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
