Elbow Pain: Comparing the Costs of Conservative and Invasive Treatments

The elbows are involved in a wide range of movements, from reaching and lifting, pushing and pulling to carrying and holding objects. Their wide range of movement makes them integral to many actions we perform, but this mobility also makes elbows prone to injuries or pain due to overuse or trauma. Elbow pain can be debilitating, making daily activities cumbersome and painful. 

This article will explore common causes of elbow pain and their treatment pathways. We compare conservative and invasive treatment options and costs as well as long-term outcomes to help readers make informed decisions about treatment options for elbow pain in Singapore.

Causes of Elbow Pain and Corresponding Treatments  

Tennis Elbow & Golfer’s Elbow

Tennis elbow (lateral epicondylitis) happens when the tendons that join the forearm muscle to the outside of the elbow get inflamed. The inflammation usually results from repetitive movements. Although the condition is called tennis elbow, it is not only tennis-related repetitive movements that lead to the condition; it can be caused by playing a musical instrument, painting, working on a computer, or using a hand tool.

The pain is due to inflammation of soft tissues such as tendons or ligaments. Tendons attach muscles to bones and ligaments link bones to each other.

In tennis elbow, the pain is in the soft tissues on the outside of the elbow; in golfer’s elbow (medial epicondylitis), the pain is in the soft tissues on the inside of the elbow.

Conservative Treatments

Most cases of elbow pain tend to get better after a few days of conservative treatments you can do at home. Conservative treatments resolve most cases of tennis elbow and golfer’s elbow.  Your provider will suggest treatments to help your tendon heal. 

RICE

The RICE method is usually the preferred home treatment advised by a doctor for tennis elbow and golfer’s elbow. RICE stands for rest, ice, compression, and elevation.

Rest: Simply resting the elbow by not using it can bring considerable relief. In particular, the activity that is causing the pain should be stopped.

Ice: This step involves applying a wrapped ice pack to the elbow for 15 to 20 minutes at a time, a few times a day helps to bring down swelling and relieve pain.

Compression: Wrapping a compression bandage around the elbow is effective for swelling and pain.

Elevation: Keeping the elbow above the level of the heart as much as possible helps with pain relief and reduces swelling.

Medication

Over-the-counter (OTC) anti-inflammatory drugs can be used to reduce pain and swelling. These medications, although effective, should not be taken for longer than 10 consecutive days. Ibuprofen is an example of an OTC NSAID.

Wearing a brace

Wrist and elbow braces help to rest tendons and ligaments. There are a range of braces available to support the elbow and the surrounding soft tissues while they heal. 

Splints

Using a splint to support the elbow while doing ordinary tasks may ease the strain and the pain. Splints, or epicondylitis clasps, are available at chemists, sports shops and physiotherapists and are easy to use.

Physical therapy

Physical therapists know many stretches and other exercises to strengthen the muscles around the elbow and increase flexibility. These exercises are usually simple to perform but very effective if practised as prescribed.

Platelet-rich plasma (PRP) Treatment

This is a biologic treatment that uses a patient’s own blood to promote healing and tissue regeneration. It involves drawing blood from the patient and processing it so platelets are concentrated and platelets and plasma are separated from red and white blood cells.

The doctor injects the platelet-rich plasma into the elbow joint, tendons or ligaments of the elbow.

Corticosteroids

Corticosteroids, or cortisone injections, are prescription anti-inflammatory medications, which are administered by doctors. In case of elbow pain, the cortisone is injected into the elbow. 

Corticosteroids are very effective anti-inflammatory medicines but their pain relief actions are short-lived. Depending on the kind of cortisone used, the pain improves for about six weeks. In many cases, the pain becomes worse directly after the injection before it gets better. 

Invasive Treatments

Surgery for Tennis and Golfer’s Elbow

Tennis and Golfer’s Elbow seldom require surgery. Surgery is usually only considered when conservative treatments fail to relieve pain and discomfort. The treatment involves open or arthroscopic surgery.

Open Surgery for Tennis Elbow 

The surgeon makes an incision over the lateral epicondyle to access the damaged tendon. The damaged part is removed and the healthy tissue is stitched to other tendons.

Arthroscopic Surgery

This is a minimally invasive procedure that uses small incisions made with a small instrument to which a camera is attached (arthroscope) to remove damaged tissue. With the scope attached to a video screen, the surgeon can see inside the elbow, which helps to guide the surgeon in removing the damaged part of the tendon.

For treating Golfer’s Elbow by a specialist doctor, the procedure is similar but focuses on the medial epicondyle and flexor-pronator tendon.

Surgery for Olecranon Bursitis

Olecranon bursitis is inflammation of the bursa at the back of the elbow. A bursa is a sack with fluid. There are many bursae throughout the body; they allow smooth movement of parts of the body over one another, preventing friction.  

The olecranon is the bony tip of the elbow; there is a bursa between it and the skin. This bursa can become inflamed when the back of the elbow experiences persistent pressure.

If olecranon bursitis doesn’t improve with conservative treatments an operation might be necessary.

Arthritis  

Arthritis causes pain and stiffness in joints. These sensations are due to deterioration of the cartilage in the joint, which normally absorbs shock and allows the joint to operate smoothly. In elbow arthritis, the cartilage that cushions the joint surfaces slowly deteriorates leading to stiffness and pain.  

Different types of arthritis affect the elbow. 

Osteoarthritis

Osteoarthritis is a degenerative joint disease caused by wear-and-tear damage to cartilage. The damage to the cartilage usually happens gradually with age or as a result of a prior injury.

Rheumatoid Arthritis

This type of arthritis is an autoimmune disease where the body’s immune system attacks its own joint tissues. Rheumatoid arthritis usually affects multiple joints.

Gout

Gout is the result of a build-up of urate crystals in the joints. It causes unbearable pain.

Post-Traumatic Arthritis

Post-traumatic arthritis happens when a person has had an injury that affects the function of the joint. It can eventually result in arthritis. It is not uncommon for athletes to develop posttraumatic arthritis later in life due to injuries suffered while active in their sport.

 Conservative Treatments for Elbow Arthritis

Patients are usually advised to reduce activities. In the case of osteoarthritis, the condition may have resulted from repetitive movements of the elbow, so avoiding these movements or activities may ease the pain. 

Other conservative treatments include:

• Over-the-counter or prescription medications can provide pain relief. These may not be effective in all arthritis cases. For rheumatoid arthritis pain, doctors usually prescribe more powerful painkillers.
• Corticosteroid injections for pain management and to reduce inflammation 
• Physical therapy to improve range of motion and joint strength 
• Physical therapy in the form of gentle exercises
• Application of heat or cold to the elbow
• A splint to support the elbow and help minimise elbow movement 
• Corticosteroid injections for pain management and reduction of inflammation and pain

Invasive Treatments

Joint Replacement Surgery 

Surgery is the next treatment option when conservative measures don’t improve the condition. Arthritis is the most common reason for unbearable pain and stiffness that necessitates surgery. However, surgery to relieve arthritis pain is more often performed for knee or hip pain.

Joint replacement surgery replaces the damaged elbow joint with an implant made of metal, plastic, ceramic or a combination of those materials. 

These operations have a high success rate, and many people live with their artificial joints for many years. However, people with an artificial elbow are restricted from lifting heavy weights. This is because prosthetic elbows can break easily since the bones they replace are relatively thin.

Joint replacement surgery can be an open procedure or a minimally invasive one.

Other surgical options include:

1. Joint debridement (removing damaged tissue) 
2. Joint fusion (arthrodesis) 
3. Osteotomy (removing part of the bone)
4. Arthroplasty (repairing, replacing, or reconstructing joint components using prosthetics)
5. Synovectomy (removing diseased synovium, the tissue that lines and lubricates the joints) 

Injuries: Fractures or Ligament Injuries  

Injuries to the elbow include sprains, elbow dislocation, and elbow fractures. Imaging tests are required to confirm the extent of these injuries.

These diagnostic imaging tests include:

• CT scans
• Musculoskeletal ultrasound
• MRIs
• X-rays

Diagnostic imaging tests add a considerable amount to the cost of the treatment. 

Conservative Treatments for Elbow Injuries

 Elbow Sprains

Elbow sprains are pulled or torn elbow joint ligaments, which can be extremely painful and limit elbow movement.

Conservative treatments are often sufficient to restore elbow function and relieve pain. They include:

• The RICE method 
• Anti-inflammatory medications to help control pain and inflammation 

Elbow Fractures

Treatment depends on the type of elbow fracture. In cases of non-displaced elbow fractures, conservative measures are normally sufficient. In non-displaced fractures, the bone is broken but still in the right place. 

Most non-displaced elbow fractures can be treated with a conservative approach involving the RICE protocol, anti-inflammatory medication, and physical exercises under the direction of a physical therapist.

In displaced elbow fractures, where the bones are severely fractured, surgery is inevitable.

Dislocated Elbow

Elbow dislocation is a dislocation of the bones of the elbow joint: the humerus, ulna and radius. When they move out of place and don’t meet anymore, you have a dislocated shoulder.

In many cases, the elbow bones can be put back into place with conservative measures, such as: 

• Immobilization with a splint
• Applying ice or heat to the elbow joint
• Anti-inflammatory medication
• Physical therapy
• Strengthening exercises

In case of a complete dislocation or, a dislocation involving bone fractures and torn ligaments and tendons, surgery may be necessary. 

Invasive Treatments

Elbow Sprain Surgery

Severe ligament damage caused by an elbow sprain may require elbow ligament reconstruction surgery. This surgery can be done using Advanced Arthroscopic Techniques that are minimally invasive and allow the patient to be discharged from the hospital on the same day.

Elbow Fracture Surgery

A displaced fracture normally requires surgery to repair it. This procedure may include bone grafting and the reconstruction or transfer of ligaments and tendons, which requires advanced surgical skills.

The different types of elbow fracture surgeries include:

• Open Reduction and Internal Fixation Surgery (Puts the bones back into place)
• Total Elbow Replacement Surgery
• Non-union Elbow Fracture Surgery (Restore a fractured bone that has failed to heal after treatment)

These operations may require the use of specialized hardware, such as screws, plates or pins to hold the bones in place. Bone grafting may need to be performed. Specialized hardware will also add to the costs of the surgery.

Total Elbow Replacement Surgery

Total elbow replacement is called for in cases of severe damage to the elbow due to an elbow fracture. During a total elbow replacement, the entire elbow is replaced with artificial parts. Total elbow replacement is a highly advanced procedure that requires advanced surgical skills plus the support of five to ten medical professionals.

The causes of elbow pain range from repetitive movements and degeneration of the cartilage in the joint to injuries. The different causes determine the treatment pathway and the costs.

Costs of Conservative Treatments  

Conservative treatments are mostly low-cost treatment options. They involve 

• Home treatments – RICE
• Physical therapy sessions, braces, and over-the-counter medication.  
• Corticosteroid Injections  

The financial cost will go up if multiple physical therapy sessions are required, and the long-term use of medications for chronic conditions will also lead to cumulative costs. 

Costs of Invasive Treatments  

Invasive treatments such as total elbow replacement or tendon repair for conditions like tennis elbow, are significantly more expensive than conservative treatments. The cost of procedures like total elbow replacement in Singapore, generally ranges from approximately $10,000 to $25,000.

The total cost depends on pre-operative assessments, the surgical procedure, surgeon’s fees, hospital charges, anaesthesia, and post-operative care. Pre-operative assessment costs include lab and diagnostic imaging tests, such as MRIs, X-rays, and CT scans. Operations like total elbow replacements require specialised equipment, such as prosthetics or surgical tools that add to the costs. 

The type of facility where the operation takes place also impacts the final amount since private hospitals and clinics with advanced facilities charge more than public hospitals.

Other costs include operating room time, physical therapy, follow-up visits, and post-operative rehabilitation. 

Advanced surgeries like these require the skills of a medical professional that specialises in treating elbow joint injuries. All these factors contribute to making surgery a more expensive option compared to non-invasive treatments.

Comparing Conservative and Invasive Treatments

Conservative treatments generally have lower upfront costs but may require ongoing expenses, such as pain medication for arthritis.  

Invasive treatments involve higher initial costs but can offer long-term or permanent relief, but also involve hidden costs like time off work and the potential for complications.  

Conservative treatment may be sufficient for certain conditions, but surgery may be the best or only option for severe cases like fractures.

Conservative treatments bring about gradual recovery but there is minimal interruption to daily life. Surgery involves significant disruption to daily life and significant recover time.  

With conservative treatments there is minimal risk; with surgery, there are always risks.

Orthopaedic Services in Singapore

Ray of Health 

Ray of Health is a top orthopaedic clinic in Singapore headed by Dr James Tan. An experienced orthopaedic doctor of Singapore, Dr James specialises in treating sports injuries of the knee, shoulder and elbow joints, as well as cartilage and meniscus surgery.

Dr Tan is a member of the elite Asian Shoulder and Elbow Group and a founding member of the Singapore Shoulder and Elbow Surgery Society. With a focus on effective, minimally invasive techniques, Dr Tan has successfully treated many orthopaedic conditions, ranging from chronic joint pain to the complete spectrum of sports injuries. 

Ray of Health is patient-centred, focusing on comprehensive diagnosis, personalised treatment plans, and long-term well-being. Part of the Ray of Health ethos is providing patients with the knowledge they need to make informed decisions.

Ray of Health is accredited with Medisave & Insurance Shield Plan, which covers the costs of most procedures.

RadLink. 

 RadLink Diagnostic Imaging provides state-of-the-art diagnostic imaging services in Singapore, including

• Magnetic Resonance Imaging (MRI)
• Computed Tomography (CT)
• Ultrasound
• Mammography
• Bone Mineral Densitometry (BMD)
• X-Ray

In addition to imaging services, RadLink also provides Breast and Prostate Biopsies for diagnostic purposes.

The comprehensive services at RadLink are provided by a team of professionals that include experienced radiologists and nuclear medicine physicians supported by technologists, radiographers, and nurses. 

RadLink is accredited with Medsave and assists patients with claims.

Weighing Costs against Outcomes

Conservative treatments are typically less expensive upfront. The treatments involve exercise, physical therapy, medications, injections, and bracing. While each session or prescription is relatively inexpensive, some treatments for chronic conditions like arthritis can lead to costs adding up over time.

Also, while PRP treatment is not nearly as expensive as operations, it is not cheap either. The cost varies between clinics and the number of sessions required, but the average cost per session can be from $500 to $2,500.

Invasive treatments like surgical procedures are expensive at the outset due surgeon fees, operating room costs, anesthesia, and hospital stays, and so forth. However, for severe conditions, such as complete dislocations or late-stage arthritis, surgery is really the only solution for pain relief. Successful surgery can mean permanent relief from pain, which means an end to pain medications and other expenses associated with conservative treatment. 

Conclusion

Two factors influence the decision between conservative an invasive treatments for elbow pain: the cost and long-term outcome.  

Conservative treatments, like rest, physical therapy, and medications, are more affordable and certainly work for mild to moderate elbow pain. These measures are also effective in treating the underlying condition that leads to pain. However, conservative treatments may not resolve pain in the long run, requiring ongoing treatment sessions or medication, which means the cost goes up over time.

On the other hand, invasive procedures, such as surgeries, are much more expensive on the whole. To make up for this, they often restore functionality and pain becomes something of the past. In cases like serious fractures or advanced arthritis, conservative measures are often not effective. 

Added costs like time off work, and rehabilitation costs also impact treatment decisions.

Ultimately, the treatment choice will hinge on several factor, such as the severity of the condition causing the pain, the chances of full recovery, and financial considerations.