Treatment for Elderly Male with Elbow Pain and Remote Heterotopic Ossification

Initial Conservative Management

The American College of Radiology recommends beginning with conservative management, including rest, activity modification, ice application, NSAIDs, and physical therapy, which successfully resolves symptoms in approximately 80% of cases within 3-6 months 1, 2
Activity modification and relative rest are essential to avoid worsening pain while continuing non-aggravating activities, and never completely immobilizing the elbow to prevent muscle atrophy 1, 2
Topical NSAIDs are preferred over oral NSAIDs in elderly patients to provide effective pain relief while avoiding gastrointestinal, renal, and cardiovascular risks 1, 2
Ice application for 10-minute periods through a wet towel provides effective short-term pain relief 1, 2

Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength through tensile loading that stimulates collagen production 2
Stretching exercises for the wrist extensors should be incorporated into the rehabilitation phase 2

Corticosteroid injections may provide short-term relief but should be used with caution in elderly patients, as they do not alter long-term outcomes and may inhibit healing 1, 2
Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 2

Surgical evaluation is warranted only if pain persists despite 6-12 months of well-managed conservative treatment, and may include excision of abnormal tendon tissue and longitudinal tenotomies 1, 2
For heterotopic ossification, surgical excision may be considered if the ossific body causes mechanical symptoms or persistent pain refractory to conservative management 3, 4

MRI elbow without IV contrast may be considered to evaluate for occult soft tissue pathology, tendon degeneration, or nerve entrapment syndromes if symptoms persist or worsen despite conservative management 1, 3, 4
CT elbow is useful for better characterization of the heterotopic ossification if surgical planning becomes necessary 3, 4

The American College of Radiology recommends obtaining plain radiographs of the elbow as the first imaging study to exclude fractures, heterotopic ossification, and osteoarthritis; radiographs can also reveal avulsion fractures at tendon attachment sites and joint effusions suggesting occult fractures. 5, 6

According to the American College of Radiology, MRI of the elbow without intravenous contrast should not be used as an initial study for acute elbow strain; it is reserved for cases where symptoms persist or worsen after 4–6 weeks of appropriate conservative management to assess for occult soft‑tissue pathology, tendon degeneration, or nerve entrapment. 7, 6
The American College of Radiology states that CT, bone scintigraphy, and contrast‑enhanced imaging have no role in the initial evaluation of elbow strain. 7, 6
The American College of Radiology advises against proceeding to advanced imaging (MRI, CT, etc.) without first completing at least 4–6 weeks of conservative treatment, emphasizing that early imaging is unnecessary and may lead to overtreatment. 7, 6