Board Review

A 42-year-old woman is evaluated for a 6-day history of right elbow pain that started after lifting a heavy box. The pain is often worse at night and sometimes radiates to the wrist. Her medical and family histories are unremarkable. Her only medication is ibuprofen as needed for the elbow pain, and she has no allergies.

On physical examination, vital signs are normal. There is tenderness over the right lateral epicondyle, but there is normal elbow range of motion and no elbow swelling. Pain is elicited with resisted wrist extension. The neck and shoulder examinations are normal.

Which of the following is the most appropriate management?

A) Advise limiting pain-inducing activities

B) Evaluation for surgical treatment

C) Glucocorticoid injection

D) MRI of the right elbow

Answer: A - Advise limiting pain-inducing activities

Objective: Treat lateral epicondylosis (lateral epicondylitis).

Key Point

The primary treatment of lateral epicondylosis is avoidance of activities that cause pain.

This patient with signs and symptoms consistent with lateral epicondylosis (lateral epicondylitis) should be advised to limit pain-inducing activities. Lateral epicondylosis, also known as tennis elbow, is induced by activities that require repetitive wrist extension, such as prolonged computer use or racquet sports. Pain is located over the lateral elbow but may also radiate to the dorsal forearm. Tenderness over the lateral elbow and pain with resisted wrist extension are characteristic examination findings. Increasing evidence suggests that epicondylosis is a chronic tendinosis with disorganization and neovascularization of the tissues, instead of an acute or chronic inflammatory process as traditionally believed. Because the primary mechanism of injury appears to be mechanical strain, and repetitive use of injured tissues diminishes healing, the primary treatment is avoidance of those activities that cause pain and continued injury to the affected area. Braces may be useful when exacerbating activities cannot be avoided, and counterforce bracing, which alters the mechanical strain on the elbow tendons, may be helpful. With rest, pain usually subsides, although performance of resistance exercises may also be beneficial. The analgesic effect of topical or oral NSAIDs may provide short-term symptomatic relief.

Surgical treatment is indicated only for refractory cases of epicondylosis. Patients should first be treated with appropriate conservative measures, including rest and NSAIDs. The risks of surgical intervention would be warranted in this patient only if she had not responded to all nonsurgical therapy.

Glucocorticoid injections may improve symptoms in the short term, but data are conflicting on long-term benefits. Additionally, there is some evidence that glucocorticoid injections may lead to an increased risk of recurrence. There are associated risks (hyperglycemia in patients with diabetes mellitus, infection) that must also be considered. Glucocorticoid injections cannot be justified in this patient who has not received an adequate trial of conservative therapy.

Imaging, including MRI, is not necessary for diagnosis of lateral epicondylosis if the patient has clinical findings consistent with this disorder. MRI would be indicated if this patient had atypical findings or did not respond to initial treatment.

Ahmad Z, Siddiqui N, Malik SS, et al. Lateral epicondylitis: a review of pathology and management. Bone Joint J. 2013;95-B(9):1158-64. Link Out