What could be causing pain in my left elbow that radiates down to my hand and is painful even when I grab things?

Elbow Pain Radiating to Hand: Differential Diagnosis and Management

Start with plain radiographs of the elbow immediately to exclude fracture, dislocation, heterotopic ossification, or arthritis, as this is the most appropriate initial imaging regardless of whether your pain is acute or chronic. 1, 2

Most Likely Diagnoses Based on Your Symptoms

Your presentation of elbow pain radiating down to the hand with difficulty gripping suggests several key possibilities:

Lateral Epicondylitis (Tennis Elbow)

• This is the most common cause if your pain is on the outer elbow and worsens with gripping or pushing against resistance. 3
• Pain is reproduced by resisted wrist extension and there is tenderness directly over the lateral epicondyle. 3
• Approximately 80% of patients fully recover within 3-6 months with conservative treatment alone. 3

Radial Tunnel Syndrome

• Consider this diagnosis if lateral elbow and dorsal forearm pain radiates to the wrist and dorsum of fingers, particularly in women aged 30-50 years. 4
• This occurs from intermittent compression of the radial nerve from the radial head to the inferior border of the supinator muscle, without obvious extensor muscle weakness. 4
• The arcade of Frohse is the most common compression site. 4
• Clinical examination is more important than electrodiagnostic tests, with the "rule of nine test" and weakness of third finger/wrist extension being valuable physical exam findings. 4

Medial Epicondylitis (Golfer's Elbow)

• If your pain is on the inner elbow, this presents with pain particularly during repetitive wrist flexion and forearm pronation. 2
• Can have associated paresthesias if there is secondary ulnar nerve irritation. 2

Ulnar Neuropathy

• Should be considered if lateral or medial epicondylitis treatments are unsuccessful. 5
• Associated with tingling and weakness radiating down the forearm. 2

Diagnostic Approach

Initial Imaging

• Plain radiographs are essential first-line imaging to exclude fractures, loose bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, or osteoarthritis. 1, 3
• Radiographs may be normal in epicondylitis but are essential to exclude other pathology. 3
• An elbow joint effusion identified by posterior and anterior fat pad elevation suggests an occult fracture in the context of trauma. 1

Advanced Imaging (If Radiographs Normal)

• MRI without contrast should be considered if radiographs are normal and soft tissue pathology is suspected. 2
• MRI may show muscle edema or atrophy along the distribution of the posterior interosseous nerve in radial tunnel syndrome. 4
• Ultrasound is useful for visualizing nerve thickening and aiding in diagnosis of nerve entrapment. 2

Treatment Algorithm

First-Line Conservative Treatment (0-4 weeks)

• Relative rest and activity modification to prevent ongoing tendon damage, but avoid complete immobilization as it causes muscle atrophy. 6, 3
• Ice application (cryotherapy) for 10-minute periods through a wet towel for short-term pain relief. 6, 3
• NSAIDs (oral or topical) for acute pain relief, though they don't affect long-term outcomes. 3, 4
• Eccentric strengthening exercises are the cornerstone of treatment, promoting tendon healing and increasing strength, combined with stretching exercises. 3

Second-Line Treatment (4-12 weeks if persistent)

• Corticosteroid injections provide short-term relief more effectively than NSAIDs in the acute phase, but do not alter long-term outcomes. 3
• Use with caution due to potential risks of skin atrophy, infection, tendon weakening, and rupture. 6, 3
• For radial tunnel syndrome, non-surgical treatments including rest, NSAIDs, injections, and physiotherapy may not provide permanent relief but are justified before surgery. 4

Surgical Referral (>6-12 months)

• If pain persists despite 6-12 months of well-managed conservative treatment, surgical evaluation is warranted. 3
• For epicondylitis, surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies. 3
• For radial tunnel syndrome, surgery can diminish pain and symptoms completely in 67-93% of patients. 4

Critical Pitfalls to Avoid

• Do not assume epicondylitis without obtaining radiographs first, as fractures and other bony pathology must be excluded. 1, 3
• If epicondylitis treatment fails, reassess for radial tunnel syndrome or ulnar neuropathy rather than continuing ineffective treatment. 5
• Longer symptom duration before treatment initiation is associated with treatment failure, emphasizing the importance of early intervention. 6
• Clinical examination findings often correlate poorly with imaging studies, so rely on both clinical assessment and appropriate imaging. 7