What are the next steps for a patient with persistent left elbow pain despite conservative management with physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), elbow sleeve, and intra-articular (IA) injection?

Next Steps for Refractory Elbow Pain After Failed Conservative Management

Order plain radiographs of the elbow immediately if not already done, followed by MRI to identify structural pathology, and refer to orthopedic surgery for evaluation given the 6-month duration of failed conservative treatment. 1

Immediate Diagnostic Workup

Imaging Studies

• Plain radiographs are the essential first step to evaluate for intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis that may have been missed 1
• Radiographs should include comparison views with the contralateral (right) elbow, which is particularly useful for detecting asymmetry 1
• If radiographs are normal or nonspecific, proceed directly to MRI of the elbow to evaluate for tendon degeneration, partial or complete tears, ligamentous injury (particularly ulnar collateral ligament given the weightlifting mechanism), biceps tendon pathology, or nerve entrapment 1, 2
• MRI is the preferred imaging modality for chronic elbow pain and provides superior visualization of muscles, ligaments, tendons, nerves, and cartilage 3

Consider Nerve Involvement

• If the patient reports any numbness, tingling, or radiating symptoms, electromyography should be obtained to evaluate for cubital tunnel syndrome or radial tunnel syndrome 1
• Ulnar neuropathy should be considered when lateral or medial epicondylitis treatments fail 4

Treatment Options While Awaiting Imaging/Referral

Biologic Injections (Consider Before Surgery)

• Platelet-rich plasma (PRP) or autologous whole blood injections may be superior to corticosteroid injections for long-term management of chronic lateral epicondylitis, particularly given that the patient has already failed one IA injection 5, 6
• These biologics show promise for cases that have not responded to standard conservative measures 7, 5
• This represents a reasonable bridge therapy while awaiting surgical evaluation 5, 6

Extracorporeal Shock Wave Therapy (ESWT)

• ESWT appears safe and effective for chronic tendinopathies refractory to other treatments, though it is expensive 1, 8
• This can be considered as an alternative to biologic injections 5

Surgical Referral

Orthopedic surgical consultation is warranted at this point given:

• 6 months of persistent symptoms despite comprehensive conservative management (physical therapy, NSAIDs, bracing, and corticosteroid injection) meets the threshold for surgical evaluation 1, 8, 6
• The American Academy of Family Physicians recommends surgical evaluation after 3-6 months of failed conservative therapy 1
• Guidelines specifically state that surgery is indicated for severe or refractory cases 1

Surgical Options

• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 1, 8
• Open, arthroscopic, and percutaneous approaches are all highly effective with no clear superiority of one method over another 5
• Arthroscopic and percutaneous techniques may result in faster recovery and earlier return to work 5
• If imaging reveals specific pathology (collateral ligament injury, biceps injury, osteochondral abnormalities), surgery becomes even more clearly indicated 1

Common Pitfalls to Avoid

• Do not repeat corticosteroid injections at this stage, as they provide only short-term relief without altering long-term outcomes and may inhibit healing, reduce tendon tensile strength, and predispose to spontaneous rupture 1, 8
• Do not delay imaging—radiographs and MRI are essential to rule out structural pathology that requires surgical intervention 1
• Do not continue ineffective conservative measures indefinitely; 6 months is sufficient to determine treatment failure 1, 6
• Ensure the patient has not been completely immobilized, as this leads to muscle atrophy and deconditioning 8