What is the appropriate management for elbow tendon issues?

Management of Elbow Tendon Issues

The appropriate management for elbow tendon issues should follow a stepwise approach beginning with conservative measures including rest, activity modification, NSAIDs, physical therapy, and eccentric strengthening exercises, with corticosteroid injections used judiciously (limited to 2-3 injections), and surgery reserved only for cases that fail 3-6 months of well-managed conservative treatment. 1, 2

Initial Assessment and Diagnosis

• Imaging: Standard radiographs (anteroposterior and lateral views) should be the first imaging study for chronic elbow pain 1, 2

  • Radiographs can identify intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis
  • Comparison with the asymptomatic side is often useful
  • Advanced imaging (MRI, CT arthrography) should be considered only after initial radiographs when more detailed assessment is needed

• Clinical Presentation: Tennis elbow (lateral epicondylitis) is the most common elbow tendon issue, presenting as pain and localized tenderness at the lateral aspect of the elbow 3

  • Lateral epicondylitis is 3-7 times more common than medial epicondylitis 4
  • These conditions represent tendinous microtearing with incomplete reparative response, not primarily inflammation 4

Treatment Algorithm

Phase 1: Conservative Management (0-4 weeks)

1. Pain Control:

   • NSAIDs (naproxen 500mg twice daily or ibuprofen 1.2g daily) for short-term pain relief 2
   • Cryotherapy in the acute stage 5
   • Rest defined as absence of painful activity 5

2. Initial Rehabilitation:

   • Protected range of motion exercises 2
   • Use of counterforce bracing for functional support 2, 6
   • Avoid complete immobilization 2

Phase 2: Progressive Rehabilitation (4-8 weeks)

1. Strengthening Program:

   • Progressive strengthening exercises 2
   • Eccentric training specifically targeting affected tendons 2
   • Heat therapy and ultrasound may be beneficial 5, 7

2. Injection Therapy (if inadequate response to initial measures):

   • Corticosteroid injections for short-term relief 2
   • Limit to 2-3 injections with 4-6 weeks between injections 2
   • Use proper aseptic technique and post-injection care instructions 2
   • Important caveat: While injections provide short-term relief, they do not improve long-term outcomes 2

Phase 3: Advanced Rehabilitation (8-12 weeks)

1. Functional Training:

   • Occupation-specific training 2
   • Sport-specific or activity-specific exercises 2
   • Equipment modification if applicable (especially for tennis players) 6

2. Assessment for Treatment Failure:

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

Phase 4: Consideration of Surgical Intervention

1. Surgical Referral Criteria:

   • Failure of conservative measures after 3-6 months of well-managed treatment 2
   • Persistent significant functional limitation 2
   • Primary surgical intervention indicated for:
     • Osteochondral fracture
     • Large loose bodies requiring removal 2

2. Surgical Options:

   • Both open and arthroscopic methods are acceptable with excellent results 3
   • Surgery should be used only as a last resort 3

Return to Activity Guidelines

• Complete resolution of pain
• Full range of motion
• Strength symmetry >90% compared to uninjured side
• Successful completion of occupation-specific functional tests 2
• Gradual return to activity following American College of Sports Medicine guidelines 2

Important Considerations and Pitfalls

• Self-limiting nature: Tennis elbow is largely self-limiting, with 90% of cases having no recurrence after the initial episode 5
• Success rate: Conservative treatment is successful in up to 90% of cases 3
• Age consideration: Peak incidence of tennis elbow occurs between ages 40-50 5
• Avoid overtreatment: Follow Hippocrates' principle of "first do no harm" - start with simple, conservative approaches before progressing to more invasive therapies 5
• Injection caution: There is "considerable disadvantage" in using more than 2 corticosteroid injections 5
• Complementary approaches: Treatments such as acupuncture may be tried before resorting to more invasive therapy, though evidence is limited 5