Acute Elbow Pain

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Taxonomy

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

Clinical Assessment

Red Flag Conditions

Red Flag Condition	Features
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

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]

Differential Diagnosis

Differential Diagnosis

Differential Diagnoses

Lateral Elbow Pain

• Lateral Elbow Tendinopathy
• Referred pain (Cervical spine, Upper thoracic spine, Myofascial)
• Synovitis of the radiohumeral joint
• Radiohumeral bursitis
• Radial Head Fractures
• Radial Head Dislocation
• Capitellar Osteochondritis Dissecans (Capitellum, Radius in adolescents)
• Capitellar Osteochondrosis
• Lateral Condyle Fracture
• Capitellum Fracture
• Lateral Collateral Ligament Complex Injury
• Radial Head Subluxation (Nursemaid Elbow)
• Radiocapitellar Osteoarthrosis
• Bone Neoplasm
• Soft Tissue Neoplasm
• Posterolateral Rotary Instability
• Posterior Interosseous Nerve Entrapment or Radial Neuropathy at the Spiral Groove
• Posterolateral Plica Syndrome

Medial Elbow Pain

• Medial Elbow Tendinopathy
• Medial collateral ligament injury (acute and chronic)
• Ulnar neuritis
• Avulsion fracture of the medial epicondyle (children and adolescents)
• Apophysitis (children and adolescents)
• Referred pain (Cervical Radicular Pain, somatic referred myofascial pain)
• Myofascial pain
• Ulnar Neuropathy
• Little Leaguer's Elbow
• Triceps Tendinopathy and rupture
• Fractures (Olecranon Fracture, Pediatric Medial Epicondyle Avulsion, Coronoid Process Fracture, Medial Condyle Fracture)
• Medial epitrochlear lymphadenopathy (e.g. from cat-scratch disease)
• Anconeus Epitrochlearis
• Cyst, Mass, Foreign Body

Posterior Elbow Pain

• Olecranon bursitis
• Triceps Tendinopathy
• Posterior impingement
• Gout

Anterior Elbow Pain

• Biceps tendinopathy or rupture

Generalised

• Osteoarthritis
• If locking consider chondromalacia, osteochondritis, loose bodies

Specific Conditions

Neurological Conditions

Main article: Elbow Neurological Conditions

• 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.

Lateral Epicondylitis

Main article: Lateral Elbow Tendinopathy

• 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

Main article: Medial Elbow Tendinopathy

• 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 and Triceps Tendonitis

Main article: Distal Biceps Tendon Disorders

Main article: Triceps Tendinopathy

• 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 Fibromuscular Impairment

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

Follow diagnostic algorithm