What are the causes and treatment options for elbow pain in a patient with unknown medical history and age?

Elbow Pain: Diagnostic Approach and Treatment

Begin with plain radiographs as the initial imaging study for any patient presenting with elbow pain to rule out fractures, dislocations, intra-articular bodies, and other osseous pathology, then proceed with targeted treatment based on the specific anatomic location and underlying cause. 1, 2

Initial Diagnostic Workup

Imaging Strategy

• Plain radiographs of the elbow are the most appropriate first-line imaging for both acute and chronic elbow pain, as they identify fractures, dislocations, intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, and osteoarthritis 1, 2
• Comparison views of the contralateral elbow can help identify asymmetry and subtle abnormalities 1
• MRI without contrast is reserved for cases where radiographs are normal or indeterminate and soft tissue injury (tendon, ligament, muscle) is suspected 1, 2, 3
• Ultrasound and bone scans have no established role in the initial evaluation of elbow pain 1

Clinical Assessment by Anatomic Location

The location of pain typically localizes the pathology 3:

Lateral elbow pain:

• Lateral epicondylitis (tennis elbow) is the most common diagnosis, affecting the extensor carpi radialis brevis tendon from repetitive wrist extension and forearm supination 2
• Pain with resisted wrist extension confirms the diagnosis 2
• Consider radial tunnel syndrome or posterior interosseous nerve entrapment if conservative treatment fails 2, 3

Medial elbow pain:

• Medial epicondylitis (golfer's elbow) results from repetitive wrist flexion and forearm pronation 4
• Ulnar collateral ligament injuries occur in overhead throwing athletes 3
• Cubital tunnel syndrome should be considered with neurologic symptoms 2

Anterior elbow pain:

• Biceps tendinopathy is common, with history of repeated elbow flexion with forearm supination and pronation 3
• MRI with flexion-abduction-supination (FABS) view can visualize the entire distal biceps tendon on a single image 1

Posterior elbow pain:

• Olecranon bursitis presents with swelling and requires bursal fluid analysis to differentiate septic from aseptic causes 3
• Triceps tendon pathology is less common but identifiable on MRI 1

Treatment Algorithm

For Lateral Epicondylitis (Tennis Elbow)

Begin with conservative management, as 80% of patients recover within 3-6 months 2:

1. First-line (weeks 0-6):

   • Relative rest and activity modification to reduce repetitive wrist extension 2
   • Eccentric strengthening exercises for wrist extensors 2
   • Counterforce bracing (tennis elbow brace) during activities 2
   • NSAIDs for short-term pain relief (10-minute ice applications for acute pain) 2
   • Deep transverse friction massage 2

2. Second-line (if symptoms persist beyond 6 weeks):

   • Manual joint mobilization combined with exercise therapy is more effective than exercise alone 2
   • Corticosteroid injections provide superior short-term pain relief compared to NSAIDs but do not improve long-term outcomes—use judiciously for temporary relief only 2

3. Refractory cases:

   • Consider surgical release of wrist extensors if conservative treatment fails after 6-12 months 5

For Medial Epicondylitis (Golfer's Elbow)

1. First-line:

   • Rest and avoid activities requiring repetitive wrist flexion and forearm pronation 4
   • NSAIDs for pain relief 4
   • Eccentric strengthening exercises for wrist flexors 4
   • Deep transverse friction massage 4

2. Second-line:

   • Corticosteroid injections for persistent symptoms, as they may be more effective than NSAIDs in the acute phase 4
   • Extracorporeal shock wave therapy (ESWT) may be considered as an alternative, though evidence is mixed 4

For Suspected Ligamentous or Tendon Injuries

If radiographs are normal or indeterminate and soft tissue injury is suspected, proceed directly to MRI without contrast 1:

• MRI demonstrates 87.5% concordance with surgical findings for medial collateral ligament injuries and 90.9% for lateral collateral ligament injuries 1
• MRI is particularly useful for detecting partial biceps tendon tears, which are more common than complete ruptures 1
• Dynamic fluoroscopy can assess elbow stability after dislocation, with joint widening >10° indicating moderate instability requiring closer follow-up 1

For Acute Traumatic Injuries

Immediate radiographs are essential to identify fractures and dislocations 1:

• Elbow dislocations require closed reduction followed by stability assessment 1
• Gross instability (frank redislocation with stress testing) requires surgical fixation 1
• Mild instability (joint widening <10°) treated conservatively achieves significantly better functional outcomes (MEPS 77.6% vs 52.6%, P=0.043) 1

Critical Pitfalls to Avoid

• Do not rely solely on corticosteroid injections without addressing underlying biomechanical issues and activity modification—this provides only temporary relief without long-term benefit 4, 2
• Night pain or pain at rest suggests inflammatory or neoplastic processes, not mechanical overuse—these patients require further workup beyond standard epicondylitis treatment 2
• Mechanical symptoms (locking, catching) indicate intra-articular pathology—obtain radiographs and consider MRI if radiographs are normal 2
• If lateral or medial epicondylitis treatments fail, consider nerve entrapment syndromes (radial tunnel syndrome, cubital tunnel syndrome) and obtain EMG/nerve conduction studies 2, 3
• Do not order MRI as the initial imaging study—plain radiographs must be obtained first to rule out osseous pathology 1, 2