How do I manage elbow pain that worsens with pushing against pressure?

Management of Elbow Pain with Pushing Against Pressure

Begin with conservative management including relative rest, activity modification, eccentric strengthening exercises, ice application, and NSAIDs, as this approach provides clinically meaningful pain relief for most patients within 3-6 months. 1, 2

Clinical Diagnosis

Your presentation of pain worsening with pushing against pressure strongly suggests lateral epicondylitis (tennis elbow) if pain is on the outer elbow, or medial epicondylitis (golfer's elbow) if pain is on the inner elbow. 1, 2

Key Diagnostic Features:

• Lateral epicondylitis: Tenderness directly over the lateral epicondyle with pain reproduced by resisted wrist extension 3
• Medial epicondylitis: Pain at the medial epicondyle with pain on resisted wrist flexion 1
• Both conditions affect the dominant arm 75% of the time 3

Initial Imaging

Plain radiographs of the elbow are the most appropriate initial imaging study to rule out fractures, loose bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, or osteoarthritis. 4, 1

• Radiographs are often normal in epicondylitis but are essential to exclude other pathology 3
• MRI should be reserved for cases where diagnosis is unclear, symptoms fail conservative treatment for 6-12 months, or surgery is contemplated 1, 3

First-Line Conservative Treatment (0-8 weeks)

Activity Modification and Rest

• Relative rest prevents ongoing tendon damage and promotes healing, but complete immobilization should be avoided as it causes muscle atrophy 2
• Modify or temporarily stop activities that aggravate symptoms, while continuing activities that don't worsen pain 2

Physical Therapy Interventions

• Eccentric strengthening exercises are the cornerstone of treatment, promoting tendon healing and increasing strength 1, 2
• Stretching exercises for wrist flexors (medial epicondylitis) or wrist extensors (lateral epicondylitis) 1, 2
• Deep transverse friction massage can reduce pain 1, 2
• Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 2

Pain Management

• Cryotherapy: Apply ice for 10-minute periods through a wet towel for effective short-term pain relief 1, 2
• NSAIDs (oral or topical): Provide acute pain relief, though they don't affect long-term outcomes 1, 2
• Topical NSAIDs reduce tendon pain while avoiding gastrointestinal risks of oral NSAIDs 2
• NSAIDs should be used at the lowest effective dose for the shortest duration due to risks of bleeding, ulcers, cardiovascular events, and kidney problems 5

Bracing

• Counterforce bracing (tennis elbow bands) help reinforce, unload, and protect tendons during activity 2

Second-Line Treatment (If No Improvement After 4-8 Weeks)

Corticosteroid Injections

• More effective than NSAIDs in the acute phase for short-term pain relief 1, 2
• Do not alter long-term outcomes and should be used with caution 1, 2
• Major caveat: Corticosteroids may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 2

Other Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence is weak 2
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 2

Expected Timeline

Approximately 80% of patients fully recover within 3-6 months with conservative treatment alone. 3

Low-certainty evidence from 12 trials shows that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, though benefits may not be sustained long-term. 6

Surgical Referral

If pain persists despite 6-12 months of well-managed conservative treatment, surgical evaluation is warranted. 2

• Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 2
• Surgery may also be indicated for collateral ligament injury, biceps injury, cubital tunnel syndrome, or osteochondral abnormalities 4

Critical Pitfalls to Avoid

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 2
• Complete immobilization leads to muscle atrophy and deconditioning—maintain some activity 2
• Premature return to aggravating activities before adequate tendon healing can perpetuate the condition 1