The Elbow in Clinic

Framework for Thinking

Where can Elbow Pain originate from?

The different locations of the elbow that we have to consider are: Lateral, medial, posterior and anterior.

Ulnar Lateral Collateral Ligament

Ligaments: Lateral Ulnar Collateral Ligament is a Ligament that sits on posterior medial side of elbow. It sits Lateral to the ulnar. Problems with this ligament can lead to Recurrent instability issues in elbow. patients can also Present with acute on chronic injury of this ligament especially when reporting a past History of dislocation.

Medial Collateral Ligament

Medial Collateral Ligament Is Very big and broad ligament and is usually described in books as having 3 portions (Anterior posterior and transverse bundle). Its Role is as a passive restraint towards valgus forces. This ligament remains lax at 80deg flexion. Injuries to this ligament is commonly seen in Throwers as they usually have huge valgus forces travelling through the elbow.

Notorious Muscles of the Elbow:

Common Extensors — Can create pain in the form of epicondylitis

Anconeus is important as a posterior stabilizer — aids extension— Role is to draw the posterior capsule out of the way of the olecronon when elbow is going into extension.

Mode of injury:

• Traumatic
• Repetitive use
• Insidious (Sudden onset, unknown in cause)
• Post Surgery

Problems in the Elbow can Arise from?

Motor Control: Muscular system around the area

Joints:

• Ulnar Humeral,
• Radio Humeral or
• Radial Ulnar Joints

The Relationship between the Radius and Humerus

Radius, Ulnar and Humerus

In Neutral position (Full Extension — There is no contact between Radius and Humerus)

70/80deg Elbow Flexion Closed Packed Position of Radius-Humerus.

Clients who experience forms of grinding, catching especially during flexion from 70–80deg are most likely to have a Radio-Humeral joint dysfunction.

Common Nerves of the Elbow

Nerves: 3 Main Nerves:

• Ulnar Nerve
• Median Nerve
• Radial Nerve

Elbow Pain

I’ve listed the areas of the elbow Lateral, Anterior, Posterior, Medial — as well as the Common Causes, Uncommon Causes and Red Flags that can cause pain.

Lateral Elbow Pain

Medial Elbow Pain

Anterior Elbow Pain

Posterior Elbow Pain

Management Approaches

Take into consideration which phase of injury someone is in: is it in the Acute Phase, Chronic or Acute on Chronic?

Not always inflammatory mechanisms involved.

Carrying Angle: Varus/Valgus Forces during loadbearing/ activity. Which sides take the most load?

Lateral Epicondylalgia or Tennis Elbow

Is probably the most common presentation of Lateral Elbow pain in clinic.

Symptoms: Lateral Elbow pain that can refer into forearm. Clients usually report that their elbow pain gradually got worse with time. This can occur after activities that involve repetitive twisting of the arms or gripping. These actions causes a reaction in the extensor tendons to kickstart tendon pathology/ Tendinopathy.

Sometimes, a deconditioned client can also report a singular action such as lifting a heavy object or heavy tennis stroke that brought on the pain.

Their common extensor origin will be tender on palpation. Gripping with a Pronated arm tends to make their pain worse. Clients may also report sensory changes such as an increase in pain when exposed to the cold (icing makes the elbow pain worse).

Demographic of Tennis Elbow: 3% of general population; 30% of and 40% of Tennis Players experience it. Most common in 33–55yr olds.

Medical Imaging of Lateral Epicondylalgia will reveal some Angiofibroblastic hyperplasia which indicates blood vessel in growth and immature collagen formation within the tendons. This is typically a non inflammatory reaction.

Motor Control:

• Pain free grip strength will be significantly lower than non-affected side.
• Reduction in wrist flexion, extension strength.
• Weaker shoulder Abduction, External Rotation and Internal rotation.
• Gripping posture of wrist will also be altered. Lateral epicondylalgia clients tend to have Less wrist extension in gripping 11deg less (Remember that wrist extension is required for best grip — Length tension for strongest grip is best)
• Poor reaction time in gripping. This can be tested by dropping a ruler with the client attempting to catch it.

Ruler Drop Test

Prognosis of Tennis Elbow

Based on the Patient-Rated Tennis Elbow Evaluation PRTEE Test.

Good Prognosis (Score of Less than 54): pain less than 3 months, No adverse indicators to affect prognosis.

Poor Prognosis (Score of More than 54): Pain is high levels, cold hyperalgesia and sensitivity. Clients here have work that his highly repetitive and manual in nature. Neck and arm pain present.

Golfer’s Elbow — Medial Elbow Pain

This is less common to Tennis elbow however behaves in a similar fashion to lateral epicondylalgia.

Clients will typically report that they are suffering from some medial elbow pain that can spread into their forearms. Again this may resemble tennis elbow as the individuals most susceptible are those who perform manual repetitive work, athletes who experience repeated heavy impact on the medial aspect of the elbow.

They will report that pain exists with gripping, twisting actions and made worse when resisted into wrist flexion. Their common flexor origin and condyle will also be tender.

Medial/ Ulnar Collateral Ligament Sprain

Clients will typically be divided into:

Acute: have some form of incident such as traumatic fall, or twisting. Children who pull on each other, Brazilian Jiu Jitsu.

Chronic: After repetitive trauma; throwing sports such as baseball, cricket (Pitchers Elbow).

MCL Strain Signs and Symptoms

• Laxity on Valgus stress
• Pain at medial elbow during flexion/ Throwing action
• Pain at Shoulder External Rotation during throwing action (Due to Increased Valgus Stress on Elbow)
• Loss of Extension Range
• Swelling (When Acute)
• Pain on Palpation
• Pain on Ulnar Nerve Palpation

If MCL is Left Unattended or Repetitively injured

There are consequences for not addressing injuries to the Medial Collateral Ligament (MCL)

• Damage to MCL usually leads to some forms of rotatory instability.
• Microtrauma to ligament and prolonged inflammation can lead to ligament rupture
• Medial Elbow/ Valgus Laxity
• Ulnar Nerve Irritation (Due to increased nerve tracking; as elbow is more susceptible to valgus forces; and an increased valgus carrying angle).
• Bony Spurs Occurring
• Bony Impingement of the Olecranon in the Superomedial Aspect of the fossa
• Loose Bodies in Olecranon Fossa

Pronator Syndrome

Is due to Median Nerve Compression and commonly affects individuals who; Participate in Throwing or Racquet sport. Some manual workers who frequently grip and twist with their hands and elbows.

Structures that are Involved in Pronator Syndrome:

• Biceps Aponeurosis (Lacterus Firbrosis)
• Ligament Struthers (Supracondylar Process & Medial Epicondyle)(Anchors down Median Nerve & Brachial Artery)
• Pronator Teres

Pronator Syndrome

Struthers Ligament

Signs and Symptoms:

• Paraesthesia Along Median Nerve Distribution
• Weakness of Flexor Policis Longus; Extensor Digitorm, Thenar Muscles
• Misdiagnosed as Carpal Tunnel Syndrome
• Pronator Muscle Tenderness
• Pronator Muscle Hypertrophy

Orthopaedic Testing for Pronator Syndrome:

• Tinel’s Sign
• Compression Around Biceps Aponeurosis via Resisted Flexion 120deg + Resisted Supination
• Compression Pronator Teres via Resisted Pronation in Elbow Extension

Radiological Signs and Symptoms

• Nerve Conduction Study

Olecranon Bursitis (Posterior Elbow Pain)

Olecranon Bursitis

Usually happens when clients go through excessive trauma through their olecranon process (Compression, Shear, Impact)

Being pushed when leaning on the elbow

Regular Olecranon Bursitis Is usually NON-Painful

Infective Bursitis will be Painful (Sustained by a physical cut or insect or animal bite) — An Infective Bursitis will look extremely Inflamed red, swollen and painful with night pains.

Olecranon Bursitis Signs and Symptoms

• Swelling over Olecranon Process

Triceps Tendinopathy

Very common in those who overload their triceps tendon (Found in throwing sports and bodybuilders). These clients will typically report pain with activities such as pushups, dips and shoulder press.

Common Ages are usually 35–55 years old; also known as the tendinopathic age as individuals around these ages are susceptible to tendinopathy (Think Weekend Warrior)

Signs and Symptoms of Triceps Tendinopathy

• Pain around distal triceps tendon especially during resisted triceps activities
• Pain with palpation

Posteriomedial Impingement

Posteriomedial Impingment of Elbow

Posteriomedial Impingement happens when the Olecranon tip impinges upon the posterormedial aspect of the olecranon fossa.

There are a few key things to look out for when looking for signs of posteriomedial impingement.

These are people who continually hyper-extend their elbow and can be quite common in the younger crowd who are lax in the elbow. Baseball players can develop this after experiencing lots of elbow injuries and developing MCL Laxity.

The elderly can also have arthritis or osteophytes.

Signs and Symptoms of Posteriomedial Impingement:

• Pain with Passive Extension of Elbow
• Tenderness on Palpation Olecranon Fossa
• Increased Valgus laxity

Distal Biceps Brachii Tendinopathy

This form of Tendiopathy affects clientele who continually overload their biceps tendon. Recently I’ve encountered it mainly in cross-fitters, bodybuilders, brick layers and tilers. Again those who fall into the tendinopathic age group are most susceptible (35–55yrs old)

Signs and Symptoms of Biceps Tendinopathy

• Pain around Distal Biceps Tendon
• Tenderness on Palpation
• Pain Provocation on Biceps during Resisted Flexion

Radiohumeral Joint Synovitis

This is where the radiohumeral joint synovium becomes inflamed usually because of osteoarthritis.

Here there will be pain in the lateral elbow alongside some redness, swelling, heat.

Pain provocation due to osteoarthritis is more prominent in closed packed positions 70–80deg elbow flexion.

Criteria: Older clientele, night pain, stiffness after prolonged rest or AM.

Posterior Interosseous Nerve Entrapment (Radial Tunnel Syndrome)

Part of the radial nerve that becomes entrapped at the Arcade of Frohse can create pain that is vague in nature, a reduction in motor control. Occasionally this is confused with tennis elbow due to the area of pain.

Clients undergoing this will show Signs and Symptoms of : Proximal motor and sensory changes, vague lateral and dorsal forearm pain, weakness in pinching (thumb grip), aggravation when the area is compressed (Usage of a Tennis elbow brace makes it worse).

Tests for PIN Entrapment: Weakness in wrist extensors (Wrist drop if severe), Resisted supination in 90 deg elbow flexion, provocation at full pronation.

Posterolateral Rotatory Instability (PLRI)

Our elbows are the second most often dislocated joint in the body after the shoulder. PLRI comes from traumatic injury to the elbow that involves the Medial Collateral Ligament MCL or Lateral Ulnar Collateral Ligament. A fall on outstretched arm can cause the Radial head and proximal ulnar to subluxate posterolaterally away from the humerus.

Signs and Symptoms of Posterolateral Rotatory Instability: lateral elbow pain accompanied by locking, slipping, clicking, snapping sensations.

Clients may be apprehensive to perform tasks such as extension (40deg Flexion-full Ext); and be afraid to weight bear in Supination. Look out for signs of a Radial Head that is very Prominent.

Ortho Tests: Tabletop Relocation Test: +ve if Pain/ Symptoms/ Apprehension typically is encountered at ~40degs, Improvement with Therapist assisted Radial Stabilization (PA Force for the Radial Head).

Lateral Pivot Shift Apprehension Test: +ve if Symptoms/ Subluxation occurs during movement phase.

Fall on Outstretched arm creating Posterolateral Rotatory Instability

Lateral Pivot-Shift Test for the Elbow

Table Top Relocation Test (Patient performed Solo & With Therapist assisted Radial Head Stabilized)

Plica Syndrome

Plica syndrome is the impingement of the capsule/ synovium between the radius and humerus. This can happen with or without trauma causing pain, a clicking and snapping sensation especially with flexion of 80degs or more (pronation).

MRI findings is used to diagnose Plica Syndrome (Hypertrophy in thickness of the synovium).

Elbow Plica Syndrome

Ulnar Nerve Irritation

Nerve irritation can occur at the elbow.

Causes: Traction Injuries, Valgus Instability, Compression (Cubital Tunnel), Prolonged Bending of the Elbow, Prolonged resting on the elbow.

Orthopaedic Tests: NTPT, Ulnar Nerve Compression Test.

Posterior Elbow Pain

Medical Conditions to Consider:

Gout: Buildup of Uric Acid; Foods that cause (Chocolates, Seafood, Red Wine); Usually in those who are older with no history of overload or injury but yet experiencing very severe pain, may have past history of gout, night pain, and AM stiffness.

Differential Diagnosis of Gout (Pseudogout): Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (CPPD).

Rheumatoid Arthritis: Criteria for Diagnosis is Joint Swelling & Pain in More than 3 Joints, Metacarpal or Metatarsal Involvement, AM Stiffness (Longer than 30 Minutes), Elevated C-Reactive Protein and Rheumatoid Factor.

Elbow RED FLAGS We MUST NEVER MISS

Osteochondritis Dissecans:

Is a disorder of subchondral bone causing impairment of blood supply to bone can cause degeneration of the articular cartilage or avascular necrosis. This is more common in the younger 12–17yr old athlete.

Signs and Symptoms: Tenderness on palpation of Radiohumeral Joint, Loss of ROM, Valgus Laxity, Crepitus with Pronation/Supination (Locking, Catching, grinding), Flexion Contractures.

MRI is required to Diagnose Osteochondritis Dissecans.

Fractures/ Dislocations:

Is more common than you think; accounts for 10–25% of all elbow injuries.

Common in children below 10 yrs old (Parents swinging children by arms)

Common Mode of Injury: Valgus + Supination + External Rotation of Forearm during Axial Loading. Fall on Outstretched arms.

Signs and Symptoms: Severe Pain, Patients usually seen supporting/ Holding their Injured Arm. Look out for shortened forearm, olecranon and radial head protruding or deformities.

Screen for Pulse and Sensation for neurovascular compromise.

Surgery Required if Terrible Triad of Dislocation + Radial Fracture + Coronoid Fracture

Terrible Triad of Elbow Fracture & Dislocation

Types of Dislocations:

Types of Elbow Dislocations

Distal Biceps Rupture

Can happen in Weightlifters and Bodybuilders particularly if they’re an Anabolic Steroid User.

Mode of Injury: Usually weight lifting incident or Trauma. Sudden added load to a 90deg flexed elbow.

Signs and Symptoms: Tenderness on palpation to the distal biceps tuberosity. Bruising anterior Elbow extending into forearm.

Often missed as losses to flexion power can be subtle (Usually weaker into supination).

Hook Test for Biceps Rupture

Hook Test for Biceps Rupture (Better than MRI)