What is the recommended treatment for a patient with left elbow pain, olecranon bursitis, lateral epicondylitis, and tendinosis, as shown on MRI?

Treatment Approach for Left Elbow Pain with Olecranon Bursitis, Lateral Epicondylitis, and Tendinosis

Begin with conservative management consisting of relative rest, ice therapy, and eccentric strengthening exercises for 3-6 months, as approximately 80% of patients with overuse tendinopathies fully recover with this approach. 1, 2

Immediate Management Strategy

For the Olecranon Bursitis (20 x 28 x 32 mm)

• Aspirate the bursa if it is causing significant discomfort or functional limitation, as aspiration combined with compression and padding is effective for acute bursitis 3
• The MRI shows subcutaneous edema/cellulitis posteriorly with thick-walled bursitis, but no evidence of osteomyelitis, which suggests this is likely non-septic 3, 4
• Avoid intrabursal corticosteroid injection as initial treatment - recent evidence demonstrates adverse effects compared with noninvasive management for nonseptic olecranon bursitis 5
• Apply compression wrapping and protective padding to prevent further trauma 3, 4
• NSAIDs can provide symptomatic relief for the bursal inflammation 4

For the Lateral Epicondylitis with Partial Tear

The cornerstone of treatment is eccentric strengthening exercises, which stimulate collagen production and guide proper alignment of newly formed collagen fibers. 1, 2

• Implement relative rest by avoiding activities that reproduce the pain (particularly repetitive wrist extension), while maintaining some activity to prevent muscle atrophy 1, 2
• Ice therapy should be applied for short-term pain relief and to reduce swelling 2
• NSAIDs (oral or topical) can effectively relieve acute pain, with topical formulations preferred due to elimination of gastrointestinal hemorrhage risk 1, 2
• Stretching exercises are widely accepted and helpful for tendon rehabilitation 2
• Consider a tennis elbow band to reinforce and unload the extensor tendons during activity 2

For the Triceps and Biceps Tendinosis

• The same eccentric strengthening protocol applies to these degenerative tendon conditions 1, 2
• These are chronic degenerative processes (tendinosis, not tendinitis), meaning anti-inflammatory treatments have limited long-term benefit 1

Timeline and Progression

Continue conservative management for a full 3-6 months before considering more invasive interventions. 1, 2

If Pain Persists After 6-8 Weeks of Conservative Treatment:

• Corticosteroid injection may be considered for the lateral epicondylitis (not the bursitis), but use with extreme caution 2, 6
• Corticosteroids provide more effective acute pain relief than NSAIDs but do not alter long-term outcomes 2, 7
• Critical caveat: Corticosteroids may inhibit healing, reduce tensile strength of tissue, and potentially predispose to tendon rupture - particularly concerning given the existing partial tear 2, 7
• Extracorporeal shock wave therapy (ESWT) is a safer alternative that appears effective, though it requires further research 2, 7
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence is weak 2

If Conservative Treatment Fails After 3-6 Months:

Surgical evaluation is warranted if pain persists despite well-managed conservative treatment for 3-6 months. 1, 2

• For lateral epicondylitis: surgical techniques include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 2
• For recalcitrant olecranon bursitis: surgical bursectomy should be reserved only for chronic/recurrent cases that fail conservative management 5, 4

Critical Pitfalls to Avoid

• Do not rush to corticosteroid injection or surgery - the natural history shows 80% recovery with conservative treatment alone 1, 2
• Do not perform intrabursal corticosteroid injection for the olecranon bursitis - recent evidence shows adverse effects compared to conservative management 5
• Do not use corticosteroid injection near the partial tear without extreme caution - risk of tendon rupture is elevated 2, 7
• Do not label these conditions as "tendonitis" - they are degenerative tendinosis, not inflammatory tendinitis, which changes the treatment approach 1
• Ensure the olecranon bursitis is truly non-septic - if fever >37.8°C, prebursal temperature difference >2.2°C, or skin lesions are present, aspirate and culture the fluid to rule out septic bursitis 4

Monitoring and Follow-up

• Pain should gradually decrease over 3-6 months with appropriate conservative treatment 1, 2
• If the bursa reaccumulates after aspiration, repeat aspiration with compression may be needed 3, 4
• Physical examination maneuvers that simulate tendon loading should show progressive improvement in pain reproduction 1
• Technique modification for any repetitive activities (occupational or recreational) is essential to minimize ongoing tendon stress 2