What is the appropriate treatment for a male patient with a high-grade partial-thickness intrasubstance tear of the common extensor tendon and associated tendinopathies in the left elbow, following a weightlifting injury?

Treatment for High-Grade Partial-Thickness Common Extensor Tendon Tear

This patient should be managed with conservative treatment consisting of relative rest, eccentric strengthening exercises, and a structured rehabilitation program over 3-6 months, with surgery reserved only if conservative management fails. 1, 2

Initial Management (Weeks 1-2)

• Implement the RICE protocol immediately (relative rest, ice, compression, elevation) to control pain and swelling 2
• Apply cryotherapy through a wet towel for 10-minute periods for short-term pain relief 3
• Use short-term NSAIDs for pain relief and inflammation reduction during the acute phase 2
• Consider counterforce bracing or straps to reduce strain on the injured tendon during daily activities 2
• Begin gentle range of motion exercises once acute pain subsides 2

Critical pitfall to avoid: Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 3

Progressive Rehabilitation (Weeks 2-12)

Weeks 2-6:

• Initiate isometric strengthening exercises without resistance as pain allows 2
• Continue relative rest while avoiding activities that reproduce pain 1, 3

Weeks 6-12:

• Gradually introduce eccentric strengthening exercises, which are the cornerstone of tendinopathy treatment 1, 2, 3
• Eccentric exercises stimulate collagen production and guide normal alignment of newly formed collagen fibers 3
• Deep transverse friction massage may be added to help reduce pain 3

Important context: The histopathology underlying this condition is tendinosis—a degenerative, noninflammatory condition—not "tendinitis," which explains why anti-inflammatory treatments alone are insufficient 4

Advanced Rehabilitation (Months 3-6)

• Progressive loading of the tendon with continued eccentric exercises 2
• Gradual return to normal activities based on functional criteria 2
• Most patients (approximately 80%) fully recover within 3-6 months with this conservative approach 1

Return to Activity Criteria

Full return to weightlifting should only occur when ALL of the following are met: 2

• Pain-free range of motion is achieved
• Strength is restored to at least 90% of the unaffected side
• Functional testing demonstrates adequate performance

Critical pitfall: Returning to full activity too soon leads to re-injury or chronic problems 2, 5

Surgical Consideration

• Surgery should be reserved for patients who have failed conservative therapy after 3-6 months 1, 3
• Surgery is effective but should not be first-line treatment for partial-thickness tears 1

Special Considerations for This Case

Avoid corticosteroid injections: Given the severe underlying tendinopathy noted on MRI, corticosteroid injections directly into the tendon substance should be avoided as they may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 3

The mild distal biceps and common flexor tendinopathies noted on MRI should be managed with the same conservative approach, as they represent the same degenerative pathology 1, 4

Maintain a strengthening and stretching program indefinitely after returning to weightlifting to prevent recurrence 5