What is the best management approach for a 34-year-old male patient with left elbow pain, likely due to overuse or strain injury from weight pulling and regular handball practice, who will be prescribed Voltaren (diclofenac) cream QID (four times a day as needed) and provided an elbow sleeve?

Management of Lateral Epicondylitis in an Active 34-Year-Old Male

For this 34-year-old active male with left elbow pain likely representing lateral epicondylitis ("tennis elbow") from overuse during weight training and handball, the initial treatment with Voltaren (diclofenac) cream QID PRN and an elbow sleeve is appropriate first-line management.

Diagnosis and Initial Assessment

Based on the clinical presentation, this patient is likely suffering from lateral epicondylitis, one of the most common causes of chronic elbow pain, affecting 1-3% of the population 1. The history of pain starting during weight pulling activities, combined with regular handball practice, strongly suggests an overuse injury affecting the common extensor tendon at the lateral epicondyle.

Key diagnostic features to confirm:

• Pain localized to the lateral epicondyle
• Pain exacerbated by gripping activities and wrist extension against resistance
• Tenderness over the lateral epicondyle

Treatment Approach

First-line Management (Current Plan)

1. Topical NSAID (Diclofenac/Voltaren cream)

   • Appropriate first-line medication for localized pain and inflammation 2, 3
   • Apply to clean, dry skin around the elbow 3
   • Wait until completely dry before covering with clothing 3
   • Wash hands thoroughly after application 3

2. Elbow Sleeve/Brace

   • Helps unload and protect the affected area 2
   • Provides compression and proprioceptive feedback

Additional Recommendations

1. Activity Modification

   • Relative rest from aggravating activities (weight pulling, handball) 2
   • Modify technique during weight training to reduce stress on the lateral epicondyle
   • Gradually return to activities as symptoms improve

2. Physical Therapy

   • Should be initiated early alongside medication 2
   • Focus on:
     • Gentle, progressive stretching exercises
     • Eccentric strengthening of wrist extensors
     • Graded activity to increase functional use

3. Ice Application

   • Apply for 15-20 minutes several times daily, especially after activity

Imaging Considerations

• Plain Radiographs (X-rays) should be the initial imaging if symptoms persist beyond 4-6 weeks to rule out other pathologies 1
• MRI without contrast is indicated if symptoms persist despite conservative management for 6-8 weeks, to evaluate for tendon tears or other soft tissue injuries 1

Follow-up and Treatment Progression

• Reassess in 4-6 weeks 2
• If minimal improvement after 8-12 weeks of consistent therapy, consider:
  • Corticosteroid injection (limited to 2-3 injections, 4-6 weeks apart) 2
  • Ultrasound therapy to increase collagen synthesis 2

Prognosis

• Over 90% of cases have good outcomes with appropriate conservative management 2
• Complete resolution typically requires 3-6 months 2
• Athletes may need more comprehensive rehabilitation before returning to full activity

Cautions and Pitfalls

• Avoid overreliance on topical NSAIDs without addressing underlying biomechanical issues
• Recognize that early return to aggravating activities can lead to symptom recurrence
• Consider that persistent pain may indicate a more serious injury requiring advanced imaging
• Avoid prolonged use of elbow sleeve/brace as it may lead to muscle atrophy

When to Consider Referral

Consider orthopedic referral if:

• Pain persists despite 3-6 months of well-managed conservative treatment
• Significant functional limitations impact quality of life
• Suspicion of more serious pathology (e.g., osteochondral lesion, ligament tear)