What is the appropriate management for a patient presenting with right elbow pain?

Management of Right Elbow Pain

Begin with plain radiographs to exclude fractures, intra-articular bodies, heterotopic ossification, or soft tissue calcification, then initiate conservative management with rest, activity modification, NSAIDs, and structured eccentric strengthening exercises as first-line treatment. 1, 2, 3

Initial Diagnostic Approach

Obtain plain radiographs first to rule out:

• Fractures (including avulsion fractures at tendon attachment sites) 3
• Intra-articular bodies 2, 3
• Heterotopic ossification 1, 2
• Osteochondral lesions 2
• Soft tissue calcification 2, 3
• Joint effusions suggesting occult fractures 3

Reserve MRI or ultrasound for cases where radiographs are normal but significant tendon or ligament pathology is suspected 1, 3

Anatomic Localization

The location of pain determines the likely diagnosis:

Lateral elbow pain (most common, 70% affect dominant arm after age 40):

• Likely lateral epicondylitis (tennis elbow) 3
• Consider radial tunnel syndrome if conservative treatment fails 3

Medial elbow pain:

• Likely medial epicondylitis (golfer's elbow) 2
• Consider ulnar neuropathy if treatment unsuccessful 2

Posterior elbow pain:

• Likely olecranon bursitis 1

First-Line Conservative Management (0-4 weeks)

Activity modification:

• For lateral pain: avoid repetitive wrist extension, radial deviation, and forearm supination 3
• For medial pain: avoid repetitive wrist flexion and forearm pronation 2

NSAIDs (oral or topical) for pain relief 1, 2, 3

Ice application (cryotherapy) for 10-minute periods through a wet towel for short-term pain relief 1

Structured exercise program focusing on:

• Eccentric strengthening exercises for wrist extensors (lateral pain) or wrist flexors (medial pain) 2, 3
• Deep transverse friction massage to reduce pain and improve function 2, 3
• Stretching exercises 3

For olecranon bursitis specifically: add padding to protect the bursa 1

Important Evidence Hierarchy

The American Academy of Family Physicians emphasizes that structured exercise programs provide superior long-term outcomes compared to passive treatments or corticosteroid injections 3. This is critical because while corticosteroids may be more effective than NSAIDs in the acute phase, they do not improve long-term outcomes and are inferior to exercise therapy 3.

Second-Line Treatment (4-12 weeks of persistent symptoms)

Continue conservative measures with emphasis on exercise compliance 1

Consider corticosteroid injections only after 6-12 weeks of failed conservative management:

• More effective than NSAIDs in acute phase but inferior to exercise therapy long-term 3
• Use with caution due to potential complications including skin atrophy, infection, and tendon weakening 1
• For olecranon bursitis, avoid oral corticosteroids as they expose patients to unnecessary systemic side effects 1

Extracorporeal shock wave therapy (ESWT) may be considered as an alternative for refractory cases, though evidence shows limited overall benefit 2, 3

Common Pitfalls to Avoid

Overreliance on corticosteroid injections without addressing underlying biomechanical issues is a major pitfall 2

Delayed treatment initiation is associated with treatment failure, emphasizing the importance of early conservative intervention 1

Failure to consider nerve entrapment (radial tunnel syndrome for lateral pain, ulnar neuropathy for medial pain) when standard epicondylitis treatment fails 3

Surgical Consideration (>6-12 months)

Surgical consultation should be considered only after failure of 6-12 months of appropriate conservative management:

• For olecranon bursitis: bursal excision 1
• For epicondylitis: arthroscopic or open release procedures 3