What are the diagnostic and treatment approaches for elbow tendinitis?

Elbow Tendinitis: Diagnosis and Treatment Approaches

Elbow tendinitis should be diagnosed clinically through history and physical examination, with initial treatment including conservative measures such as rest, activity modification, NSAIDs, and eccentric strengthening exercises for 3-6 months before considering surgical options. 1

Diagnosis

Clinical Presentation

• Lateral epicondylitis (tennis elbow):
  • Lateral elbow pain
  • Pain with wrist extension
  • Weakened grip strength 2
  • 7-10 times more common than medial epicondylitis
  • Affects dominant arm 75% of the time
  • Equally affects men and women
  • Most common after age 40 3

Physical Examination

• Tenderness over lateral epicondyle
• Pain with resisted wrist extension
• Pain exacerbated by activities requiring repetitive wrist extension 3

Imaging

• Plain radiographs are beneficial as initial imaging to rule out other causes 1
• Advanced imaging (MRI, ultrasound) only necessary if:
  • Conventional therapy fails
  • Suspicion of complete tendon rupture
  • Need to rule out other pathology 4

Treatment Algorithm

Phase 1: Initial Conservative Management (0-4 weeks)

1. Relative rest and activity modification

   • Avoid activities that exacerbate symptoms
   • Modify techniques in sports or occupational activities 1

2. Pain control

   • NSAIDs as first-line medication
   • Acetaminophen (up to 4g/day) if NSAIDs are contraindicated 1

3. Physical therapy

   • Eccentric strengthening exercises (cornerstone of rehabilitation)
   • Deep transverse friction massage 1

4. Bracing

   • Counterforce bracing can provide symptom relief 4

Phase 2: Persistent Symptoms (4-12 weeks)

1. Corticosteroid injections

   • More effective than NSAIDs in acute phase
   • Does not change long-term outcomes
   • Limit to 2-3 injections with 4-6 weeks between injections
   • Avoid peri-tendon injections (risk of tendon rupture) 3, 1

2. Continue physical therapy

   • Progress eccentric strengthening program
   • Sport-specific or activity-specific exercises 1

3. Consider orthotic devices

   • Though definitive evidence for effectiveness is lacking 3

Phase 3: Refractory Cases (>3-6 months)

1. Consider surgical referral if:

   • Pain persists despite 3-6 months of well-managed conservative treatment
   • Tears >50% of tendon thickness
   • Cases requiring quick recovery 1

2. Surgical options:

   • Excision of abnormal tendon tissue
   • Longitudinal tenotomies to release areas of scarring and fibrosis
   • Can be performed via percutaneous, arthroscopic, or open approaches 3, 2

Important Considerations

Pathophysiology

• Despite being called "tendinitis," the condition actually demonstrates angiofibroblastic degeneration (tendinosis) rather than inflammation 4
• Activities requiring repetitive wrist extension contribute to lateral epicondylosis 3

Prognosis

• Over 90% of cases have good prognosis with appropriate conservative management 1
• Even with optimum management, resolution typically requires 3-6 months 5
• Surgery is required in less than 10% of cases 5
• Post-surgical recovery also requires 3-6 months 5

Common Pitfalls to Avoid

1. Misdiagnosis

   • Thorough understanding of differential diagnosis is essential 2
   • Consider other causes of lateral elbow pain (radial nerve entrapment, cervical radiculopathy)

2. Overuse of corticosteroid injections

   • Limit to 2-3 injections
   • Avoid peri-tendon injections due to risk of tendon rupture 1

3. Premature return to aggravating activities

   • Ensure adequate healing time before resuming full activities
   • Modify technique to prevent recurrence 1

4. Delayed surgical referral

   • Consider surgical options if no improvement after 3-6 months of consistent therapy 1

5. Special populations

   • Diabetic patients tend to respond less to conservative measures
   • May require different treatment strategies 1