What is the most likely diagnosis and first‑line treatment for a 22‑year‑old right‑handed woman with overuse‑related elbow pain radiating to the hand?

Diagnosis and Treatment of Overuse Elbow Pain in a Young Active Woman

Most Likely Diagnosis

This presentation is most consistent with lateral epicondylosis (tennis elbow), a degenerative tendinopathy of the common extensor tendon origin caused by repetitive wrist extension and gripping activities from extensive writing and manual work. 1

Clinical Reasoning

• Lateral epicondylosis is 7 to 10 times more common than medial epicondylosis and affects the dominant arm 75% of the time, making the right elbow the typical site in right-handed individuals 1
• The condition commonly occurs after repetitive wrist flexion and extension activities, which aligns perfectly with extensive exam writing and manual work 2
• This is a degenerative condition (tendinosis), not an inflammatory one (tendonitis), despite common misconceptions—most patients seen in primary care have chronic symptoms suggesting degenerative changes 2
• Pain radiating down the forearm is characteristic, as the common extensor tendon origin involves multiple forearm muscles 1

Key Diagnostic Features to Confirm

• Tenderness on palpation directly over the lateral epicondyle with pain reproduced by resisted wrist extension is the characteristic sign 1
• The natural history is gradually increasing load-related localized pain coinciding with increased activity 2
• Examination should include thorough inspection for swelling and asymmetry, range-of-motion testing, palpation for tenderness, and maneuvers that simulate tendon loading 2

Important Differential Diagnoses to Exclude

• Radial tunnel syndrome (posterior interosseous nerve entrapment) is a critical differential that can coexist with lateral epicondylosis 1, 3
• Brachioradialis muscle pain can cause similar symptoms with sharp shooting pain during activity and aching at rest radiating through the forearm to the thumb and index finger 4
• Cervical radiculopathy, de Quervain's tenosynovitis, and carpal tunnel syndrome should be considered if symptoms don't fit the classic pattern 4

First-Line Treatment Approach

Conservative treatment consisting of relative rest from aggravating activities, ice application, and eccentric strengthening exercises should be initiated immediately, as approximately 80% of patients fully recover within 3 to 6 months with this approach. 1

Specific Treatment Algorithm

Phase 1: Immediate Management (First 2-4 Weeks)

• Relative rest: Avoid repetitive writing and gripping activities that reproduce pain, not complete immobilization 2
• Activity modification is critical: Modify gripping technique, avoid sustained wrist extension positions, and incorporate rest breaks between repetitive movements 1
• Ice application: Apply to the lateral elbow for pain relief 2
• NSAIDs for acute pain relief: While effective for short-term pain control, they cannot be recommended over other analgesics for long-term management 1

Phase 2: Rehabilitation (Weeks 2-12)

• Eccentric strengthening exercises: This is the cornerstone of treatment to promote tendon healing 2
• Physical therapy modalities may be helpful, though evidence is limited 2
• Gradual return to activities as pain permits 2

Phase 3: Refractory Cases (After 6-12 Weeks)

• Corticosteroid injections are more effective than NSAIDs in the acute phase but do not change long-term outcomes 1
• These should be used with caution and reserved for cases not responding to conservative measures 2
• Consider advanced imaging (MRI or ultrasound) if diagnosis is unclear or symptoms fail conservative treatment 1

Critical Pitfalls to Avoid

• Do not label this as "tendonitis"—this is a degenerative condition (tendinosis/tendinopathy), not primarily inflammatory, which affects treatment expectations 2
• Avoid complete rest or immobilization, as relative rest with gradual return to activity is more effective 2
• Do not rush to corticosteroid injection, as it provides only short-term benefit without improving long-term outcomes 1
• Ensure adequate duration of conservative treatment (3-6 months) before considering surgical referral 2

When to Consider Further Evaluation

• Plain radiographs of the elbow should be obtained initially to exclude other pathology such as soft tissue calcification or occult fractures, though they are often normal in epicondylosis 1
• MRI or ultrasound are reserved for cases where diagnosis is unclear, surgery is contemplated, or symptoms fail conservative treatment after 3-6 months 1
• Surgical referral is warranted only if pain persists despite well-managed conservative treatment for 3-6 months 2