What is the best approach to diagnose and treat elbow pain in an adult patient with no significant medical history?

Diagnosis of Elbow Pain in Adults

Initial Diagnostic Approach

Plain radiographs (anteroposterior, lateral, and oblique views) are the essential first-line imaging study for evaluating elbow pain in adults, regardless of whether the pain is acute or chronic. 1, 2

What Radiographs Can Detect

• Fractures and dislocations, with radial head/neck fractures being most common (50% of adult elbow fractures) 1
• Joint effusion indicated by anterior and posterior fat pad elevation, which suggests occult fracture even when no fracture line is visible 1, 3
• Intra-articular loose bodies, heterotopic ossification, osteochondral lesions, soft tissue calcification, and osteoarthritis 1, 2
• Avulsion fractures at tendon and ligament attachment sites 1

Key Technical Point

• Always compare with the contralateral asymptomatic elbow to improve diagnostic accuracy 1, 2, 4

Clinical Localization Strategy

The anatomic location of pain directs your diagnostic approach: 5

Lateral Elbow Pain

• Lateral epicondylitis (tennis elbow) is the primary consideration, caused by pathology at the common wrist extensor origin 5, 6
• Pain worsens with wrist extension against resistance or repetitive wrist/elbow extension 5, 6
• If treatment fails, consider radial tunnel syndrome as an alternative diagnosis 5

Medial Elbow Pain

• Medial epicondylitis affecting the common flexor tendon origin 5
• Ulnar collateral ligament injury in overhead throwing athletes 5
• Ulnar neuropathy should be considered if epicondylitis treatment is unsuccessful 5

Anterior Elbow Pain

• Biceps tendinopathy from repeated elbow flexion with forearm supination/pronation 5

Posterior Elbow Pain

• Olecranon bursitis (septic vs. aseptic) diagnosed by history, examination, and bursal fluid analysis if needed 5
• Triceps tendon pathology with pain during active extension against resistance 3
• Olecranon spurs causing mechanical impingement during extension 3

Advanced Imaging Algorithm

When Radiographs Are Normal But Fracture Still Suspected

Order CT without contrast to clarify fracture morphology and detect occult fractures 1

• CT is particularly valuable when the elbow extension test is positive (pain with elbow extension), as 12.8% of these patients have occult fractures despite normal radiographs 7
• CT has 93% sensitivity for detecting loose bodies 1

For Chronic Pain with Mechanical Symptoms (Locking, Catching)

MRI without contrast is the preferred next study for detecting intra-articular pathology 1, 2, 3

• MRI detects loose bodies (best on T2-weighted sequences), enlarged synovial plicae, and osteochondral lesions 1, 2
• MR arthrography offers higher sensitivity (100%) for intra-articular bodies and evaluating osteochondral lesion stability 1, 2
• CT arthrography is an alternative with 93% sensitivity for loose bodies and superior assessment of heterotopic ossification 1, 2

Important limitation: MRI has poor accuracy for cartilage defects (18-64% depending on location) 1, 2

For Suspected Tendinopathy or Epicondylitis

MRI without contrast provides high diagnostic accuracy 1, 2

• Sensitivity of 90-100% and specificity of 83% for epicondylalgia 1
• Look for intermediate-to-high T2 signal within the common flexor or extensor tendon and paratendinous soft tissue edema 1
• MRI also identifies associated ligament injuries that may complicate treatment 1

Ultrasound with advanced techniques (sonoelastography, superb microvascular imaging) is an excellent alternative 1, 2

• Sensitivity of 94% and specificity of 98% when combining superb microvascular imaging with conventional ultrasound 1, 2
• Allows dynamic evaluation and is less expensive than MRI 5
• For biceps tendon tears, ultrasound performs similar to or slightly better than MRI 1

For Suspected Nerve Entrapment

T2-weighted MR neurography is the reference standard for imaging ulnar nerve entrapment, showing high signal intensity and nerve enlargement 2

For Suspected Occult Stress Fracture

MRI without contrast or 3-phase bone scan are equally sensitive 1

• MRI has the advantage of demonstrating associated soft tissue injuries 1
• Bone scan shows increased uptake in areas of active bone turnover and may be positive before symptoms develop 1

Critical Pitfalls to Avoid

• Don't miss referred pain: Cervical spine pathology or radial tunnel syndrome can mimic elbow pain; consider broader evaluation when initial imaging is negative 2
• Don't overlook dynamic pathology: Static MRI may miss instability patterns; consider dynamic ultrasound or stress imaging for persistent symptoms despite negative MRI 3
• Don't rely on MRI alone for cartilage assessment: MRI has significant limitations (18-64% accuracy) for detecting cartilage abnormalities 1, 2
• Don't forget the elbow extension test: In trauma patients with normal radiographs, a positive elbow extension test identifies 12.8% with occult fractures requiring CT 7
• Don't confuse normal variants with pathology: Careful correlation with clinical findings is essential 2

Imaging Modalities NOT Recommended as Initial Studies

The following have no supporting evidence for initial evaluation: 1

• 3-phase bone scan (except for suspected stress fracture)
• CT with IV contrast
• MRI with IV contrast
• MR arthrography as first-line (reserve for specific indications after initial MRI)