What are the treatment options for left elbow pain and snapping with no identifiable tear on Magnetic Resonance Imaging (MRI)?

Treatment Options for Left Elbow Pain and Snapping with No Tear on MRI

Conservative management with rest, activity modification, physical therapy, and NSAIDs should be the initial treatment approach, with arthroscopic resection of hypertrophic synovial tissue reserved for cases failing conservative therapy after 5-9 months. 1, 2

Initial Conservative Management

The first-line treatment for elbow pain and snapping without identifiable tear follows the standard approach for chronic elbow conditions:

• Rest and activity modification to reduce mechanical irritation 1
• Analgesic medications including NSAIDs for pain control 1
• Physical therapy focusing on range of motion and strengthening 1
• Corticosteroid injections may be considered for persistent symptoms 1

Conservative treatment should typically be attempted for at least 5-9 months before considering surgical intervention 2

Diagnostic Considerations for Snapping

When MRI shows no identifiable tear but snapping persists, several specific pathologies should be considered:

Hypertrophic Synovial Plica

• Hypertrophic synovial folds in the radiohumeral joint are a recognized cause of lateral elbow snapping and pain 3, 2
• MRI typically reveals hypertrophic synovial plicae with associated joint effusion 2
• Clinical examination shows painful snapping between 80-100 degrees of flexion with forearm in pronation 2

Annular Ligament Hypertrophy

• Thickening of the annular ligament can cause lateral elbow snapping even without frank tear 3, 4
• MRI demonstrates hypertrophy of the annular ligament, often with associated lateral epicondylitis 3
• This condition is frequently misdiagnosed as lateral epicondylitis alone 3

Ulnar Nerve Pathology

• Dynamic ultrasound is superior to MRI for detecting ulnar nerve dislocation and snapping triceps syndrome 1
• MRI neurography remains the reference standard for ulnar nerve entrapment, showing high signal intensity and nerve enlargement 1
• CT in flexion and extension can demonstrate recurrent ulnar nerve dislocation from snapping medial triceps head 1

Additional Imaging When MRI is Non-Diagnostic

If standard MRI shows no tear but symptoms persist:

• Dynamic ultrasound is highly valuable for detecting nerve dislocation and snapping triceps syndrome with sensitivity/specificity of 96%/81% 1
• MR arthrography at 3T is more accurate than standard MRI for detecting collateral ligament injuries 1
• CT in flexion and extension can reveal dynamic pathology not visible on static imaging 1

Surgical Intervention

When conservative management fails after 5-9 months:

Arthroscopic Treatment

• Arthroscopic resection of hypertrophic synovial plicae is the preferred surgical approach for radiohumeral plica 2
• Arthroscopy allows direct visualization of transient interposition and compression of synovial folds during elbow motion 2
• Outcomes are excellent at 6-12 months follow-up after arthroscopic plica resection 2

Open Surgical Options

• Open excision of thickened annular ligament may be necessary when arthroscopic debridement fails 4
• Complete symptom resolution typically occurs after open resection of hypertrophied annular ligament 3
• Early surgical intervention is recommended to prevent articular cartilage erosion and early-onset arthritis 3

Critical Pitfalls to Avoid

• Do not dismiss snapping as benign when MRI shows no tear—hypertrophic synovial tissue and ligament thickening may not appear as "tears" but still cause significant pathology 3, 2
• Misdiagnosis as lateral epicondylitis alone is common and can lead to unnecessary repeat surgeries 3, 4
• Static MRI may miss dynamic pathology—consider dynamic ultrasound or stress imaging if symptoms persist despite negative MRI 1
• Bilateral involvement is rare but possible, particularly in patients performing repetitive exercises 5

Treatment Algorithm

1. Initial phase (0-5 months): Conservative management with rest, NSAIDs, physical therapy, and possible corticosteroid injection 1
2. If symptoms persist (5-9 months): Consider additional imaging with dynamic ultrasound or MR arthrography 1, 2
3. Surgical consideration (after 5-9 months of failed conservative care): Arthroscopic evaluation and resection of identified pathology 2
4. If arthroscopy fails: Open surgical excision may be required 4