Bone & Joint Expert Care
EXTENSOR TENDINOPATHY (Tennis Elbow)
With this very common condition, pain is experienced at the bony, lateral or outside aspect of the elbow, known as the lateral epicondyle. At this point, the tendon of the wrist extensor muscle (extensor carpi radialis brevis, ECRB) is attached, where there is also located a large number of nerve endings, which may explain why the condition is so painful.
Tennis elbow occurs in association with any activity involving repeated wrist extension movements against resistance. In sporting terms, tennis, squash and badminton can lead to the onset of this condition. In occupational terms, carpentry, bricklaying and computer-based work have been associated with the development of these symptoms. The peak incidence is between the ages 40 and 50 years, but this condition may affect any age group.
The most common clinical presentation is an insidious onset of pain, which occurs 24-72 hours after unaccustomed activity involving repeated wrist extensions. This occurs typically after a person has spent alot of time either screwdriving, bricklaying, typing, or in sporting terms, playing tennis. This insidious onset is thought to correspond to microscopic tears within the tendon.
At examination, the maximal area of tenderness is usually just 1-2 cm below the lateral epicondyle at the ECRB tendon. There may also be areas of tightness and hypersensitivity along the muscle towards the forearm region. Typically, pain is reproduced by resisted wrist extension and commonly, resisted extension of the middle finger.
In terms of treatment, there is currently no single modality to be totally effective. However, a combination of different treatments will result in the resolution of the symptoms in nearly all cases. The aim of soft tissue treatment is to control pain, encourage healing, restore strength and function and correct any aggravating factors.
This is achieved by a combination of ice massage, electrotherapy modalities, soft tissue therapy, acupuncture, bracing, corticosteroid injection and eccentric strengthening exercises.
FLEXOR TENDINOPATHY (Golfer’s Elbow)
This condition is not as common as lateral elbow pain, but tends to exist with keen golfer’s. On examination, there is localised tenderness on the medial (inside) aspect of the elbow at the site of the tendinous origin of the forearm flexor muscles, with pain on resisted wrist flexion and forearm pronation.
Treatment is along the same lines as that of extensor tendinopathy, but due to its close proximity to the ulnar nerve, stretching of this nerve is indicated as it may become trapped within scar tissue.
POSTERIOR ELBOW PAIN
This condition may present after a single episode of trauma or repeated trauma, such as falls onto a hard surface affecting the posterior aspect of the elbow. Whilst this trauma can occur during sport, particularly on a hard surface, it is also seen in individuals who rest their elbow on a hard surface for long periods of time and is known as “students elbow”.
The olecranon bursa is a subcutaneous bursa that may become filled with blood and inflammation causing a gross swelling and pain at its site at the point of the elbow.
Treatment consists initially of taking anti-inflammatory medication, rest and ice application and the fitting of a firm compression across the elbow. If this does not settle the symptoms, then aspiration of the inflammatory contents within the bursa and injection with a mixture of corticosteroid and local anaesthetic agents will usually be effective.
Tendinopathy at the insertion of the triceps muscle onto the olecranon (point of the elbow) is occasionally seen. Treatment strategies as outlined with extensor and flexor tendinopathy of the elbow are used, including, soft tissue therapy, electrotherapy and strengthening exercises.
Elbow pain is a common complaint and there are many common causes of this problem. If you have elbow pain, some common causes include:
The most common cause of elbow pain is lateral epicondylitis, also called tennis elbow. Patients with lateral epicondylitis have pain over the outside of the joint and difficulty gripping objects. Interestingly, most patients with lateral epicondylitis are not tennis players.
Similar to lateral epicondylitis, medial epicondylitis, or golfer's elbow, causes discomfort around the joint. However, the symptoms of medial epicondylitis are on the inner side of the joint. Again, most patients with this condition are not golfers.
Tendonitis can occur in any of the tendons that surround the joint. The most common types of tendonitis that cause elbow pain are biceps tendonitis (in front of the joint) and triceps tendonitis (in the back of the joint).
This presents as a swelling and tenderness behind the joint over the bony prominence called the olecranon.
Cubital tunnel syndrome occurs when there is compression of the ulnar nerve as is wraps around the inside of the joint causing elbow pain.
Radial tunnel syndrome is an uncommon condition that causes nerve compression of the radial nerve.
An elbow dislocation occurs when the upper arm and forearm get separated from their normal position.
Distal biceps rupture
2. How do you diagnose the cause of elbow pain?
Finding the cause of elbow pain begins with a detailed history, physical examination and the use of several diagnostic tests. These tests are used to find out the cause of your pain and not to make your pain better. An anesthetic injection into the elbow is used to determine the source of the pain. X-rays of the elbow are usually a first step and will help determine if more tests are needed. An ultrasound scan can be used to diagnose tendon tears around the shoulder. The MRI is commonly used to evaluate the elbow because it can show abnormal areas of the soft tissues. It is done to find out tendon disorders, infection and tumours. Blood tests are done to look for infection or arthritis.
3. When do you need to call your doctor about your elbow pain?
Inability to carry objects or use the arm
Injury that causes deformity of the joint
Elbow pain that occurs at night or while resting
Elbow pain that persists beyond a few days
Inability to straighten or flex the arm
Swelling or significant bruising around the joint or arm
Signs of an infection, including fever, redness, warmth
Any other unusual symptoms
Infection – symptoms may include severe pain that makes you unable to move your arm, swelling, fever, heat and redness
Elbow Fracture - pain, swelling and deformity which keeps getting worse
Tingling, numbness or weakness in your arm or little finger
4. What are the treatments for elbow pain?
The treatment of elbow pain depends entirely on the cause of the problem. Not all treatments listed here are appropriate for every condition, but may be helpful in your situation.
Rest: The first treatment for many common conditions that cause elbow pain is to rest the joint, and allow the acute inflammation to subside. However, prolonged immobilization can cause a stiff joint.
Ice and Heat Application: Ice packs and heat pads are commonly used to treat elbow pain.
Anti-Inflammatory Medication: Nonsteroidal anti-inflammatory pain medications can be used for elbow pain caused by arthritis, bursitis, and tendonitis.
Stretching: Stretching the muscles and tendons can help with some causes of elbow pain.
Physical Therapy: Physical therapy uses different modalities to increase strength, regain mobility and help return patients to their pre-injury level of activity.
Cortisone injections: Cortisone can be used in inflammatory causes of elbow pain.
Arthroscopic Elbow Surgery: This is key hole surgery of the elbow. It can be used to debride an arthritic joint and remove inflamed synovial tissue.
5. How do you take care of your elbow?
Stop doing any activity that is causing your elbow pain. Rest for awhile or find another way to do the activity that does not cause the pain. Elbow pain can also be a sign of overuse in the fingers or wrist. In order to prevent elbow pain, your shoulders and upper arms need to be strengthened to keep you from overusing your elbows. Your elbow also needs to be kept strong and supported by a brace if you are feeling tenderness. If you focus on using your upper arms and shoulders as opposed to your elbow for strenuous activities, you can prevent elbow pain.
Warm up before playing sports or participating in activities that require extensive use of the elbow. Begin a program of stretching several weeks in advance.
To prevent underuse, participate in a well-rounded exercise program including upper-body activities and strengthening.
Prevent elbow pain when working on a computer by positioning your keyboard and mouse so that your arms are relaxed at your side. You should also have a slightly open angle at your elbow and your wrists should be straight.
Your pain may make it difficult for you to carry out your usual activities, and you might want to avoid using your elbow completely. However, it is important to resume normal activities as soon as possible. Staying active helps to prevent long-term problems.
You may need to use pain-relieving measures to help you return to your usual activity level. If you are working, the plan could include a
programme of selected duties or reduced hours of work.
Unfortunately osteoarthritis is a problem we will all have to deal with at some point in our lives. But if you keep yourself fit and active, correct your posture and keep your shoulder strong and flexible you can help to alleviate and manage your shoulder symptoms