What are the treatment options for nerve pain in the elbow?

Treatment of Nerve Pain in the Elbow

For nerve pain in the elbow, begin with conservative management including activity modification, eccentric strengthening exercises, NSAIDs, and counterforce bracing, reserving corticosteroid injections for refractory cases and surgical consultation only after 6-12 months of failed conservative treatment. 1, 2

Diagnostic Workup

Initial imaging should be plain radiographs of the elbow to rule out bony abnormalities and other causes of elbow pain. 3, 1

For suspected nerve entrapment after normal or nonspecific radiographs:

• T2-weighted MR neurography is the reference standard for imaging ulnar nerve entrapment (UNE), showing high signal intensity and nerve enlargement as the most common findings. 3
• Ultrasound is an excellent alternative, with high accuracy rates for assessing cross-sectional area and nerve thickness, and can demonstrate hourglass constriction of the nerve. 3
• Dynamic ultrasound is particularly helpful for demonstrating nerve dislocation in ulnar neuropathy and snapping triceps syndrome. 3
• MRI can also evaluate radial nerve, median nerve, and other entrapment syndromes beyond just ulnar nerve pathology. 3

Clinical diagnosis relies on pain at the medial epicondyle with resisted wrist flexion for medial epicondylitis, or lateral pain with neural tension testing for radial nerve entrapment. 1, 4

First-Line Conservative Management (0-4 weeks initial phase)

Activity modification is essential - avoid repetitive loading activities that aggravate symptoms, but do not completely immobilize as this leads to muscle atrophy. 1, 2

• Relative rest prevents ongoing damage and promotes tendon healing while maintaining activities that don't worsen pain. 1, 2
• Cryotherapy (ice application) for 10-minute periods through a wet towel provides effective acute pain relief. 1, 2
• NSAIDs (oral or topical) effectively relieve pain, though they may not affect long-term outcomes; topical formulations avoid gastrointestinal risks. 1, 2
• Counterforce bracing/orthotics help reinforce, unload, and protect tendons during activity. 1, 2

Rehabilitation Phase (2-8 weeks)

Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength by stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 1, 2

• Progressive strengthening exercises should focus on the flexor-pronator muscle group for medial epicondylitis or wrist extensors for lateral epicondylitis. 1, 2
• Stretching exercises for the affected muscle groups (wrist flexors or extensors) are widely accepted and beneficial. 1, 2
• Deep transverse friction massage can reduce pain. 1, 2
• Neural mobilization techniques may be useful for patients with signs of nerve entrapment (such as radial tunnel syndrome), designed to free nerves for movement. 4

Second-Line Treatment Options

Corticosteroid injections may be more effective than NSAIDs in the acute phase and can provide short-term pain relief, but they do not change long-term outcomes. 1, 2

Critical Caveat About Corticosteroids:

• Use with extreme caution - corticosteroids may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture. 2
• Overreliance on corticosteroid injections is a common pitfall that can lead to tendon weakening. 2

Additional second-line modalities with limited evidence:

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence is weak. 2
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research. 2

Surgical Management

Surgical evaluation is warranted only if pain persists despite 6-12 months of well-managed conservative treatment. 2

For ulnar nerve entrapment specifically:

• Treatment should be tailored to the presumed etiology - surgical release for entrapment under the humeroulnar aponeurosis versus avoidance of inappropriate arm positioning for extrinsic compression in the retrocondylar groove. 5
• Both surgical decompression and non-operative treatment show similar improvement rates (83-84%) at 2.5 years follow-up, with improvements in nerve conduction velocity and decreased nerve cross-sectional area. 5
• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 2

Common Pitfalls to Avoid

• Never completely immobilize the elbow - this leads to muscular atrophy and deconditioning. 2
• Avoid overusing corticosteroid injections due to risk of tendon weakening and rupture. 2
• Consider nerve entrapment in the differential - activities involving extreme elbow flexion and shoulder abduction (such as prolonged phone use) can increase ulnar nerve strain significantly, especially if nerve gliding motion is restricted. 6, 7
• Electrodiagnostic studies can be a useful adjunct to clinical examination to help localize the site and quantify the grade of nerve compression. 8