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Chapter 16 Elbow Pain

Manual of Rheumatology and Outpatient Orthopedic Disorders

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Chapter 16 Elbow Pain

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Robert N. Hotchkiss

Anatomy
Examination
Imaging and other diagnostic techniques
Specific problems

I. Anatomy

1. Joint. The articular anatomy of the elbow is unique because it contains two independent axes of motion in the same synovial pouch. The ulnohumeral joint determines flexion and extension, and the radiocapitellar joint pronation and supination of the forearm. The axis of rotation moves very little throughout flexion and extension, making a nearly perfect hinge that is highly constrained. The normal range of motion is 0 to 140 degrees of flexion and extension, 80 degrees of pronation, and 90 degrees of supination.

   The elbow naturally deviates away from the body, the carrying angle, which varies from person to person.

2. Stability. The hemi-circumferential articulation of the humerus and ulna combined with tension in the biceps-brachialis and triceps makes the elbow extremely stable. The radial head also contributes to stability by providing a wider base of support.
   1. Ligaments
      1. Because of the natural valgus (away from the body) angulation, valgus stress develops when a load is thrown or borne load. The medial collateral ligament, specifically the anterior portion, is the most important stabilizer.
      2. On the lateral side, the radial collateral ligament helps to stabilize the ulna and humerus. The annular ligament wraps around the radial head, securing the proximal radius to the proximal ulna while allowing rotation of the radius.
3. Muscles
   1. Flexors. The biceps and brachialis combine to function as the most powerful muscles in the upper extremity . Because of the location of the long head of the biceps, proximal ruptures can occur. The distal biceps tendon can also rupture . Depending on the patient's needs, some of the ruptures should be surgically repaired.
   2. Extensors. The triceps is less powerful than the combined flexors. Active extension is needed for throwing and is especially important for patients who use their arms in transferring from bed to wheelchair or while using crutches. The triceps is much less prone to injury or rupture than the biceps.
4. Nerves. The medial, ulnar, and radial nerves all cross the elbow. The ulnar nerve is subcutaneous along the medial side and is palpable posterior to the medial epicondyle in the cubital tunnel. The radial nerve courses along the lateral side and is not palpable. The median nerve lies next to the brachial artery in the cubital fossa.

II. Examination

1. Etiology . In the examination of a painful elbow, it is helpful to categorize patients according to the suspected etiology.
   1. Acute pain after trauma will be most likely associated with fracture or dislocation. Muscle tears of the biceps in middle-aged men can also occur. Acute pain on the medial or lateral sides of the elbow may be associated with sports such as golf or tennis, as the result of an acute muscle tear. Without a history of trauma, inflammation from gout, infection, rheumatoid arthritis (RA), or other rheumatic conditions should be investigated.
   2. Chronic pain that develops slowly may be related to repetitive use; it is sometimes seen in assembly line workers or tennis enthusiasts . RA can present as recurrent warm effusions in the elbow or progressive, indolent loss of motion.
   3. Episodic pain, characterized as sudden twinges and locking of the elbow, may be caused by loose cartilaginous fragments , commonly referred to as loose bodies.
2. Localization of pain by the patient is the single most important part of the examination. If the patient can specifically identify a reproducible location for the pain, the chances of diagnosis are greatly enhanced. Once the pain has been localized, or at least regionalized, the most common causes of pain in the given region can be investigated.
3. Palpation
   1. Point of maximal tenderness. Once the pain is localized by the patient, examine for tenderness at that same location. Does direct pressure (gently applied) reproduce the discomfort? If pressure causes pain, local inflammation, from any of the sources listed below, should be suspected.
   2. Synovitis and effusions. Proliferative synovium is usually associated with RA. Unlike effusions in the the knee, effusions in the elbow are often difficult to notice. Effusions can sometimes be palpated just anterior or posterior to the radial head, where arthrocentesis is performed.
   3. Crepitus. Grinding and popping in a joint as it moves through a range of motion can often indicate severe erosions of articular cartilage. Both flexion-extension and pronation-supination should be checked. By placing a thumb over the radiocapitellar joint during passive forearm rotation, the status of the radial head can be assessed.
4. Range of motion
   1. Flexion-extension. Flexion and extension should be recorded both actively and passively . With mild inflammation or minor trauma, extension is lost first. It is helpful to compare active and passive extension in the affected joint with the range of motion on the other side.
   2. Pronation-supination. Forearm rotation should also be measured and compared with that on the other side.

III. Imaging and other diagnostic techniques

1. Plain radiographs. Plain radiographs of the elbow should include a true lateral and an anteroposterior film. The lateral film is the most difficult to obtain. If a flexion contracture exists, an anteroposterior film of the distal humerus and of the proximal forearm can be helpful. A radiocapitellar view can sometimes be helpful in assessment of the radiocapitellar joint. In the normal elbow, the head of the radius always points toward the capitellum in all views. If an effusion is present, the lateral view may demonstrate displacement of the anterior or posterior fat pad.
2. Bone scans can be useful in an attempt to localize or diagnose pain of unknown origin. A single-phase , bone static image may show uptake in a particular region and lead to closer scrutiny.
3. Computed tomography (CT) of the elbow can be useful in fracture and reconstructive problems. It is important to review the clinical history with the radiologist and to describe the area of interest, so that proper angulation of the cuts can be made.
4. Magnetic resonance imaging (MRI). The effectiveness of MRI in detecting a variety of painful conditions is steadily improving. The detail and resolution of images obtained with specialized surface coils permit visualization of ligament, cartilage, nerve, and muscle.
5. Arthrocentesis. As in all conditions of the joints, analysis of joint fluid can be valuable . (Analysis and technique are reviewed in other chapters.) Tapping the elbow requires knowledge of the surface anatomy to visualize effective needle placement.

   In addition to synovial fluid analysis, instillation of 1% lidocaine or 0.5% bupivacaine can be diagnostically helpful if the examiner is unsure whether the source of the pain is intraarticular.

IV. Specific problems

1. Lateral elbow pain
   1. Lateral epicondylitis
      1. Sports-related. Tennis elbow or lateral epicondylitis associated with racquet sports is common in amateurs and professionals. Onset can be rather acute or build slowly over months.
         1. The diagnosis is made by palpating the area of the lateral epicondyle with the elbow in nearly full extension and asking the patient to extend the wrist against resistance. This usually reproduces pain.
         2. Proper racquet size and proper backhand technique can lessen the severity of pain. The first line of treatment is rest, a short course of antiinflammatory medicine, and a wrist splint. Specialized braces that increase pressure in the forearm have also been used with success.
         3. The second line of treatment is local steroid injection in the area of greatest pain and symptom. The patient should be warned of possible skin depigmentation. It is mandatory for the patient to reduce the load on the elbow for at least 2 weeks after the injection.
         4. If these measures fail, excision of the degenerative fascia (Nirschl procedure) can be helpful in decreasing pain and restoring function.

            Surgery should be reserved for severe, recalcitrant cases. Consideration should also be given to a change in avocation (i.e., avoiding racquet sports).

      2. Cumulative trauma from work. Lateral elbow pain from repetitive labor is typically more resistant to treatment than is sports-related tennis elbow. The onset can be insidious or begin with a direct blow to the lateral elbow. The pain is usually more diffuse throughout the extensor muscle mass. The same conservative measures listed in section IV.A.1.a should be tried. Return to work is often difficult.
   2. Radial tunnel syndrome
      1. Diagnosis. Entrapment of the posterior interosseous nerve, a branch of the radial nerve at the elbow, is a diagnosis that can be difficult to make. These patients frequently are indistinguishable from those with lateral elbow pain caused by work trauma (see section IV.A.1.b ). Exquisite but dull pain over the anterior lateral elbow, distinct from the lateral epicondyle, may be present. Direct pressure over this same area should reproduce the symptoms. Weakness and pain during active extension of the middle finger can be present but is not necessarily diagnostic of this condition. Nerve conduction studies and electromyography have not been helpful the way they are in carpal tunnel syndrome.
      2. Treatment. Surgical release of the radial and posterior interosseous nerves has been advocated for this condition, but consistent and effective treatment remains elusive .
   3. Radial head fracture. People who fall on an outstretched hand are at special risk for this fracture.
      1. The diagnosis is frequently missed because of inadequate radiography and examination. The symptoms may be a vague discomfort of the elbow, with little swelling. An ipsilateral fracture of the distal radius (Colles' fracture) may draw attention away from the elbow, and the radial head fracture goes unrecognized. Palpation of the radial head during gentle passive pronation and supination can be diagnostic, revealing exquisite tenderness or crepitation. Anteroposterior and lateral radiographs usually are diagnostic.
      2. Treatment depends on the degree of displacement and other features. Most nondisplaced fractures require no splinting and benefit from early active motion.
   4. Bicipital tendinitis and distal biceps rupture. Distal bicipital tendinitis can occur and may presage a distal biceps rupture.
      1. Diagnosis. A patient who describes a heavy lifting activity followed by tenderness and soreness along the distal biceps tendon should be warned and the arm put at rest. A bone scan at this time can show increased uptake along the tendon, down to the insertion at the proximal radius. The biceps tendon can rupture at either end, but it is the distal end that can present as elbow pain or weakness. The rupture is usually seen in men 40 to 50 years of age, but it can also occur in younger weight lifters. Most patients feel a sudden snap or tearing in the elbow while lifting and notice a sudden bulge in the distal forearm with weakness of supination. Ecchymosis may or may not be evident. Given the appearance of the arm, the amount of discomfort can be surprisingly minimal.
      2. Treatment. The decision to repair this rupture surgically must be individualized. If repair is contemplated, it is best accomplished within days of injury.
2. Medial elbow pain
   1. Medial epicondylitis. Inflammation of the medial side of the elbow is less common than inflammation of the lateral side. Overuse at work or throwing sports can initiate the process. As in lateral epicondylitis, there may be some tearing of the fibers of the muscle that originate from the medial side of the elbow.
      1. Diagnosis. Direct palpation over the medial epicondyle usually elicits pain. This tenderness can be accentuated by resisted active flexion of the wrist. The zone of tenderness in medial epicondylitis is usually less discrete than that on the lateral side. The cubital tunnel, through which the ulnar nerve passes , is posterior to the epicondyle, and the examiner should attempt to distinguish between medial epicondylitis and cubital tunnel syndrome. Entrapment of the ulnar nerve can occur in patients with medial epicondylitis (often in throwing athletes ), but the two conditions are separable and should be distinguished.
      2. The treatment of medial epicondylitis is the same as that for the lateral side, but success is less predictable.
   2. Cubital tunnel syndrome. Entrapment of the ulnar nerve at the elbow can occasionally begin as pain in the elbow. Associated with the local pain are the symptoms of nerve entrapment, paresthesias, numbness, and weakness in the ulnar nerve distribution. If the ulnar nerve subluxates over the medial epicondyle during flexion and extension, the pain can have quite an electric quality. It is useful to try to palpate the nerve during flexion and extension if you suspect subluxation. Tapping the ulnar nerve (Tinel's sign) may elicit paresthesia or dysesthesia in the distribution of the ulnar nerve. A full assessment of ulnar nerve function by motor and sensory examination is essential. Nerve conduction studies can be helpful to detect slowing of conduction across the elbow.
   3. Valgus strain. Falls on an outstretched hand can cause sudden valgus loading or near dislocations. Tenderness along the medial side of the elbow is usually present, with swelling. Look for fractures of the radial head or avulsions of the medial epicondyle. It is not uncommon to see the medial collateral ligaments calcify several months later. This usually causes no functional loss and does not require any treatment.
3. Stiffness and contracture
   1. Posttraumatic. Stiffness of the elbow after trauma is quite common, and physical therapy is usually required to minimize it. The functional range of motion of the elbow is in an arc of approximately 30 to 130 degrees of flexion, and 50 to 150 degrees of pronation-supination range. Each patient must be examined individually to determine whether treatment should be tried and which specific modality is appropriate. Forced, sudden, passive motion can be deleterious.
   2. Heterotopic bone formation. Loss of motion may also be caused by juxtaarticular bone formation at the elbow. Patients who have experienced cranial trauma are especially prone to heterotopic bone formation and may require excision and contracture release.
4. Olecranon bursitis. Acute inflammation of the olecranon bursa is a common condition that can result from infection or an acute gouty attack. Distinguishing infection from nonseptic inflammatory conditions such as gout or RA is often impossible on clinical examination alone. It becomes especially difficult in the diabetic patient with a history of gout. Both demonstrate erythema, fluctuance, and generalized tenderness. Adenopathy may be more prominent in infection, but it is not always present. Traumatic bursitis can cause bursal swelling and even some warmth. Fluid analysis demonstrates bloody or xanthochromic fluid that is culture negative.
   1. Laboratory studies. Aspirating the bursal fluid for Gram's stain , culture, crystal examination, and cell count is most helpful, and findings can be diagnostic. Unfortunately, some patients are placed on antibiotics before specimens are taken, and the diagnosis remains elusive. The simultaneous use of antiinflammatory agents and antibiotics, although not technically graceful , may be prudent in some of these patients until the final culture results are available. Because Staphylococcus aureus is most commonly cultured, dicloxacillin or a cephalosporin should be started pending the results of the culture. In those patients with infection who do not respond to a 1- to 2-day course of oral antibiotics, intravenous therapy is indicated. Daily aspiration of the bursa is also mandatory.
   2. Treatment. Recurrent bouts of inflammatory olecranon bursitis can be treated with repeated aspirations. In noninfectious cases, treatment of the underlying systemic disorder or avoidance of local trauma are indicated. However, if the frequency and severity of the episodes do not abate, operative bursectomy should be considered .
5. Osteoarthritis . Primary symptomatic osteoarthritis is less common in the elbow than in the weight- bearing joints of the lower extremities and interphalangeal joints of the hands. Inflammatory arthritis of the elbow is more likely to be a crystal-based arthropathy than a primary degenerative joint disease.
6. Rheumatoid arthritis. Rheumatoid involvement of the elbow usually begins with repeated effusions. Control of the effusions may require systemic medications or intraarticular steroid injections. Depending on the severity of disease, there is a gradual loss of motion as the joint surfaces become barren of articular cartilage. The loss of motion becomes more debilitating and self-care more difficult when the adjacent joints become affected. For patients with significant pain and joint destruction, total elbow replacement is often the best option.
7. Hemophilia. Recurrent hemarthrosis of the elbow may lead to a gradual loss of elbow function. In the early stages of recurrent hemarthrosis, a mild flexion contracture exists, with little chronic pain. Recurrent bleeds lead to destruction of the articular cartilage and a generalized arthropathy with pain, and fibrosis of the joint ensues.
   1. Medical management. In the early phases of the bleeds, standard care includes factor VIII or IX infusions with plasma levels monitored . Initially, some restriction of activity is necessary, but when the acute bleed has resolved, motion exercises should be encouraged. Pain control is always difficult.
   2. Surgery. Synovectomy of the elbow may be indicated for recurrent hemarthrosis unresponsive to medical management. For painful arthropathy, total elbow replacement offers improved function in selected cases.

Bibliography

Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Fractures in adults, 4th ed. Philadelphia: Lippincott “ Raven Publishers, 1996.

Morrey BF. The elbow and its disorders, 2nd ed. Philadelphia: WB Saunders, 1993.

Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

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