What is the best course of treatment for right shoulder pain radiating to the elbow with a recent increase in repetitive movement?

Right Shoulder Pain Radiating to Elbow with Increased Repetitive Movement

This presentation is consistent with an overuse tendinopathy (likely rotator cuff or lateral epicondyle involvement), and you should initiate conservative management with relative rest, ice application, eccentric strengthening exercises, and short-term NSAIDs for pain relief. 1

Initial Diagnostic Approach

Clinical Evaluation

• Obtain plain radiographs of the shoulder and elbow as the initial imaging study to rule out fracture, heterotopic ossification, soft tissue calcification, or osteoarthritis 1
• Look for insidious onset of load-related localized pain that initially occurs during activity but may subside after warm-up, with pain described as "sharp" or "stabbing" 1
• Examine for muscle atrophy (suggests chronicity), swelling, erythema, and asymmetry; joint effusions are uncommon with tendinopathy and suggest intra-articular pathology 1
• Assess range of motion and palpate for tenderness at the rotator cuff insertion and lateral epicondyle 1

Advanced Imaging (If Radiographs Normal/Nonspecific)

• Consider MRI without contrast if diagnosis remains unclear after radiographs and clinical examination, as it can identify rotator cuff pathology, tendinosis, and other soft tissue abnormalities 1
• Ultrasound is an alternative for evaluating rotator cuff and tendon pathology 2

Conservative Treatment Protocol (First 3-6 Months)

Immediate Interventions

• Relative rest and activity modification to reduce repetitive loading of the damaged tendon; this prevents further damage and promotes healing 1
• Cryotherapy with melting ice water through a wet towel for 10-minute periods, repeated multiple times daily for acute pain relief 1

Exercise Therapy (Primary Treatment)

• Eccentric strengthening exercises are the cornerstone of treatment and may reverse degenerative changes in the tendon 1
• Physical therapy focusing on range of motion and strengthening should be initiated early 3, 4
• Avoid overhead pulleys as they encourage uncontrolled abduction and may worsen symptoms 1

Pharmacological Management

• NSAIDs (oral or topical) for short-term pain relief (typically 2-4 weeks), though they do not alter long-term outcomes 1
• Topical NSAIDs may have fewer systemic side effects than oral formulations 1
• NSAIDs are effective for acute pain but should not be used long-term as they provide no benefit beyond initial symptom control 1

Corticosteroid Injections (If Needed)

• Locally injected corticosteroids may be more effective than oral NSAIDs for acute-phase pain relief but do not alter long-term outcomes 1
• Use with caution and reserve for patients with persistent symptoms after initial conservative measures 1, 3
• Subacromial injection may be appropriate if rotator cuff pathology is confirmed 1

Additional Treatment Modalities

Evidence-Based Options

• Extracorporeal shock wave therapy is a safe, noninvasive option for chronic tendinopathies but is expensive 1
• Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis have uncertain benefit 1

Modalities with Limited Evidence

• Ice, heat, and soft tissue massage may provide symptomatic relief 1
• Functional electrical stimulation can be considered 1

Surgical Consideration

Surgery should be reserved for carefully selected patients who have failed 3-6 months of conservative therapy 1, 3

• Arthroscopic decompression or debridement may be indicated for refractory cases 3, 2
• Most patients (approximately 80%) fully recover within 3-6 months with conservative management alone 1

Critical Pitfalls to Avoid

• Do not label this as "tendonitis" - most patients presenting to primary care have chronic degenerative tendinopathy (tendinosus), not acute inflammation 1
• Do not rely on NSAIDs as the primary treatment - they provide only short-term pain relief and should be adjunctive to exercise therapy 1
• Do not use corticosteroid injections as first-line treatment - reserve for persistent symptoms as they do not improve long-term outcomes 1
• Do not recommend complete immobilization - relative rest with gradual return to activity is preferred over complete cessation 1

Treatment Timeline

• 0-6 weeks: Relative rest, ice, NSAIDs for pain control, begin gentle range of motion 1, 3
• 6 weeks-3 months: Progress to eccentric strengthening exercises, continue activity modification 1, 3
• 3-6 months: If no improvement, consider corticosteroid injection or advanced imaging if not yet obtained 1, 3
• After 6 months: Consider surgical consultation for refractory cases 1, 3