Management of Lateral Epicondylitis with Mild Hypertension and Stable Depression
Elbow Pain Management: Lateral Epicondylitis (Tennis Elbow)
The clinical presentation—elbow pain radiating to the forearm, exacerbated by repetitive activities like knitting, with 10/10 pain intensity preventing lifting but preserved overhead motion—is classic for lateral epicondylitis and requires conservative management with activity modification, NSAIDs or topical analgesics, and physical therapy as first-line treatment.
Initial Conservative Management
Immediately advise cessation of aggravating activities (knitting and repetitive motions) for at least 2-4 weeks to allow inflammation to subside, as continued use perpetuates the inflammatory cycle and delays healing [@general medical knowledge@]
Prescribe topical NSAIDs (diclofenac gel 1% applied to the lateral elbow 4 times daily) as first-line pharmacologic treatment, which provides effective pain relief with minimal systemic absorption and avoids the blood pressure elevation associated with oral NSAIDs 1
If topical NSAIDs are insufficient, consider a short course (7-10 days maximum) of oral NSAIDs with gastroprotection, recognizing that NSAIDs can elevate blood pressure by 3-5 mmHg and interfere with antihypertensive efficacy 1
Physical Therapy and Bracing
Refer to physical therapy for eccentric strengthening exercises of the wrist extensors, which have demonstrated superior outcomes compared to rest alone in lateral epicondylitis [@general medical knowledge@]
Provide a counterforce brace (tennis elbow strap) worn 1-2 inches below the lateral epicondyle during activities, which reduces tendon stress and provides symptomatic relief [@general medical knowledge@]
Addressing Numbness and Tingling
The presence of numbness and tingling requires evaluation for radial tunnel syndrome or posterior interosseous nerve compression, which can coexist with lateral epicondylitis and may require different management [@general medical knowledge@]
Perform a focused neurologic examination assessing radial nerve distribution (dorsal first web space sensation), resisted supination with elbow extended, and resisted middle finger extension to differentiate tendinopathy from nerve entrapment [@general medical knowledge@]
Escalation if Conservative Management Fails
If symptoms persist beyond 6-8 weeks despite conservative measures, consider corticosteroid injection (methylprednisolone 40mg mixed with 1-2mL lidocaine) into the lateral epicondyle, though evidence shows short-term benefit only with potential long-term tendon weakening [@general medical knowledge@]
For refractory cases (>6 months), refer to orthopedics for consideration of platelet-rich plasma injection, extracorporeal shockwave therapy, or surgical debridement [@general medical knowledge@]
Blood Pressure Management
The mildly elevated blood pressure attributed to family stress does not require immediate pharmacologic intervention but warrants confirmation with home blood pressure monitoring and lifestyle counseling, as stress-related elevations are often transient.
Confirmation and Assessment
Provide home blood pressure monitoring instructions with measurements twice daily (morning and evening) for 7 days, using a validated automated device with proper cuff size and technique 1
Home BP ≥135/85 mmHg or office BP ≥140/90 mmHg on repeated measurements confirms hypertension requiring treatment 1
Stress Management and Lifestyle Modifications
Recommend evidence-based stress reduction techniques including progressive muscle relaxation, autogenic training, or mindfulness-based practices, which can reduce systolic blood pressure by 5-10 mmHg 2
Reinforce sodium restriction to <2g/day (approximately 5g salt/day or one teaspoon), which provides 5-10 mmHg systolic reduction with greater benefit in older patients 1
Counsel on alcohol limitation to <100g/week (approximately 7 standard drinks), as excessive alcohol significantly interferes with blood pressure control 1
Encourage moderate-intensity aerobic exercise ≥150 minutes/week (30 minutes, 5-7 days/week) complemented with resistance training 2-3 times/week, which reduces blood pressure by 4-8 mmHg 1
Pharmacologic Considerations if Confirmed Hypertension
If home monitoring confirms sustained hypertension ≥140/90 mmHg, initiate antihypertensive therapy with either an ACE inhibitor, ARB, calcium channel blocker, or thiazide-like diuretic as first-line options 1
For this 62-year-old woman, a calcium channel blocker (amlodipine 5mg daily) or thiazide-like diuretic (chlorthalidone 12.5-25mg daily) would be appropriate initial choices, with target blood pressure <140/90 mmHg minimum, ideally <130/80 mmHg 1
Critical Interaction: Sertraline and Blood Pressure
Sertraline 75mg is generally blood pressure-neutral, though rare cases of sertraline-associated hypertension have been reported, particularly with paroxysmal elevations 3, 4
Do not discontinue sertraline abruptly, as withdrawal can cause orthostatic hypotension and other discontinuation symptoms 5
Sertraline is safe in cardiovascular disease and does not adversely affect blood pressure in most patients, making it appropriate to continue at the current stable dose 6
Medication Refills and Laboratory Follow-up
Sertraline Continuation
Continue sertraline 75mg daily as the patient reports it is "sustainable and working well," indicating good therapeutic response and tolerability 6
No dose adjustment is needed unless depressive symptoms re-emerge or side effects develop 6
Laboratory Monitoring
Order comprehensive metabolic panel (serum creatinine, eGFR, electrolytes, glucose) and lipid panel as part of routine cardiovascular risk assessment 1
Check urinary albumin-to-creatinine ratio (uACR) if hypertension is confirmed, as this identifies hypertension-mediated organ damage and guides treatment intensity 1
Obtain 12-lead ECG if not done within the past year, as this is recommended for all patients with hypertension to assess for left ventricular hypertrophy 1
Follow-up Plan
Schedule return visit in 2-4 weeks to review home blood pressure readings, assess elbow pain response to conservative management, and review laboratory results 1
If blood pressure remains elevated, initiate antihypertensive therapy and reassess within 2-4 weeks after medication initiation 1
If elbow pain persists or worsens despite activity modification and topical NSAIDs, consider corticosteroid injection or refer to physical therapy if not already done [@general medical knowledge@]
Goal is to achieve target blood pressure <140/90 mmHg within 3 months of initiating or modifying therapy 1