How should I evaluate and initially manage a patient with non‑traumatic elbow pain (no obvious fracture history), whether acute or chronic?

Evaluation and Initial Management of Non-Traumatic Elbow Pain

Start with plain radiographs (AP, lateral, and oblique views) as your initial imaging study for all patients with elbow pain, whether acute or chronic, to identify fractures, joint effusions, intra-articular bodies, heterotopic ossification, and soft tissue calcifications. 1, 2, 3

Initial Clinical Assessment

Key History Elements to Obtain

• Onset and duration: Distinguish acute (days to weeks) versus chronic (>3 months) presentations 1
• Location of pain: Lateral, medial, anterior, or posterior compartment localizes the likely injured structure 4
• Occupational and recreational activities: Repetitive overhead throwing, gripping activities, or repeated elbow flexion/extension with forearm rotation 1, 4
• Associated symptoms: Swelling, restricted range of motion, stiffness, numbness, tingling, or instability 1, 4

Physical Examination Findings to Document

• Lateral elbow pain with tenderness over lateral epicondyle: Suggests lateral epicondylitis (tennis elbow), the most common cause of chronic elbow pain occurring in 1-3% of the population 1, 4
• Medial elbow pain with tenderness over medial epicondyle: Suggests medial epicondylitis (golfer's elbow) involving the flexor-pronator tendon origin 1, 5
• Anterior elbow pain: Consider biceps tendinopathy, especially with history of repeated elbow flexion with forearm supination/pronation 1, 4
• Posterior elbow pain with swelling: Olecranon bursitis is common; assess for septic versus aseptic causes 4
• Pain with specific movements: Accentuates the diagnosis of epicondylitis 4

Initial Imaging Strategy

Plain Radiographs (Always First)

Obtain AP, lateral, and oblique views of the elbow as your initial imaging for both acute and chronic presentations. 1, 2, 3

What Radiographs Can Identify:

• Fractures and dislocations: Radial head/neck fractures account for 50% of elbow fractures 3
• Joint effusion: Identified by posterior and anterior fat pad elevation, which may indicate an occult fracture even without visible fracture line 2, 3
• Intra-articular bodies and heterotopic ossification 1
• Osteochondral lesions and soft tissue calcifications 1
• Osteoarthritis changes 1
• Avulsion fractures at tendon/ligament attachment sites 3

Critical Pitfall to Avoid:

Do not assume all elbow effusions represent occult fractures; other causes include ligament injuries and synovial pathology. 2

Advanced Imaging Algorithm (When Radiographs Are Normal or Nonspecific)

For Suspected Occult Fracture or Bony Pathology:

Order CT without contrast as the next appropriate study when clinical suspicion for fracture remains high despite normal radiographs. 3

• CT is particularly useful for identifying occult fractures of the radial head, olecranon, and coronoid process 3

For Suspected Soft Tissue Injury:

Order MRI without contrast when radiographs show effusion but no visible fracture, or when soft tissue pathology is suspected. 1, 2

MRI Without Contrast Is Highly Sensitive For:

• Bone marrow edema associated with occult fractures 2
• Ligament and tendon injuries: Including ulnar collateral ligament tears, biceps tendon tears, and epicondylitis 2, 3
• Osteochondral lesions and intra-articular bodies 1, 2
• Stress fractures: MRI is as sensitive as 3-phase bone scan but provides superior soft tissue detail 2

When to Consider MRI With Contrast:

• MRI with contrast offers no significant advantage for simple joint effusion evaluation 2
• Reserve contrast for specific evaluation of intra-articular bodies and assessment of osteochondral lesion stability 2

Critical Pitfall to Avoid:

Do not use contrast unnecessarily; non-contrast MRI is sufficient for initial evaluation of most elbow pathology. 2

Special Imaging Considerations:

• Stress radiographs: Useful to detect medial joint line opening and valgus instability, particularly for ulnar collateral ligament injury 1
• Comparison views with contralateral elbow: Often helpful to assess for asymmetry 1
• Dynamic fluoroscopy: Can distinguish among different stages of collateral ligament injury, with >10° of joint widening indicating moderate instability 1

Initial Management Based on Diagnosis

For Epicondylitis (Lateral or Medial):

• Conservative management first: Rest, activity modification, NSAIDs, physical therapy, and counterforce bracing 1, 6
• Corticosteroid injection: Consider if initial conservative measures fail 1, 6
• Coordinated rehabilitation: Range-of-motion and strengthening exercises, technique enhancement, and equipment modification 6
• Surgery: Reserved for debilitating pain persisting despite 6 months of well-managed nonoperative treatment 6

For Olecranon Bursitis:

• Bursal fluid analysis: Necessary to distinguish septic from aseptic causes 4
• Treatment depends on whether infection is present

For Ulnar Collateral Ligament Injuries:

• Common in overhead throwing athletes 4
• Management ranges from conservative measures to surgical repair depending on severity and patient activity level

Refractory Cases Requiring Further Workup:

If lateral or medial epicondylitis treatments are unsuccessful, consider ulnar neuropathy and radial tunnel syndrome as alternative diagnoses. 4

Modalities to Avoid Initially

• 3-phase bone scan: No evidence supports its use as initial imaging for acute or chronic elbow pain 1
• CT arthrography: Limited evidence for initial evaluation 1
• MR arthrography: Limited evidence for initial evaluation of chronic elbow pain 1