Management of Pending Elbow MRI and Groin Rash
Await the MRI results before proceeding with elbow-specific treatment, while simultaneously evaluating and treating the groin rash as a separate clinical entity that requires immediate attention.
Elbow Management Strategy
While Awaiting MRI Results
Do not delay obtaining the MRI results – the American College of Radiology confirms that MRI elbow is the appropriate advanced imaging study for chronic elbow pain when radiographs are normal or nonspecific 1
Review any prior plain radiographs if they were obtained before the MRI was ordered, as radiographs should have been the initial imaging study to rule out osseous pathology, intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, or osteoarthritis 1, 2
If no prior radiographs exist, this represents a deviation from standard practice, as the American College of Radiology recommends beginning with plain radiographs (AP and lateral views) before advanced imaging 2, 3
Clinical Assessment to Perform Now
Assess for red flag symptoms including night pain or pain at rest, which suggests inflammatory or neoplastic processes requiring urgent investigation 2
Evaluate for mechanical symptoms such as locking, clicking, or catching, which indicate intra-articular pathology like osteochondral lesions or loose bodies 2
Test for lateral epicondylitis with resisted wrist extension if pain is lateral 2
Perform valgus stress testing if pain is medial to assess for UCL injury 2
Check for ulnar nerve subluxation with elbow flexion/extension and assess for neurologic symptoms (paresthesias, weakness) 2
Evaluate for diffuse swelling that may indicate upper extremity DVT, especially if there are risk factors 2
Interpreting the MRI When Results Arrive
MRI without contrast detects loose bodies (enhanced by joint fluid on T2-weighted images), enlarged plica causing locking/pain with extension, osteochondral lesions, and soft tissue injuries 1
MRI has limitations – it is less sensitive than radiographs for detecting heterotopic ossification and calcifications 1, 4
T2-weighted MR neurography is the reference standard if ulnar nerve entrapment is suspected, showing high signal intensity and nerve enlargement 1, 2
If the MRI shows UCL injury in a throwing athlete, note that 3T MR arthrography would have been more accurate (81% sensitivity, 91% specificity) than non-contrast MRI 2
Groin Rash Management
Immediate Evaluation Required
Examine the rash characteristics including distribution (bilateral vs unilateral), morphology (macular, papular, vesicular, scaling), color, and associated symptoms (pruritus, pain, discharge)
The most common causes of inner thigh and groin rash include tinea cruris (fungal infection), intertrigo (skin fold irritation), contact dermatitis, candidiasis, and inverse psoriasis
Assess for fungal infection features: well-demarcated erythematous patches with raised scaly borders, central clearing, and sparing of the scrotum (if male) suggests tinea cruris
Look for intertrigo signs: erythema, maceration, and satellite lesions in skin folds, often with secondary candidal infection
Treatment Algorithm for Groin Rash
For suspected tinea cruris: initiate topical antifungal therapy with terbinafine 1% cream or clotrimazole 1% cream twice daily for 2-4 weeks, with instructions to continue for one week after clinical resolution
For suspected candidiasis: use topical nystatin cream or miconazole 2% cream twice daily, with attention to keeping the area dry
For intertrigo without infection: recommend barrier creams, moisture-wicking fabrics, and weight loss if applicable
If diagnosis is uncertain or rash is severe: consider KOH preparation or fungal culture before initiating treatment
Advise hygiene measures: keep area clean and dry, wear loose-fitting cotton underwear, avoid sharing towels, and treat any concurrent tinea pedis to prevent reinfection
Critical Pitfalls to Avoid
Do not assume the elbow and groin issues are related – these are separate anatomic regions requiring independent evaluation 2
Do not order additional elbow imaging before reviewing the pending MRI results, as this wastes resources 4
Do not prescribe corticosteroid cream for the groin rash without ruling out fungal infection, as this can worsen tinea cruris
Do not delay groin rash treatment while focusing solely on the elbow problem – the rash requires immediate attention and can be managed concurrently
Do not miss upper extremity DVT if the elbow has diffuse swelling with risk factors 2