What is the diagnosis and treatment for an adult patient with swelling at the lateral forearm close to the elbow and pain at the lateral epicondyle?

Diagnosis and Management of Lateral Epicondylosis (Tennis Elbow)

Diagnosis

This presentation is consistent with lateral epicondylosis (tennis elbow), a degenerative tendinopathy of the common extensor tendon origin at the lateral epicondyle. 1

Clinical Features

• Tenderness on palpation directly over the lateral epicondyle with pain reproduced by resisted wrist extension is the characteristic diagnostic finding 1
• The swelling at the lateral forearm near the elbow represents inflammation and degeneration of the extensor carpi radialis brevis tendon origin 2
• This condition affects the dominant arm 75% of the time and is 7-10 times more common than medial epicondylosis 3, 1
• Most common after age 40, affecting men and women equally 3

Initial Imaging Approach

• Start with plain radiographs of the elbow, which may show soft tissue calcification or exclude other pathology (though often normal in epicondylosis) 3, 1
• If radiographs are normal or indeterminate and the diagnosis remains unclear, ultrasound or MRI without IV contrast are equivalent next-step options for evaluating suspected tendon injury 3
• Reserve advanced imaging (MRI/ultrasound) for cases where diagnosis is unclear, surgery is contemplated, or symptoms fail conservative treatment 1

Treatment Algorithm

First-Line Conservative Management (Months 0-3)

Begin with relative rest, activity modification, eccentric strengthening exercises, and cryotherapy—approximately 80% of patients fully recover within 3-6 months with conservative treatment alone. 1, 4

Activity Modification

• Reduce repetitive wrist extension and forearm movements that aggravate symptoms 1
• Avoid sustained wrist extension positions and incorporate rest breaks 1
• Continue activities that do not reproduce pain, as tensile loading stimulates collagen production 4
• Avoid complete immobilization, which causes muscle atrophy 4

Physical Therapy

• Eccentric strengthening exercises are the cornerstone of rehabilitation and may reverse degenerative tendon changes 4
• Deep transverse friction massage can reduce pain 3

Pain Management

• Apply ice through a wet towel for 10-minute periods for acute pain relief 4
• NSAIDs provide short-term pain relief but do not alter long-term outcomes 3, 1, 4

Second-Line Interventions (Months 3-6)

If symptoms persist despite adequate conservative management:

• Local corticosteroid injections are more effective than NSAIDs for acute-phase pain relief but do not change long-term outcomes 3, 1, 4
• Orthotics are commonly used, though definitive evidence for effectiveness is lacking 3
• Extracorporeal shock wave therapy has demonstrated mixed benefit 3
• Iontophoresis and phonophoresis are widely used but lack well-designed RCTs to permit reliable recommendations 3, 4

Surgical Management (After 6-12 Months)

Surgery should only be considered after failure of 6-12 months of appropriate conservative treatment. 4

• Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 3
• Referral to an orthopedic surgeon is warranted if pain persists despite well-managed conservative treatment 3
• Common surgical approaches include percutaneous, arthroscopic, or open release of the extensor carpi radialis brevis tendon 2

Critical Pitfalls to Avoid

• Do not rely solely on imaging for diagnosis—this is a clinical diagnosis based on history and physical examination findings 2, 5
• Do not use corticosteroid injections as first-line treatment—while effective for acute pain, they offer no long-term benefit over conservative management 3, 1
• Do not rush to surgery—the condition is self-limiting in most cases over 12-18 months 5
• Consider evaluation for rheumatic disease if bilateral symptoms are present 4