What is the first line treatment for an adult patient with elbow and nerve entrapment and no significant underlying medical history?

First-Line Treatment for Elbow Nerve Entrapment

Conservative treatment for 3-6 months is the first-line approach for elbow nerve entrapment in patients without significant motor weakness or muscle atrophy. 1

Initial Conservative Management Protocol

The cornerstone of first-line treatment involves activity modification and positioning strategies:

• Maintain a neutral forearm position when the arm is at the side to minimize nerve tension 1
• Avoid elbow flexion beyond 90 degrees to reduce compression and subluxation risk 1
• Apply proper padding (foam or gel pads) at the elbow to prevent direct compression, ensuring the padding is not too tight to avoid creating a tourniquet effect 1
• Provide patient education on movements and positions to avoid, which has been shown effective in improving subjective discomfort in mild to moderate cases 2

Additional Conservative Measures

For symptomatic relief during the conservative trial:

• NSAIDs (oral or topical) can be used for short-term pain relief (typically 2-4 weeks), though they do not alter long-term outcomes 3, 4
• Cryotherapy with melting ice water through a wet towel for 10-minute periods, repeated multiple times daily for acute pain relief 4
• Relative rest and activity modification to reduce repetitive loading while avoiding complete immobilization 4

Note that evidence from one small RCT showed that information on avoiding prolonged movements or positions was effective, while night splinting and nerve gliding exercises did not produce additional improvement beyond education alone 2.

When Conservative Treatment Fails

Surgery should be considered only after 3-6 months of failed conservative therapy in carefully selected patients 1, 4. The evidence suggests that approximately 80% of patients fully recover with conservative management alone 4.

When surgery becomes necessary, the available evidence shows:

• Simple decompression and decompression with transposition are equally effective for clinical and neurophysiological outcomes 2
• Simple decompression has fewer wound infections compared to transposition procedures (RR 0.32,95% CI 0.12 to 0.85) 2
• Medial epicondylectomy and anterior transposition show no difference in clinical or neurophysiological outcomes 2

Diagnostic Confirmation During Conservative Trial

If symptoms persist or diagnosis is uncertain:

• Dynamic ultrasound is the preferred initial diagnostic modality to directly visualize ulnar nerve subluxation during elbow flexion 1
• MRI with T2-weighted neurography serves as the reference standard if ultrasound is inconclusive, showing nerve signal intensity and enlargement 1
• Electromyography and nerve conduction studies help confirm the diagnosis, particularly in atypical presentations, and differentiate between demyelinating versus axonal injury 1

Critical Pitfalls to Avoid

• Never use padding that is too tight, as this creates a tourniquet effect and paradoxically increases compression risk 1
• Do not proceed directly to surgery without a 3-6 month conservative trial unless significant motor weakness or muscle atrophy is present 1, 2
• Avoid relying on corticosteroid injections as first-line treatment for nerve entrapment—unlike tendinopathy, injections are not recommended as primary therapy for nerve compression 3, 4
• Do not allow elbow flexion greater than 90 degrees during the conservative period, as this may increase the risk of ulnar neuropathy 1