What causes elbow pain and how is it treated?

Elbow Pain: Causes and Treatment

Begin with plain radiographs to exclude fractures and bony pathology, then treat most cases with relative rest, activity modification, and eccentric strengthening exercises, which resolve 80% of cases within 3-6 months. 1

Common Causes by Anatomic Location

Lateral Elbow Pain

• Lateral epicondylitis (tennis elbow) is the most common cause, resulting from repetitive wrist extension, radial deviation, and forearm supination that causes degenerative tendinopathy of the extensor carpi radialis brevis tendon, affecting patients most commonly after age 40 and involving the dominant arm in 75% of cases 1
• Radial tunnel syndrome or posterior interosseous nerve entrapment should be considered if lateral epicondylitis treatment fails 1
• Radiocapitellar arthritis and osteochondral lesions of the capitellum can mimic lateral epicondylitis 1

Medial Elbow Pain

• Medial epicondylitis (golfer's elbow) from repetitive wrist flexion and forearm pronation 2
• Ulnar collateral ligament injuries occur in overhead throwing athletes 2, 3
• Cubital tunnel syndrome (ulnar nerve compression) presents with medial pain and neurologic symptoms 1, 3

Posterior Elbow Pain

• Olecranon bursitis (septic or aseptic) causes posterior swelling and pain; bursal fluid analysis differentiates infection from inflammation 2
• Triceps tendinopathy or rupture in active individuals 4

Anterior Elbow Pain

• Biceps tendinopathy from repeated elbow flexion with forearm supination and pronation 2
• Distal biceps tendon rupture (partial tears are more difficult to diagnose than complete ruptures) 4

Traumatic Injuries

• Radial head fractures are the most common elbow fracture in adults; types III and IV require surgical referral 3
• Supracondylar fractures and posterior elbow dislocations are common in children 3
• Elbow dislocations account for approximately 5% of emergency department visits for upper extremity injuries 5

Diagnostic Workup

Initial Imaging

• Obtain plain radiographs first to identify fractures, intra-articular bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, occult fractures, and osteoarthritis 1, 6
• Look specifically for avulsion fractures at tendon attachment sites and joint effusions indicating occult fractures 6
• Comparison views of the contralateral elbow are useful for evaluating subtle abnormalities 1

Advanced Imaging (When Radiographs Are Normal)

• Reserve MRI or ultrasound for cases with normal radiographs but clinical suspicion for tendon tear, ligament injury, nerve entrapment, or other soft tissue pathology 1, 6
• MRI is preferred for chronic elbow pain because it detects bone marrow edema, tendinopathy, nerve entrapment, and joint effusion 3
• Ultrasound allows dynamic evaluation of tendons, ligaments, and osseous structures 3

Red Flags Requiring Further Evaluation

• Night pain or pain at rest suggests inflammatory or neoplastic process 1
• Mechanical symptoms (locking, catching) suggest intra-articular pathology 1
• Neurologic symptoms warrant EMG and nerve conduction studies to localize nerve entrapment 1

Treatment Algorithm

First-Line Conservative Management (All Patients)

• Relative rest and activity modification to reduce repetitive loading of damaged structures 1, 6
• Eccentric strengthening exercises as the cornerstone of treatment to promote tendon healing and increase strength 1, 6
• Progressive stretching exercises for affected muscle groups 1
• Cryotherapy (ice application) for 10-minute periods for acute pain relief 1
• NSAIDs provide short-term pain relief but do not affect long-term outcomes 1, 6
• Counterforce bracing (tennis elbow brace) may improve function during daily activities 1
• Deep transverse friction massage to reduce pain 1, 6

Critical Point: Manual joint mobilization combined with exercise therapy is more effective than exercise alone 1

Second-Line Interventions (After 6-12 Weeks of Failed Conservative Management)

• Corticosteroid injections are more effective than NSAIDs in the acute phase but do not improve long-term outcomes and are inferior to exercise therapy; use judiciously for short-term relief only 1, 6
• Extracorporeal shock wave therapy (ESWT) for refractory cases, though evidence demonstrates limited benefit overall 6

Surgical Intervention

• Consider surgery for persistent symptoms despite conservative management, including release of wrist extensors in refractory lateral epicondylitis, nerve decompression for entrapment syndromes, and repair of torn tendons or ligaments 7
• Radial head fractures classified as Modified Mason type III and IV require surgical referral 3
• Advances in arthroscopic techniques have expanded treatment options for elbow arthritis and other conditions 8

Common Pitfalls to Avoid

• Do not rely solely on corticosteroid injections; they provide short-term relief but worsen long-term outcomes compared to exercise therapy 1, 6
• Do not overlook nerve entrapment syndromes when lateral or medial epicondylitis treatments fail 1
• Do not skip plain radiographs as the initial imaging study; they are essential to exclude bony pathology before attributing pain to soft tissue causes 1, 6
• Do not order MRI or ultrasound as first-line imaging; reserve these for cases where radiographs are normal but significant soft tissue injury is suspected 6

Expected Outcomes

• 80% of patients with lateral epicondylitis recover within 3-6 months with conservative management 1
• Patients with mild elbow instability after dislocation achieve significantly better functional scores (77.6% vs 52.6% on Mayo Elbow Performance Scores) compared to those with moderate instability 5
• 70% of lateral epicondylitis cases affect the dominant arm, requiring realistic expectations about recovery timeline 6