What is the treatment for a 47-year-old prediabetic patient presenting with left elbow pain without signs of inflammation?

From the Guidelines

For a 47-year-old prediabetic patient with left elbow pain without inflammation, I recommend starting with conservative management including rest, activity modification, and over-the-counter NSAIDs such as ibuprofen 400-600mg three times daily with food for 1-2 weeks as needed. Physical therapy focusing on eccentric strengthening exercises should be initiated, with 3 sets of 15 repetitions daily for 6-8 weeks. A counterforce brace worn during activities can provide symptom relief. If pain persists after 4-6 weeks of conservative treatment, consider a corticosteroid injection (e.g., methylprednisolone 40mg with 1-2ml of lidocaine 1%). For this prediabetic patient, monitor blood glucose levels closely if using corticosteroids, as they may cause transient hyperglycemia, as noted in standards of care in diabetes 1. The pain likely represents lateral epicondylitis (tennis elbow) or medial epicondylitis (golfer's elbow), which are overuse tendinopathies caused by repetitive microtrauma to the wrist extensor or flexor tendons at their attachment to the elbow. Without inflammation signs, this represents a degenerative process rather than an acute inflammatory condition, explaining why long-term healing requires progressive loading through physical therapy rather than just anti-inflammatory treatments, as discussed in the context of chronic elbow pain management 1.

Some key points to consider in the management of this patient include:

• The importance of optimizing glucose control to prevent or delay the development of neuropathy, as recommended in standards of medical care in diabetes 1.
• The role of physical therapy and conservative management in the treatment of chronic elbow pain, as outlined in the ACR Appropriateness Criteria for chronic elbow pain 1.
• The potential use of corticosteroid injections for persistent pain, with careful monitoring of blood glucose levels due to the potential for transient hyperglycemia 1.
• The consideration of other potential causes of elbow pain, such as epicondylalgia, osteoarthritis, and nerve-related abnormalities, and the use of imaging studies such as radiographs and MRI to aid in diagnosis, as discussed in the ACR Appropriateness Criteria for chronic elbow pain 1.

Overall, the management of this patient should prioritize conservative management and progressive loading through physical therapy, with careful consideration of the potential impact of treatments on blood glucose levels and the potential for other underlying causes of elbow pain.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment for Left Elbow Pain in a Prediabetic Patient

The patient presents with left elbow pain without signs of inflammation. Considering the patient's prediabetic condition, it is essential to rule out any underlying neuropathic causes.

• The study 2 suggests that ulnar neuropathy at the elbow is more common in patients with diabetic polyneuropathy (DPN). However, this study does not directly address the treatment of elbow pain in prediabetic patients.
• For lateral elbow pain, the study 3 provides low-quality evidence that topical NSAIDs may be beneficial in improving pain for up to 4 weeks. However, the evidence regarding oral NSAIDs is conflicting.
• The study 4 discusses nonarticular causes of elbow pain, including muscle strains, ligamentous injuries, epicondylitis, olecranon bursitis, and compressive neuropathies. Treatment consists of prevention from further overuse, protection by rest and splinting, pharmacologic intervention, and physical therapy.
• The study 5 focuses on treating diabetic peripheral neuropathic pain, which may not be directly applicable to this patient's condition. However, it highlights the importance of considering multiple treatment options and potential drug interactions.
• The study 6 describes a case report of a patient with chronic lateral elbow pain and signs of nerve entrapment, who was treated with neural mobilization techniques, ultrasound, strengthening exercises, and stretching, resulting in minimal symptoms at discharge.

Possible Treatment Approaches

Based on the available evidence, possible treatment approaches for the patient's left elbow pain may include:

• Topical NSAIDs for short-term pain relief 3
• Rest, splinting, and physical therapy to address nonarticular causes of elbow pain 4
• Further evaluation to rule out nerve entrapment or other underlying conditions 2, 6
• Consideration of pharmacologic interventions, such as tricyclic antidepressants or anticonvulsants, if neuropathic pain is suspected 5