Acute Elbow Pain

ACUTE ELBOW PAIN (White Paper)

Algorithm as noted

RED FLAG CONDITIONS

Fractures

• .history of trauma is cardinal indicator
• risk factors –visual & balance impairment
• underlying osteoporosis - [ # in 56% of women , 29% of men > 60yrs]
• 11% in humerus, [mainly surgical neck- not elbow]
• FOOSH- usually # wrist not elbow
• Pathological #- Pagets, Ca, osteomalacia etc

Neoplasia

• risk factors are: age > 50; past history of ca; unexplained weight loss >4.5 kg, pain non-responsive to treatment > 1month- stronger viewed as negative predictors
• palpable mass/ deformity
• bone tenderness with no incriminating features of any other cause of pain

Infection

• pre-test probability not tested –but likely to be low
• cardinal indicator is fever
• portal of entry penetration by object, surgery, catheter etc
• underlying joint abnormalities or immunosuppression increased risk
• joint swelling/ bursal swelling/ bone tenderness

inflammatory arthropathies

• caused by crystal, psoriatic, rheumatoid & reactive
• joint effusion
• can be difficult to diagnose

Referred pain & visceral

• MI [referred to arm in 30% of cases]
• Usually affects area greater than elbow in typical dermtomal/sclerotomal distribution

NEUROLOGICAL

• CNS/ cord/ radiculopathy/peripheral neuropathy- pain over area greater than elbow and symptoms & signs of numbness/weakness/parasthesiae/allodynia

Radial tunnel syndrome

• entrapment of radial nerve passing through the arcade of Frohse in supinator muscle- ? a cause of refractory lateral elbow pain
• EMG studies – no evidence of radial nerve compression found
• Surgery to release nerve- 13 obtained relief out of 37 [16 rtw]
• Another study- 2 ops- nerve release in tarsal tunnel & lengthening of ERCB muscle- both groups did as well- both ops released extensor tendon and this was presumed to be the mode of improvement , not decompression of tunnel.

Posterior interosseus nerve entrapment

• weakness of wrist & finger extension

Ulnar neuropathy

• pain & aching over medial elbow and prox forearm with tingling /parasthesiae in 4&5th fingers.

HISTORY

Circumstance of onset

• ?trauma- no valid features to rule out #
• repetitive strain- cardinal condition involves throwing/swinging- strain of MCL and common flexor origin
• spontaneous- ? red flag

Radiation

• tends to be well localised

No historical feature is diagnostic- NB patient’s general medical history & system review

EXAMINATION

Inspection

• superficial joint- rewarding
• swellings/oedema/skin changes in colour, trophic changes etc

Palpation

• tenderness cannot be validly ascribed to any specific structure

Range Of Movement

• no data re diagnostic value of range of movement
• Mill’s manoeuvre – pain pronation/wrist flexion/ elbow extension- lateral epicondylitis
• Resisted extension of 3rd metacarpal- [ insertion of ECRB]- ? lateral epicondylitis – no data

IMAGING

• cardinal role detection of #- increased risk if –significant force/immediate loss of function/bony swelling & tenderness/compression of joint causes pain
• rare - cancer/osteomyelitis/osteonecrosis/osteochondritis
• first xray  ? bone scan
• otherwise not indicated.- especially in lat/med epicondylitis; biceps & triceps tendonitis–are all purely clinical diagnosis [even if test 100% sensitivity /specificity – nothing added]

TAXONOMY

• best is lateral /medial elbow pain
• nerve compression syndromes only if focal neurological abnormalities and nerve conduction abnormalities proven

LATERAL EPICONDYLITIS

• No accepted definition
• Most common cause of pain around elbow
• Swedish study- prevalence 1-3%- peak incidence 10% women in 5th decade
• Tennis players prevalence 50%

Risk factors

• no prospective/case-controlled studies
• increased incidence in strenuous occupations

natural history

• no prospective cohort study with a no treatment arm- therefore natural history uncertain but recurrence rate of 50% over 1 year

pathology

• only in chronic lateral epicondylitis
• hyaline degradation with chronic repair with vascular & fibroblastic proliferation* very little inflammation
• mainly affecting common extensor tendon and surrounding tissues
• recent high resolution ultrasound shows thickening of tendon & peri tendon suggestive of inflammation

treatment with corticosteroid injections

class 1 evidence

• not many papers of adequate methodological quality- but best paper showed large benefit for steroid over saline/lignocaine
• pooled odds ratio-0 .15 at 6 weeks- definite benefit for injections but after 6 weeks- no statistical benefit but better outcomes.
• Side effects- pain in 50% and skin atrophy in 20-30%
• Technique and dosage are varied- no one best way- use 1ml cortisone +- lignocaine- target site is point of maximal tenderness- usually in prox end of extensor tendon rather than epicondyle

Treatment with rest

• avoidance of usual activities or splinting [not counterforce brace]
• rationale- caused by excessive loads
• efficacy- no class 1 & 2 evidence
• class 3- two studies showing no benefit for rest
• class 4- most authorities recommend rest for the first 2 weeks

treatment with exercise

• stretching or resisted isometric or isotonic contractions of forearm extensors
• rationale [based on evidence in knee] lateral epicondylitis causes disuse – extensors become weaker wit reduced muscle resistance and increased forces on the common extensor tendon.
• Evidence- no class 1 or 2
• Class 3 – one study- significant difference in favour of active stretching vs counterforce brace.
• Class 4 – virtually universally prescribed by experts – no consensus on type, frequency duration etc

Treatment with passive modalities

• ultrasound/interferential/ laser- supposed to heat and increases blood flow
• evidence
• class 1
• - ultrasound [US] review- initially US significantly > placebo but 3rd arm using sham US vs real US- no difference – showing power of hands on placebo
• second review showed no difference at 3 & 12 months followup
• laser - no real benefit
• class 2
• pulsed electromagnetic field therapy [PEMF]- no real benefit
• extracorporeal shockwave thereapy- [same as lithotropsy]- shows significant improvement in grip & pain at 3,6 24 weeks in refractory cases due for surgery
• Rebox- low current electrical treatment – minor but significant effect- poor study.

Treatment with NSAID’s

• class 1- no real benefit beyond analgesia

treatment with topical NSAID

• no real benefit

treatment with SURGERY

• only for chronic
• 3 aims;-
• dissect common extensor tendon off epicondyle -to get a better ‘join’ from scarring
• denervation of epicondyle
• excise aberrant tissue
• No controlled data.- best is class3
• Results largely positive- but not indicated for acute lateral epicondylitis

MEDIAL EPICONDYLITIS

• less common that lateral epicondylitis ratio 1:6
• seem to be lumped in with lateral epicondylitis – same treatment criteria probably apply
• diagnosis entirely clinical

treatment

• no class 1 trial
• class 2 – improved pain relief at 6 weeks for local cortisone shot- [major risk is injecting into ulnar nerve]
• class 4- surgical – showed tear in common origin with varying degrees of inflammation

DISTAL BICEPS & TRICEPS TENDONITIS

• no studies on these entities
• treatment as for other tendonitis- rest then graded exercise with stretching + ?cortisone
• avoid expensive investigations

FIBROMUSCULAR IMPAIRMENT

• tenderness usually over the common tendon insertion distal to the lateral epicondyle
• other structures possibly involved are radiohumeral joint with capsule & annular ligament and fibrous tissue derived from fascia overlying the extensor muscles. - [no independent radial collateral ligament exists]
• clinical examination cannot determine which structure is involved
• - therefore use lateral fibromuscular impairment
• possible pathologies- tears or sprains of extensor muscles near origin [no formal studies done] , capsule tears [no formal studies] , synovitis, meniscoid entrapment [ joint has a fibrous meniscoid- fibrous extension of capsule covered by synovium. If joint distracted, meniscoid could be trapped outside joint under the capsule and act as a FB- increased tension in capsule causing pain.- no formal studies done but reports claiming relief from excising these structures – also treatment could use distraction, varus bending and replacing of meniscoid] , radio-humeral arthropathy [this may resolve or progress]
• None of these have been proven

MEDIAL FIBOMUSCULAR IMPAIRMENT

• joint covered by ulnar collateral ligament and common flexor muscles
• treatment with rest and time

Follow diagnostic algorithm