What is the recommended treatment for a patient with a small enthesophyte at the triceps insertion site, presenting with elbow pain?

Treatment for Enthesophyte at Triceps Insertion Causing Elbow Pain

Conservative management with NSAIDs and physical therapy is the recommended first-line treatment for a small enthesophyte at the triceps insertion site presenting with elbow pain. 1

Diagnostic Approach

When evaluating a patient with elbow pain and radiographic evidence of an enthesophyte at the triceps insertion, consider:

• Radiography is appropriate as the initial imaging study for chronic elbow pain 2
• If symptoms persist or diagnosis is unclear, advanced imaging may be indicated:
  • MRI without IV contrast is recommended if symptoms persist despite conservative management for 6-8 weeks 1
  • Ultrasound can be useful for evaluating tendon pathology and enthesitis 1, 3

Treatment Algorithm

First-Line Treatment (0-6 weeks)

• NSAIDs: First-line pharmacological treatment
  • Ibuprofen 1.2g daily (can be increased to 2.4g daily if needed)
  • Can be combined with acetaminophen (up to 4g daily) for inadequate relief 1
• Physical therapy:
  • RICE protocol (Rest, Ice, Compression, Elevation) for initial pain management
  • Progressive loading exercises focusing on triceps strengthening
  • Range of motion exercises 1
• Activity modification: Avoid activities that exacerbate symptoms

Second-Line Treatment (6-12 weeks)

If symptoms persist after 6 weeks of conservative management:

• Corticosteroid injection: Consider local injection for moderate to severe cases
  • Limited to 2-3 injections with 4-6 weeks between injections 1
• Advanced imaging: MRI without contrast to evaluate for associated soft tissue injuries 2, 1

Third-Line Treatment (>12 weeks)

For persistent symptoms despite 3-6 months of well-managed conservative treatment:

• Orthopedic referral for surgical evaluation 1
• Surgical management: Excision of the olecranon traction spur may be considered in refractory cases 4
  • Surgical outcomes are generally favorable with acceptable short to mid-term results
  • Mean QuickDASH score of 3 and mean Mayo Elbow Performance Score of 96 reported after surgical intervention 4

Rehabilitation Protocol

The rehabilitation protocol can be divided into three phases:

1. Initial Phase (0-4 weeks):

   • Pain control and protected range of motion
   • Low-load strengthening exercises

2. Intermediate Phase (4-8 weeks):

   • Progressive strengthening exercises
   • Gradual increase in resistance

3. Advanced Phase (8-12 weeks):

   • Occupation-specific or sport-specific training 1

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates:

• Complete resolution of pain during and after activity
• Full range of motion compared to the uninjured side
• Strength symmetry >90% compared to the uninjured side 1

Important Considerations

• Enthesophytes at the triceps insertion can occasionally fracture, which would require different management 5
• Recurrence of enthesophyte formation is possible even after surgical excision (reported in 2 out of 11 patients in one study) 4
• Enthesitis may be a manifestation of seronegative arthropathies, and if multiple joints are involved, early rheumatology referral should be considered 1, 3

Monitoring and Follow-up

• Follow-up within 1-2 weeks after initial treatment
• Consider repeat imaging or specialist referral if no improvement after 3-4 weeks of conservative management 1