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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 |
|
| Neoplasia |
|
| Infection |
|
| inflammatory arthropathies |
|
| Referred pain & visceral |
|
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
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
