What is the treatment plan for lateral elbow pain with a 4 mm cortical spur at the distal triceps tendon insertion, distal triceps enthesopathy, and a thickened ulnar nerve?

Treatment Plan for Lateral Elbow Pain with Triceps Enthesopathy and Ulnar Nerve Thickening

Begin with conservative management including activity modification, NSAIDs, and physical therapy for 3-6 months, as this approach resolves symptoms in over 90% of chronic elbow tendinopathy cases without requiring surgery. 1

Initial Conservative Management

The cornerstone of treatment for distal triceps enthesopathy follows established protocols for chronic elbow tendinopathies:

• Activity modification is the first-line intervention, requiring patients to avoid aggravating movements and reduce repetitive elbow extension activities 1, 2
• Topical or oral NSAIDs for acute symptom management, though the underlying pathology is degenerative rather than inflammatory 3, 2
• Physical therapy should include:
  • Eccentric strengthening exercises for the triceps tendon 2
  • Stretching protocols 4
  • Progressive loading as tolerated 3

Expect a minimum of 3-6 months for symptom resolution even with optimal management 1

Addressing the Ulnar Nerve Thickening

The thickened ulnar nerve identified on ultrasound requires specific attention, as this finding suggests nerve pathology that may contribute to the lateral elbow pain:

• Neural tension testing should be performed clinically to assess for nerve entrapment or irritation 4
• Neural mobilization techniques may be beneficial if examination suggests nerve involvement, as demonstrated in cases of chronic lateral elbow pain with nerve entrapment signs 4
• Electrophysiology studies can be considered if clinical examination suggests significant ulnar nerve dysfunction 3

Injection Therapy for Refractory Cases

If conservative measures fail after 3-6 months:

• Corticosteroid injections serve a role in symptom resolution for recalcitrant tendinopathy 1, 3
• Target the triceps insertion site where the 4 mm cortical spur and enthesopathy are present 3

Surgical Consideration

Surgery is required in less than 10% of chronic elbow tendinopathy cases and should only be considered after failed conservative management 1:

• Surgical excision of the triceps enthesopathy and spur removal may be indicated for persistent symptoms beyond 6 months of conservative treatment 3
• Recovery from surgery similarly requires 3-6 months, so the timeline is comparable to conservative management 1
• The prognosis with appropriate treatment is very good 1

Critical Pitfalls to Avoid

Do not rush to surgery - the natural history of chronic elbow tendinopathies favors conservative management, with surgery reserved only for the minority of cases that fail prolonged non-operative treatment 1, 2

Do not ignore the ulnar nerve thickening - while the imaging focused on the triceps pathology, the thickened ulnar nerve may be a significant pain generator and requires clinical correlation with examination findings 4, 3

Do not expect rapid resolution - patient education about the 3-6 month timeline is essential to maintain compliance with conservative treatment and avoid premature surgical intervention 1