What is the treatment for right elbow pain?

Treatment for Right Elbow Pain

Begin with plain radiographs as first-line imaging, followed by conservative management including relative rest, ice application, NSAIDs, and activity modification for 4-12 weeks before considering advanced interventions. 1, 2, 3

Initial Diagnostic Approach

Plain radiographs are mandatory as the first imaging study to exclude fractures, intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, and tumors. 1, 3 This imaging helps differentiate between infectious, inflammatory, traumatic, and neoplastic causes, with the most critical distinction being septic arthritis versus other etiologies due to urgent treatment implications. 3

Key Red Flags Requiring Urgent Evaluation

• Septic arthritis: Joint effusion with systemic signs of infection requires immediate arthrocentesis with culture, followed by empiric antibiotics and potential surgical debridement. 3
• Soft tissue infection/cellulitis: Identified by effacement of fat planes and soft tissue swelling without intra-articular involvement. 3
• Osteomyelitis: Presents with periosteal reaction and erosions acutely, or bone sclerosis chronically. 3

First-Line Conservative Treatment (0-4 weeks)

Relative rest is essential to prevent ongoing damage and promote healing, though complete immobilization should be avoided as it leads to muscle atrophy and deconditioning. 2, 4 Activities that don't worsen pain may be continued, but those aggravating symptoms should be modified or temporarily stopped. 2, 4

Specific Conservative Modalities

• Cryotherapy: Apply ice for 10-minute periods through a damp towel for effective short-term pain relief. 2, 4
• NSAIDs: Both oral and topical formulations effectively relieve pain, with topical NSAIDs reducing tendon pain while avoiding gastrointestinal risks of oral NSAIDs. 3, 4, 5 Topical NSAIDs are significantly more effective than placebo for pain relief (weighted mean difference -1.88,95% CI -2.54 to -1.21) and participant satisfaction. 5
• Protection/bracing: Counterforce bracing (tennis elbow bands) helps reinforce, unload, and protect tendons during activity. 4
• Compression wrap and semirigid supports: Used in management of traumatic injuries. 3

Rehabilitation Phase (2-8 weeks)

Progressive eccentric strengthening exercises are beneficial for promoting tendon healing and increasing strength, as tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers. 4

• Stretching exercises for wrist extensors are widely accepted and helpful. 4
• Continue bracing as needed during this phase. 4

Second-Line Treatments (After 4-12 Weeks of Failed Conservative Management)

Local corticosteroid injections may be more effective than NSAIDs for relief in the acute phase, but should be used with extreme caution. 2, 3, 4 Corticosteroids may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture. 4 Do not use more than 2 corticosteroid injections, as there is no advantage and considerable disadvantage to exceeding this number. 6

Additional Second-Line Options

• Therapeutic ultrasound: May decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak. 4
• Extracorporeal shock wave therapy (ESWT): Appears safe and effective but requires further research. 4
• Deep transverse friction massage: Can reduce pain. 4

Evidence for Manual Therapy and Exercise

Low-certainty evidence indicates that manual therapy and prescribed exercises may slightly reduce pain (MD -0.53 points, 95% CI -0.92 to -0.14) and disability (MD -5.00 points, 95% CI -9.22 to -0.77) at 4 weeks to 3 months, but these effects are not sustained and may not be clinically worthwhile. 7

Advanced Imaging (When Initial Radiographs Are Normal or Nonspecific)

If intra-articular pathology is suspected (osteocartilaginous body, osteochondral lesion, synovial abnormality) and radiographs are normal or nonspecific:

• MRI or MR arthrography: Useful for detecting loose bodies (sensitivity 100%, specificity 67%), evaluating osteochondral lesion stability, UCL injuries, lateral collateral complex injuries, and tendinous pathology. 1, 3
• CT or CT arthrography: Useful for assessing heterotopic ossification, loose bodies (sensitivity 93%, specificity 66%), and osteoarthritis. 1, 3
• Image-guided aspiration: Essential when imaging cannot distinguish infected from noninfected fluid collections. 3

Surgical Treatment

Surgical intervention should only be considered after failure of 6-12 months of appropriate conservative treatment. 2, 4 Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 4 Surgical consultation is also necessary for refractory cases or unstable fractures. 3

Common Pitfalls to Avoid

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture. 4
• Complete immobilization should be avoided as it leads to muscle atrophy. 2, 4
• Oral NSAIDs cause significantly more gastrointestinal adverse effects (RR 3.17,95% CI 1.35 to 7.41) compared to placebo. 5
• Patients with cardiovascular disease or risk factors for ischemic heart disease should follow a gradual approach to pharmacological treatment. 2