usually occurs in regular tennis players affecting functional ability, including their work, however, it is not restricted to tennis players but can affect anyone engaging in repetitive wrist and arm movements such as violinists, baseball players, blacksmiths, golfers, and telephone operators.^2,4 Although tennis elbow is self-limiting, treatment options such as physiotherapy, bracing, and anti-inflammatory medications manage symptoms and improve function.³ 

Role of inflammation in the condition

Terms like epicondylitis and tendinitis are misleading because they imply an inflammatory process. However, tennis elbow is not only caused by inflammation but also involves microtears and degeneration in the extensor tendons. Although there is little or no inflammation, people with lateral epicondylitis report pain, especially when performing wrist-extension-related tasks.⁴ Inflammation plays a role in the early stage of the condition, this is why anti-inflammatory medications are often used as part of the therapy. These medications help reduce pain and promote good function in the short term.⁵

Types of anti-inflammatory medications

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are crucial in the pharmacological treatment of acute and chronic pain. NSAIDs act by inhibiting cyclooxygenase (COX) isozymes, which are COX-1 and COX-2 enzymes, reducing the production of prostaglandins, which contribute to pain and inflammation. COX-2 inhibition is responsible for the anti-inflammatory effects, while COX-1 inhibition can lead to unwanted side effects, such as stomach irritation and ulcers.⁶ They are the most commonly used medications for managing tennis elbow and the first line of treatment. NSAIDs are available as tablets, taken orally, and gels administered directly to the skin. 

Oral NSAIDs include;⁷

• Over-the-counter NSAIDs such as naproxen, ibuprofen, and aspirin can provide short-term pain relief but should not be used for a long period as there are possible gastrointestinal side effects like stomach ulcers
• Prescription-strength NSAIDs such as Celecoxib and Diclofenac are stronger NSAIDs that may be prescribed for severe cases of tennis elbow but require medical supervision due to the high risks they pose which include cardiovascular and kidney complications

Topical NSAIDs are a safer alternative to oral NSAIDs due to their reduced risk of side effects. They are applied directly to the affected area of the skin and are absorbed locally offering targeted pain relief. Topical NSAIDs are easy to use, available without a prescription, effective for localised inflammation, and have a lower risk of stomach irritation. Examples are diclofenac gel and ketoprofen gel.⁷

Corticosteroids

Corticosteroids serve as anti-inflammatory medications solely in the worst cases of tennis elbow. Oral corticosteroids like prednisolone are occasionally used for tennis elbow because they have large systemic side effects, such as weight gain, mood changes, along immunity weakening. Cortisone injections are commonly used only when other treatments do not work.

They deliver strong anti-inflammatory medicine straight to each sore tendon. These give comfort fast but are often kept for bad pain that also stops a person from moving. Risks and side effects of corticosteroids include temporary pain flare-ups, tissue weakness which can cause tendon rupture, and repeated steroid injections, per multiple studies, which might yield diminished results with extended use and have the potential to worsen outcomes.⁸

Effectiveness of anti-inflammatory medications

Short-term vs. long-term relief

NSAIDs and corticosteroid injections can provide large short-term relief, but people debate their overall long-term effectiveness. Although NSAIDs might relieve pain, they do not repair the tendon's breakdown.²

Comparison of oral, topical, and injected medications

Although oral NSAIDs work well, they carry high systemic risks. Topical NSAIDs are definitively safer with a smaller number of side effects; however, they may not be quite as strong. Because of potential tendon damage, cortisone injections, while powerful, should be used carefully.⁸

Situations where anti-inflammatory medications are most effective

Anti-inflammatory medications are most effective in the early stages of tennis elbow when they are combined with physiotherapy and activity modification, and when you feel acute flare-ups which can be painful.⁷

Potential side effects and risks

Common side effects of NSAIDs

NSAIDs are widely used to manage inflammation and pain, but they come with notable side effects. Some common side effects of NSAIDs include;⁹

• Stomach ulcers and irritation
• High risk of bleeding
• Hepatotoxicity
• Skin irritation from topical NSAIDs
• Allergic reactions
• Fluid retention
• High blood pressure

Risks of prolonged NSAID use

Long-term use of NSAIDs can lead to a high risk of cardiovascular disorder and renal complications, especially with NSAIDs like diclofenac, and gastrointestinal bleeding.⁹

Side effects of corticosteroid injections

Some side effects of corticosteroid injections include temporary pain increase after administration of the injection, possible reduction of effectiveness over repeated use, and weakening of tendons and soft tissues.⁸

Alternative and complementary treatments

There are other treatment options available for managing tennis elbow. Anti-inflammatory medications are best used for short-term management and not long-term due to the increased risk of side effects, because of this, alternative and complementary treatments for tennis elbow are recommended for long-term effective management.⁵ These treatments include;

• Physical therapy and exercise: Exercises, such as stretching the forearms and wrists, extending and flexing the elbows and wrists, and eccentric grip-strengthening exercises, are the most effective ways to treat persistent symptoms of tennis elbow. It also reduces the possibility of needing surgical intervention for these persistent symptoms¹⁰
• Bracing, which involves using a wrist extension brace or a counterforce brace, can help the rest of the injured tissue by blocking the extension of the wrist or forearm extensor muscles⁵
• Activity modification and patient education involve educating the patient on the factors leading to tennis elbow and the activity modifications to treat it like using the correct sports equipment, training with a professional sports trainer to improve the wrong sports technique, and resting the arm⁵
• Lifestyle adjustments such as improved dietary habits decreased alcohol drinking and no smoking promote the effectiveness of tennis elbow treatment because alcohol consumption and smoking can lead to failure of non-operative treatment¹⁰
• Other pain management options such as cold therapy, acupuncture, Platelet-Rich Plasma (PRP) injections, Autologous blood injections, Laser, and Radiotherapy reduce inflammation and help speed up and stimulate the body’s natural healing of the tendons⁸ 

FAQs

Are NSAIDs safe for long-term use in tennis elbow?

No, prolonged use can lead to stomach ulcers, kidney damage, and possible tendon healing impairment​.

How many corticosteroid injections can I get for tennis elbow?

Most doctors recommend no more than two to three injections in a lifetime due to the risk of tendon weakening and rupture​.

Do corticosteroid injections cure tennis elbow?

No, they provide temporary relief, but symptoms often return and may worsen over time​.

Are topical NSAIDs as effective as oral NSAIDs?

Yes, studies show that topical NSAIDs provide similar pain relief with fewer side effects​.

What is the best long-term treatment for tennis elbow?

Physiotherapy with eccentric exercises is the most effective long-term treatment for improving function and reducing pain.​ Lifestyle adjustments such as avoiding smoking and alcohol drinking can also promote recovery.

Summary

Tennis elbow, or lateral epicondylitis, is common in people who repeatedly move their arms. Office workers, manual workers, musicians, and others linked historically to tennis players are affected. Anti-inflammatory drugs are particularly effective short-term treatments for tennis elbow because the condition involves more than just inflammation in the extensor tendons; it also involves micro tears and degeneration.

NSAIDs are the main medications used to manage inflammation and pain. They work by inhibiting cyclooxygenase (COX) enzymes to lower prostaglandin production. Oral NSAIDs such as ibuprofen and naproxen, offer temporary relief, but these drugs can cause several gastrointestinal problems. Medical supervision is needed because prescription NSAIDs like diclofenac and celecoxib may be dangerous for the cardiovascular system and kidneys. Topical NSAIDs like diclofenac gel are a safer choice because they decrease pain in a localised area and have fewer adverse effects.

Cortisone injections, a form of corticosteroids, are used to treat several serious problems. Risks such as weaker tendons and decreased long-term effectiveness occur, nevertheless, they provide quick pain relief. Although NSAIDs and corticosteroids could provide relief for a short time, they do not solve the underlying tendon degeneration.

Physiotherapy is one of the alternative therapies that enhances tendon regeneration and recovery. Supportive braces, with ergonomic adjustments and thorough patient education, are also helpful. Several strengthening exercises, in conjunction with activity changes, also improve recovery. Lifestyle adjustments, such as reducing smoking and drinking, are also effective. Other therapies, including acupuncture, cold therapy, and platelet-wealthy plasma (PRP) injections, may provide additional treatment.

Anti-inflammatory medications should be used as part of a larger treatment plan that guarantees recovery and prevents the recurrence of symptoms.