What is the recommended treatment for a patient with mild tendinosis and possible ulnar neuropathy?

Treatment Recommendations for Mild Tendinosis and Possible Ulnar Neuropathy

Begin with conservative management for both conditions: relative rest, eccentric strengthening exercises for the tendinosis, and activity modification with avoidance of prolonged elbow flexion for the ulnar neuropathy. 1, 2, 3

Initial Conservative Management for Tendinosis

First-Line Interventions

• Relative rest is essential by reducing repetitive loading activities that stress the affected tendons (common flexor, common extensor, and distal biceps). 1, 2
• Apply cryotherapy using melting ice water through a wet towel for 10-minute periods to provide acute pain relief. 2
• Consider topical NSAIDs for pain control, which offer fewer systemic side effects than oral formulations. 2

Rehabilitative Therapy

• Eccentric strengthening exercises are the cornerstone of treatment and may reverse degenerative tendon changes; these should be initiated once acute pain subsides. 2, 4
• Deep transverse friction massage may help reduce pain in tendinopathies. 2
• Tennis elbow bands or counterforce bracing can unload the common extensor and flexor tendons during activities, though evidence is limited. 1

Medications to Consider

• Oral NSAIDs (such as naproxen 500 mg twice daily for acute tendinitis) may provide short-term pain relief, though their long-term effectiveness for chronic tendinosis is not well-established. 5, 4
• Avoid corticosteroid injections into the tendon substance, as they may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture despite providing short-term pain relief. 1, 4

Management of Possible Ulnar Neuropathy

Conservative Approach (First-Line)

• Provide education on avoiding prolonged elbow flexion positions (such as during sleep or phone use), as this is effective in improving subjective discomfort in mild to moderate cases. 3
• Night splinting to maintain the elbow in extension may be considered, though evidence for additional benefit beyond positional education is limited. 3
• Nerve gliding exercises have not demonstrated clear benefit beyond activity modification alone. 3

When Conservative Management Fails

• Corticosteroid injections show no significant benefit over placebo at three months for ulnar neuropathy. 3
• If symptoms persist or worsen after 3-6 months of conservative treatment, refer for surgical evaluation. 3, 6
• Simple decompression and decompression with transposition are equally effective for ulnar neuropathy, though simple decompression has fewer wound infections. 3

Timeline and Expected Outcomes

• Approximately 80% of patients with tendinopathies fully recover with conservative management within 3-6 months. 2
• Many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously with conservative care. 7
• Surgery should only be considered if conservative measures fail after 3-6 months of consistent treatment for either condition. 2, 3

Critical Pitfalls to Avoid

• Do not misdiagnose these conditions as inflammatory ("tendinitis") rather than degenerative ("tendinosis"), as this leads to overreliance on anti-inflammatory treatments that may not address the underlying pathology. 1, 2
• Failure to address biomechanical issues or technique problems (especially in athletes or manual laborers) will lead to recurrence. 1, 2
• The MRI findings of "mild enlargement and increased fluid signal of the ulnar nerve proximal to the cubital tunnel" suggest early neuropathy, but this does not automatically warrant surgical intervention. 3, 7
• Avoid injecting corticosteroids directly into tendon substance, as peritendinous injections may also have deleterious effects on healing. 1