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

Medial Elbow Pain

  • Medial Elbow Tendinopathy
  • Medial collateral ligament sprain (acute and chronic)
  • Ulnar neuritis
  • Avulsion fracture of the medial epicondyle (children and adolescents)
  • Apophysitis (children and adolescents)
  • Referred pain

Posterior Elbow Pain

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

References