What is the diagnosis and recommended treatment for an elderly patient with worsening right arm pain, mainly around the elbow, triggered by lifting and certain movements, with associated weakness and tingling, and minimal relief from conservative measures?

Diagnosis and Management of Lateral Epicondylitis (Tennis Elbow)

Clinical Diagnosis

This patient has lateral epicondylitis (tennis elbow), a degenerative tendinopathy of the common extensor tendon origin at the lateral epicondyle, triggered by repetitive wrist extension activities like painting, hanging washing, and lifting. 1, 2

The clinical presentation is classic:

• Pain localized to the lateral elbow and forearm with radiation from wrist to shoulder 2
• Tenderness directly over the lateral epicondyle 2
• Pain reproduced by resisted wrist extension and lifting movements 2
• Weakness in grip strength and inability to lift >3-5kg 3
• Symptoms triggered by repetitive wrist extension and supination activities 1, 2

The associated tingling warrants consideration of concurrent nerve compression (radial tunnel syndrome or C6-C7 radiculopathy), though the predominant presentation is consistent with lateral epicondylitis 3.

Initial Diagnostic Workup

Obtain plain radiographs of the elbow first to exclude fractures, intra-articular bodies, heterotopic ossification, osteochondral lesions, or soft tissue calcification. 4, 1

• Look specifically for avulsion fractures at tendon attachment sites 1
• Radiographs are often normal in epicondylosis but are essential to exclude other pathology 2
• Reserve ultrasound or MRI without contrast only if radiographs are normal but significant tendon tear or ligament injury is suspected, or if symptoms fail conservative treatment 4, 2

First-Line Conservative Management

Begin immediately with rest, activity modification, NSAIDs for pain relief, and a structured exercise program focusing on eccentric strengthening—this approach provides superior long-term outcomes compared to passive treatments or corticosteroid injections. 1

Activity Modification

• Avoid activities requiring repetitive wrist extension, radial deviation, and forearm supination 1
• Modify gripping technique and avoid sustained wrist extension positions 2
• Incorporate rest breaks between repetitive movements 2

Exercise Therapy (Cornerstone of Treatment)

• Implement eccentric strengthening exercises for wrist extensors as the primary treatment modality 1
• Add progressive resistance exercises for modest intermediate-term results 5
• Include stretching exercises 1
• Add deep transverse friction massage to reduce pain and improve function 1

Pharmacologic Management

• Use NSAIDs for acute pain relief 1, 5
• NSAIDs provide short-term benefits but cannot be recommended over other analgesics for long-term management 2, 5

Adjunctive Measures

• Apply ice to the affected area 6
• Consider an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) to improve function during daily activities, though evidence supporting bracing alone is weak 1, 5

Expected Timeline and Prognosis

Approximately 70-80% of patients fully recover within 3-6 months with conservative treatment alone. 2, 7

A "watch-and-wait" approach is reasonable given the high spontaneous resolution rate 5, 7.

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

Reserve corticosteroid injections only for persistent symptoms despite 6-12 weeks of conservative management. 1

Critical Caveats About Corticosteroid Injections:

• Corticosteroids are more effective than NSAIDs in the acute phase but do not improve long-term outcomes and are inferior to exercise therapy 1, 2
• Corticosteroids may inhibit healing, reduce tensile strength of tissue, and predispose to spontaneous rupture 1
• Physical therapy achieves 91% success rates at 52 weeks compared to 69% for corticosteroid injections 1

Alternative Therapies for Refractory Cases:

• Consider extracorporeal shock wave therapy (ESWT) as an alternative, though evidence demonstrates limited benefit overall 1, 5
• Topical NSAIDs and iontophoresis with NSAIDs may provide short-term benefits 5
• Evidence is mixed on acupuncture and mobilization 5
• Laser treatment and electromagnetic field therapy do not appear effective 5

Surgical Referral

Refer to orthopedic surgery if debilitating pain persists despite a well-managed conservative treatment trial of at least 6-12 months. 1, 8

Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release scarring and fibrosis 1.

Addressing the Tingling Sensation

The tingling warrants clinical assessment for:

• Radial tunnel syndrome (compression of posterior interosseous nerve) 3
• Cervical radiculopathy (C6-C7 nerve root compression) 3
• Concurrent ulnar or median nerve compression 3

If neurologic symptoms persist or worsen despite treatment of the lateral epicondylitis, consider nerve conduction studies and cervical spine imaging.

Common Pitfalls to Avoid

• Do not rely on corticosteroid injections as first-line therapy—they provide short-term relief but worsen long-term outcomes 1, 2
• Do not skip eccentric strengthening exercises—they are the most effective long-term treatment 1
• Do not rush to advanced imaging (MRI/ultrasound) without first obtaining plain radiographs 4, 1
• Do not refer for surgery before completing at least 6 months of conservative management 1, 8