Conservative Management of Elbow Injuries

Pharmacological Interventions

The American Academy of Family Physicians recommends the use of NSAIDs or acetaminophen for pain control in patients undergoing conservative management 1

Radiographs are the initial imaging assessment, with conventional radiographs being the first-line imaging modality to exclude fractures or dislocations that may require urgent intervention, according to the ACR Appropriateness Criteria for acute elbow pain 2
A standard three-view radiographic series, consisting of anteroposterior (AP), lateral, and oblique views of the elbow, is recommended by the American College of Radiology (ACR) for patients with acute elbow pain to evaluate the joint space, medial and lateral aspects of the elbow, and provide additional perspective of the radiocapitellar joint and lateral epicondyle 2
Ultrasound is recommended as the preferred next imaging study after normal radiographs, due to its non-invasive, readily available, and cost-effective nature, with reports showing 95% sensitivity, 71% specificity, and 91% accuracy for diagnosing complete versus partial distal biceps tendon tears 3, 2
CT without contrast may be considered if complex fracture patterns are suspected but not well visualized on plain films, and MRI without contrast is superior for definitive assessment, more accurate identification of tear type, better visualization of associated injuries, and is indicated when ultrasound is inconclusive or surgery is being considered, with sensitivity 76% and specificity 50% 2, 4

Complete tears typically require early surgical intervention for better outcomes, and partial tears >50% may require surgical treatment similar to complete tears, according to the American College of Radiology 2
Conservative management, including rest, immobilization, elevation, and judicious use of analgesics, is recommended for partial tears, with regular follow-up to monitor progress, and pain management should include regular administration of simple analgesics (acetaminophen) and NSAIDs if not contraindicated, with limited use of opioids for severe pain if necessary 2, 5
Gradual progressive strengthening exercises should begin after 1-2 weeks, and range of motion exercises should start early to prevent stiffness, as recommended by physical therapy guidelines, with supervised physical therapy considered for optimal functional outcomes 2

A comprehensive physical examination should include inspection, palpation, range of motion testing, strength assessment, and specific provocative tests to assess for tendon rupture, with findings such as visible deformity, ecchymosis, and asymmetry compared to the unaffected arm 2
Strength testing, including elbow flexion, forearm supination, and shoulder flexion, should be performed and compared to the unaffected side, and the examination should also assess for associated conditions such as rotator cuff pathology and joint instability 2

Pediatric patients are at higher risk from radiation exposure, and the lowest dose protocols should be used for X-rays and CT when needed, and signs of compartment syndrome should be watched for, including pain out of proportion to injury, pain with passive stretching, paresthesia, pallor, and pulselessness, with immediate surgical consultation for potential fasciotomy if suspected 2
The American Heart Association and American Stroke Association suggest avoiding overhead pulley exercises in patients with shoulder pain following stroke, which may also apply to other upper extremity injuries 6
The American Society of Anesthesiologists recommends limiting arm abduction to 90° in supine patients to decrease the risk of brachial plexus neuropathy during procedures 7
The American College of Radiology recommends avoiding prolonged immobilization to prevent elbow stiffness, with brief immobilization only necessary immediately after reduction, and early mobilization is preferred to prevent elbow stiffness and limited joint mobility 2