What is the first line treatment for a patient with elbow pain radiating down the arm?

First-Line Treatment for Elbow Pain Radiating Down the Arm

Begin with plain radiographs to exclude fracture, dislocation, or structural pathology, followed by conservative management with activity modification, NSAIDs, and early mobilization—avoiding complete immobilization which leads to muscle atrophy. 1, 2, 3

Initial Diagnostic Imaging

• Obtain plain radiographs first as the initial imaging study to exclude fracture, dislocation, heterotopic ossification, arthritis, or osteochondral lesions 1, 2, 3
• Radiographs can identify joint effusion (posterior and anterior fat pad elevation), which in the context of trauma implies occult fracture 1
• Advanced imaging (MRI, CT, bone scan) is not indicated as first-line evaluation and should only be considered if radiographs are normal and soft tissue pathology is suspected 1, 2

Conservative Management (First 0-4 Weeks): Pain Control and Protection

Activity Modification

• Avoid activities that worsen pain while continuing those that don't aggravate symptoms—specifically avoid repetitive wrist extension, forceful gripping with simultaneous wrist extension, and activities like shaking hands or opening doors 3
• Never completely immobilize the elbow, as this leads to muscle atrophy and deconditioning 3
• Early mobilization is superior to immobilization, showing improved range of motion with less extension deficit (16° ± 13° vs. 19.5° ± 3°, p < 0.05) 4

Pharmacologic Management

• Topical NSAIDs are preferred in elderly patients to provide effective pain relief while avoiding gastrointestinal risks 3
• Oral NSAIDs (such as naproxen) effectively relieve pain, though they may not affect long-term outcomes 3, 5
• Naproxen has been shown to cause statistically significantly less gastric bleeding and erosion than aspirin in controlled studies 5
• NSAIDs should be used at the lowest effective dose for the shortest time needed, as they can cause ulcers and bleeding at any time during treatment 5

Physical Modalities

• Apply cryotherapy for 10-minute periods through a wet towel for effective short-term pain relief 3
• Use counterforce bracing (tennis elbow bands) to reinforce, unload, and protect tendons during activity 3

Rehabilitation Phase (2-8 Weeks): Restore Function

• Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength through tensile loading that stimulates collagen production 3
• Incorporate stretching exercises for the wrist extensors, which are widely accepted as beneficial 3
• Exercise-based physiotherapy is recommended as first-line intervention by 81% of UK clinicians surveyed 6
• Physical therapy has been shown to be effective first-line therapy, with symptom resolution occurring in 70-80% of patients within the first year 7

Critical Pitfalls to Avoid

Corticosteroid Injections

• Use corticosteroids with extreme caution: while they may provide relief in the acute phase, they do not alter long-term outcomes and may inhibit healing, reduce tendon tensile strength, and potentially predispose to spontaneous rupture 3
• Corticosteroids may be detrimental to recovery in the long term despite providing short-term pain relief 7

Nerve Entrapment Considerations

• If weakness and tingling are prominent, consider nerve entrapment (ulnar, median, or radial nerve compression) as the underlying cause 2, 8
• Medial epicondylitis can have associated paresthesias if there is secondary ulnar nerve irritation 2
• Ultrasound may be useful for visualizing nerve thickening and aiding in diagnosis of nerve entrapment if conservative measures fail 2

When Conservative Treatment Fails

• A "watch-and-wait" approach can be appropriate, as symptom resolution occurs in 70-80% of patients within the first year 7
• Surgical evaluation is warranted only if pain persists despite 6-12 months of well-managed conservative treatment 3
• Conservative treatment with early functional training remains the first-line therapy for simple elbow dislocation, with surgical approaches reserved for patients with severe bilateral ligament injuries or moderate to severe instability 4