Treatment of Degenerative Changes of the Elbow Joint
Conservative management with relative rest, activity modification, eccentric strengthening exercises, and NSAIDs should be the first-line treatment for degenerative elbow joint disease, with surgery reserved only for carefully selected patients who fail 3-6 months of conservative therapy. 1, 2, 3
Initial Conservative Management (First 2-8 Weeks)
Relative rest and activity modification form the foundation of treatment, preventing ongoing tendon damage while avoiding complete immobilization that leads to muscular atrophy and deconditioning. 1, 2, 3 Patients should continue activities that don't worsen pain while temporarily stopping aggravating movements. 3
Cryotherapy provides effective short-term pain relief through 10-minute applications of melting ice water through a wet towel, repeated multiple times daily. 1, 2, 3 This reduces tissue metabolism and blunts the inflammatory response. 3
NSAIDs (oral or topical) effectively relieve pain for 2-4 weeks, though they don't alter long-term outcomes. 2, 3 Topical NSAIDs reduce pain while avoiding gastrointestinal risks, while oral NSAIDs like naproxen have been shown to cause statistically significantly less gastric bleeding than aspirin. 3, 4 Naproxen has demonstrated efficacy in reducing joint pain, increasing range of motion, and improving capacity to perform daily activities in osteoarthritis patients. 4
Counterforce bracing (tennis elbow bands) helps reinforce, unload, and protect tendons during activity. 3
Rehabilitation Phase (Weeks 2-12)
Eccentric strengthening exercises are the cornerstone of treatment and may reverse degenerative changes in the tendon by stimulating collagen production and guiding normal alignment of newly formed collagen fibers. 1, 2, 3 Approximately 80% of patients fully recover within 3-6 months with conservative management alone. 2
Stretching exercises for the affected muscles maintain range of motion and are widely accepted as beneficial. 1, 3
Avoid overhead pulleys as they encourage uncontrolled movements that may worsen symptoms. 2
Imaging Considerations
Plain radiographs should be obtained initially to rule out osteophyte formation at the epicondyles, degenerative joint disease, loose bodies, or fractures. 1, 2, 3
Ultrasonography or MRI is appropriate if radiographs are normal but tendon injury is suspected, showing tendon thickening, heterogeneous echogenicity, fibrovascular proliferation, and mucoid degeneration. 1, 3 Ultrasound has moderate diagnostic accuracy (sensitivity 64.52%, specificity 85.19%) for common extensor tendon tears. 3
Second-Line Interventions (For Persistent Symptoms After 4-8 Weeks)
Corticosteroid injections may provide more effective short-term pain relief than oral NSAIDs in the acute phase, but should be used with caution and reserved for persistent symptoms after initial conservative measures. 2, 3 They don't alter long-term outcomes and may inhibit healing and reduce tendon tensile strength. 3
Therapeutic ultrasound may decrease pain and increase collagen synthesis. 3
Extracorporeal shock wave therapy (ESWT) appears safe but requires further research. 3
Surgical Considerations
Surgery should be reserved for carefully selected patients who have failed 3-6 months of well-managed conservative therapy. 2, 3 Surgical evaluation may be warranted if pain persists despite 6-12 months of conservative treatment. 3
Surgical options include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 3 For advanced degenerative changes with pain throughout the entire arc of motion, joint resurfacing with interposition arthroplasty, partial joint arthroplasty, or total joint arthroplasty may be required, though total elbow arthroplasty should be regarded as a salvage procedure in young, active patients. 5
Critical Pitfalls to Avoid
Don't label this as "tendonitis" – most patients presenting with elbow pain have chronic degenerative tendinopathy (tendinosus), not acute inflammation. 2
Don't rely on NSAIDs as primary treatment – they provide only short-term pain relief and should be adjunctive to exercise therapy. 2
Don't use corticosteroid injections as first-line treatment – reserve for persistent symptoms as they don't improve long-term outcomes and may weaken tendons. 2, 3
Don't completely immobilize – relative rest with gradual return to activity is preferred over complete cessation. 1, 2, 3
Don't fail to address underlying biomechanical issues or activity modifications, as this may lead to recurrence. 3