What is the initial treatment for a partial tear of the common extensor tendon at the elbow?

Treatment of Partial Tear Common Extensor Tendon at Elbow

The initial treatment for a partial tear of the common extensor tendon at the elbow should focus on conservative management including relative rest, activity modification, ice application, NSAIDs, and bracing. 1

First-Line Conservative Management

• Relative rest is essential to prevent ongoing damage, reduce pain, and promote tendon healing, while avoiding complete immobilization that could lead to muscular atrophy 1
• Activity modification should include continuing activities that don't worsen pain while temporarily stopping those that aggravate symptoms 1
• Cryotherapy (ice application) for 10-minute periods through a wet towel provides effective short-term pain relief by reducing tissue metabolism and blunting the inflammatory response 2, 1
• NSAIDs (oral or topical) effectively relieve tendon pain:
  • Topical NSAIDs can reduce pain while avoiding gastrointestinal risks associated with oral NSAIDs 2, 1
  • Oral NSAIDs may offer additional benefit in acute inflammatory tendonitis due to their anti-inflammatory properties 2
• Counterforce bracing/orthotics (tennis elbow bands) help reinforce, unload, and protect tendons during activity 1

Rehabilitation Phase (2-8 weeks)

• Eccentric strengthening exercises are beneficial for promoting tendon healing and increasing strength 1
• Stretching exercises for the wrist extensors are widely accepted and helpful for maintaining range of motion 1
• Tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers 2, 1
• Continue bracing as needed during activities 1

Imaging Considerations

• Initial radiography is appropriate for acute elbow pain to rule out fractures or other bony abnormalities 2
• If radiographs are normal or indeterminate and tendon injury is suspected:
  • Ultrasound or MRI without IV contrast is appropriate for assessment of suspected tendon injury 2
  • Ultrasound has moderate agreement with MRI for diagnosis and grading of common extensor tendon tears (sensitivity 64.52%, specificity 85.19%, accuracy 72.73%) 2

Second-Line Treatments (for persistent symptoms)

• Corticosteroid injections may provide more effective short-term pain relief than NSAIDs in the acute phase 2, 1
• CAUTION: Corticosteroid injections should be used with caution as they:
  • Do not tend to alter long-term outcomes 2, 1
  • May inhibit healing and reduce tendon tensile strength 1
  • Can be a contributory cause of tendon rupture 3
• Therapeutic ultrasound may decrease pain and increase collagen synthesis 1
• Extracorporeal shock wave therapy (ESWT) appears safe but requires further research 1
• Deep transverse friction massage can reduce pain 1

Surgical Considerations

• Surgical evaluation may be warranted if pain persists despite 6-12 months of well-managed conservative treatment 1
• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1
• Newer treatments like microfragmented adipose transfer show promise for full-thickness tears but require further research 4

Common Pitfalls and Caveats

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 1, 3
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 2, 1
• Failure to address underlying biomechanical issues or activity modifications may lead to recurrence 1
• Early aggressive activity before adequate healing can worsen the tear 2