What is the initial evaluation and management approach for a patient presenting with elbow pain?

Initial Evaluation and Management of Elbow Pain

Begin with plain radiographs (AP, lateral, and oblique views) as first-line imaging, followed by a focused history to localize pain to one of four anatomic regions (anterior, medial, lateral, or posterior), which will guide your diagnostic and treatment algorithm. 1, 2

Initial Imaging

• Plain radiographs are mandatory first-line imaging to identify fractures, intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcifications, and osteoarthritis 1, 2, 3
• Compare with the contralateral asymptomatic elbow when findings are subtle, as this improves diagnostic accuracy 1, 2
• Do not order MRI before plain radiographs—MRI is less sensitive for calcifications and may delay diagnosis of urgent conditions 2

Critical History Elements

Onset and Mechanism

• Determine if pain is acute (trauma, infection) versus chronic (overuse, degenerative) 4
• Identify the specific activity when pain started—overhead throwing suggests medial pathology, repetitive gripping suggests lateral epicondylitis 5, 4
• Document occupational and athletic activities, as lateral and medial epicondylitis commonly result from work-related repetitive motions 4

Pain Localization by Anatomic Region

• Lateral pain: Lateral epicondylitis (most common), radial tunnel syndrome 4
• Medial pain: Medial epicondylitis, ulnar collateral ligament injury (overhead athletes), ulnar neuropathy, anconeus epitrochlearis 1, 5, 4
• Posterior pain: Olecranon bursitis, valgus extension overload, triceps pathology 4
• Anterior pain: Biceps tendinopathy (history of repeated flexion with supination/pronation) 4

Red Flags Requiring Urgent Evaluation

• Acute swelling with systemic signs (fever, chills): Suspect septic arthritis—perform immediate arthrocentesis with culture and start empiric IV antibiotics 2, 3
• Joint effusion with warmth and erythema mandates urgent aspiration to exclude infection 3

Physical Examination Findings

• Lateral epicondylitis: Tenderness over lateral epicondyle, pain with resisted wrist extension 4
• Medial epicondylitis: Tenderness over medial epicondyle, pain with resisted wrist flexion and pronation 4
• Ulnar collateral ligament injury: Medial joint line tenderness, positive valgus stress test (consider stress radiographs to detect medial joint opening) 1
• Olecranon bursitis: Posterior swelling—determine if septic (warmth, erythema, systemic signs) versus aseptic through bursal fluid analysis if necessary 4
• Mechanical symptoms (locking, catching) suggest intra-articular loose bodies 1, 3

Advanced Imaging Algorithm

When Plain Radiographs Are Negative or Inconclusive

For chronic pain with mechanical symptoms:

• MR arthrography provides 100% sensitivity for intra-articular bodies and osteochondral lesion stability 1
• CT arthrography offers 93% sensitivity for loose bodies and excellent assessment of heterotopic ossification 1

For medial pain with suspected ligament or nerve pathology:

• MRI shows 90-100% sensitivity for medial epicondylitis and ulnar collateral ligament injuries 1
• T2-weighted MR neurography is the reference standard for ulnar nerve entrapment 1

For lateral epicondylitis:

• Ultrasound with advanced techniques has 94% sensitivity and 98% specificity for common extensor tendon tears 1
• MRI demonstrates 90-100% sensitivity and 83% specificity 1

For suspected infection when imaging cannot distinguish infected from noninfected fluid:

• Image-guided aspiration with culture is essential and directly affects treatment 3
• CT with IV contrast can differentiate cellulitis, myositis, abscess, and septic arthritis 3

Initial Management Approach

Conservative Management (First-Line for Most Conditions)

• NSAIDs for pain relief combined with activity modification and relative rest 2, 3
• Counterforce bracing for lateral and medial epicondylitis 2
• Manual therapy and prescribed exercises may provide slight reduction in pain and disability at 4 weeks to 3 months (MD -0.53 points for pain, MD -5.00 points for disability), though benefits are modest and not sustained long-term 6
• Gentle range-of-motion exercises for heterotopic ossification (avoid complete immobilization to prevent muscle atrophy and joint stiffness) 2

When to Consider Corticosteroid Injections

• Use for persistent symptoms despite first-line treatment, but exercise caution due to risk of tendon rupture with over-reliance 2, 3

Surgical Consultation Indications

• Refractory cases failing conservative management for 3-6 months 3, 7
• Unstable fractures 3
• Persistent symptoms from anconeus epitrochlearis after failed conservative management (isolated muscle release without ulnar nerve transposition can successfully return athletes to previous function) 5

Common Pitfalls to Avoid

• Failing to exclude septic arthritis when swelling is acute with systemic signs—this is the most critical distinction due to implications for urgent treatment 2, 3
• Ordering MRI before plain radiographs wastes time and resources 2
• Over-reliance on corticosteroid injections increases tendon rupture risk 2
• Complete immobilization leads to muscle atrophy and joint stiffness 2
• Consider referred pain from cervical spine pathology or radial tunnel syndrome when initial imaging is negative and symptoms persist 1
• MRI without contrast may be insufficient for complete collateral ligament evaluation—use MR arthrography for better accuracy 1