What is the recommended assessment and treatment for tendinitis of the elbow?

Assessment and Treatment of Elbow Tendinitis

The recommended approach for elbow tendinitis includes relative rest to reduce repetitive loading, cryotherapy for acute pain relief, eccentric strengthening exercises, and short-term NSAIDs, with corticosteroid injections considered for acute pain relief when conservative measures fail. 1

Clinical Assessment

History

• Look for insidious onset of load-related localized pain coinciding with increased activity 1
• Most patients report engaging in a new activity or increasing intensity of current activity before symptom onset 1
• In early stages, pain is present during activity but may subside after warm-up; later stages show increased pain intensity and duration, possibly present at rest 1
• Patients typically describe pain as "sharp" or "stabbing" 1
• For lateral epicondylitis (tennis elbow), inquire about activities requiring repetitive wrist extension and supination 2

Physical Examination

• Inspect for muscle atrophy, asymmetry, swelling, erythema, and joint effusions 1
• Note that atrophy suggests chronicity, while joint effusions are uncommon with tendinopathy and suggest intra-articular pathology 1
• Assess range of motion, which is often limited on the symptomatic side 1
• Palpate for well-localized tenderness that reproduces the patient's activity-related pain 1
• Perform physical maneuvers that simulate tendon loading to reproduce pain 1
• For lateral epicondylitis, check for lateral elbow pain during twisting and gripping, and tenderness at lateral forearm exacerbated by stress testing of forearm extensors 3
• Multiple symptomatic tendons should prompt evaluation for rheumatic disease 1

Imaging

• Plain radiography is the initial choice for acute injuries 4
  • May show osteophyte formation at epicondyles, degenerative joint disease, loose bodies, or fractures 1
  • Limited ability to demonstrate soft-tissue changes of tendinopathy 1
• Reserve further imaging for unclear diagnoses, recalcitrant pain despite adequate conservative management, or preoperative evaluation 1
• Ultrasonography can show thickening and heterogeneous echogenicity in elbow tendinopathy 1
  • Provides dynamic, functional assessment of tendons and ligaments under stress and motion 5
  • Cost-efficient and portable for point-of-care examination 5
• MRI can show degenerative thickening of tendons, fibrovascular proliferation, and mucoid degeneration 1
  • Preferred imaging modality for chronic elbow pain 4

Treatment Approach

First-Line Management

• Relative rest to decrease repetitive loading of the damaged tendon 1
  • Avoid complete immobilization to prevent muscular atrophy and deconditioning 6
  • Allow patients to continue activities that don't worsen pain 1
• Cryotherapy for short-term pain relief 1
  • Apply melting ice water through a wet towel for 10-minute periods 1
• Eccentric strengthening exercises 1
  • Proven beneficial in tendinosis and may reverse degenerative changes 6
  • Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
• Stretching exercises 1

Pharmacologic Interventions

• NSAIDs for short-term pain relief (no effect on long-term outcomes) 1, 6
• Topical NSAIDs may provide similar pain relief with fewer systemic side effects 1, 6
• Corticosteroid injections 1
  • More effective than NSAIDs for acute pain relief 1
  • Do not alter long-term outcomes 1, 6

Advanced Interventions

• Deep transverse friction massage to reduce pain 1, 6
• Extracorporeal shock wave therapy (ESWT) 1
  • Safe, noninvasive option for chronic tendinopathies, though expensive 6
• Therapeutic ultrasonography, corticosteroid iontophoresis, and phonophoresis have uncertain benefit 1
• Surgical intervention if conservative treatment fails after 3-6 months 1, 7
  • Effective in carefully selected patients 1
  • For lateral epicondylitis, release of the extensor carpi radialis brevis tendon may be performed via percutaneous, arthroscopic, or open approaches 2

Special Considerations for Elbow Tendinopathy Types

Lateral Epicondylitis (Tennis Elbow)

• Seven to ten times more common than medial epicondylitis 1
• Involves the dominant arm 75% of the time 1
• Affects men and women equally, most common after age 40 1
• Common in racquet sports players and occupations requiring repetitive wrist flexion/extension 1
• If treatment is unsuccessful, consider radial tunnel syndrome 4

Medial Epicondylitis

• Less common than lateral epicondylitis 1
• If treatment is unsuccessful, consider ulnar neuropathy 4