What is the appropriate management for chronic elbow pain lasting 2 months?

Management of Chronic Elbow Pain (2 Months Duration)

For chronic elbow pain lasting 2 months, begin with radiographs as the initial imaging study, followed by conservative treatment including rest, activity modification, NSAIDs, physical therapy, and possibly corticosteroid injections if needed. 1, 2

Initial Diagnostic Approach

Imaging

• First-line imaging: Standard radiographs of the elbow 1, 2
  • Helps identify: intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis
  • Include comparison views of the asymptomatic side when possible
  • AP views in internal and external rotation are recommended

Advanced Imaging (if radiographs are normal or nonspecific)

• MRI elbow: Consider if suspecting soft tissue pathology not visible on radiographs
• CT arthrography: Useful for evaluating heterotopic ossification, loose bodies, and osteoarthritis (93% sensitivity for loose body detection) 1

Treatment Algorithm

First-line Treatment (0-4 weeks)

• Rest and activity modification: Avoid aggravating movements
• Pain management:
  • NSAIDs: Ibuprofen 1.2-2.4g daily or naproxen 500mg twice daily 2
  • Can combine with acetaminophen (up to 4g daily) for enhanced pain relief
  • Ice application for pain control

Second-line Treatment (4-8 weeks)

• Physical therapy: Focus on progressive strengthening and eccentric training 2
  • For lateral epicondyle tendinopathy: Education, stretching, and activity modification have shown significant improvement in pain and function 3
• Bracing: Functional support may be beneficial during activities

Third-line Treatment (if inadequate response after 8 weeks)

• Corticosteroid injections: Consider if conservative measures fail 1, 2
  • Limit to 2-3 injections with 4-6 weeks between injections
  • Use proper aseptic technique
  • Monitor diabetic patients for transient hyperglycemia
  • Note: While providing short-term relief, injections don't change long-term outcomes

When to Consider Surgical Referral

• Persistent symptoms despite 3-6 months of well-managed conservative treatment 2
• Presence of:
  • Collateral ligament injury
  • Biceps injury
  • Cubital tunnel syndrome
  • Osteochondral abnormalities
  • Significant functional limitation

Special Considerations

For Suspected Ulnar Neuropathy at the Elbow

• If mild symptoms: Information on avoiding prolonged movements or positions may improve subjective discomfort 4
• If moderate to severe symptoms: Consider surgical options (simple decompression has similar outcomes to transposition with fewer wound infections) 4

For Elbow Stiffness

• Initial conservative treatment with physiotherapy and splinting for soft tissue contractures 5
• Early surgical intervention if osseous deformities limit range of motion 5

Follow-up Assessment

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement
  • Signs of recurrent instability 2

Common Pitfalls to Avoid

• Delayed imaging: Don't postpone radiographs as they're essential for initial assessment
• Prolonged immobilization: This can lead to stiffness and delayed recovery
• Overuse of corticosteroid injections: Limit to 2-3 injections to avoid tendon weakening
• Premature return to aggravating activities: Ensure adequate healing before resuming activities that caused the initial injury
• Missing nerve entrapment: Consider ulnar neuropathy if paresthesias or weakness are present