DIAGNOSIS AND MANAGEMENT OF

ELBOW PAIN

ELBOW PAIN

• Lateral elbow pain

• Medial elbow pain

• Posterior elbow pain

Lateral elbow pain - Causes

• Common– Extensor tendinopathy– Referred pain (cervical/ upper thoracic/ neural)

• Less common– Sinovitis of radiohumeral joint– Posterior interosseous nerve entrapment

• Rare– Osteocondritis dissecans (capitulum/ radius)

Lateral elbow pain - History

• History of pain– Onset, duration, character, severity, radiation,

aggravating movements.

– Recent change of activity

– Treatment obtained

– RA , DM

Lateral elbow pain- Examination

1. Observation

2. Active movements

3. Passive movements

4. Resisted movements

5. Palpation

6. Special tests

Wrist flexion with forearm fully pronated

Examination of the patient with lateral elbow pain

Active movement

Examination of the patient with lateral elbow pain

Resisted muscle testing

Wrist extension

Examination of the patient with lateral elbow pain

Resisted muscle testing

Extension at third metacarpophlangeal joint

Examination of the patient with lateral elbow pain

Restricted muscle testing

Grip strength,

attempt to reproduce pain

Examination of the patient with lateral elbow pain

Palpation

Lateral epicondyle

Try to locate painful site distal to the lateral epicondyle

Neural tension test

Upper limb tension test with forearm pronation to isolate the radial nerve

Examination of the patient with lateral elbow pain

Lateral elbow pain - Causes

• Common– Extensor tendinopathy– Referred pain (cervical/ upper thoracic/ neural)

• Less common– Sinovitis of radiohumeral joint– Posterior interosseous nerve entrapment

• Rare– Osteocondritis dissecans (capitulum/ radius)

Extensor tendinopathy

• Pathology– Degeneration of ECRB tendon in proximal 1-2 cm

– Angiofibroblstic hyperplasia which contain large number of nociceptive nerve endings.

– Microscopic tears in degenerative tissue leading to scarring

Process leading to development of ERCB tendinoathy

Clinical features• 40 to 50 years• Associated with repeated wrist extension activity• Maximal tendernes is 1 to 2 cm distal to lateral

epicondyle• Rest of the muscle is tight and hypersensitive• Tests – Mills’ test , Extension of middle finger

• *perform neural tension tests• *Examine cervical spine

Treatment• A combination of different treatments necessary

1.Control of inflammation with rest, ice, NSAIDS

2.Electrotheraputic modalitiesultrasound, laser, galvanic stimulation

3. Local heat therapy (heat retaining brace)

4. Massage therapysustained myofascial tensiontransverse frictiondigital ischemic pressure

5. Dry needling of trigger points

Treatment cont.

6. Muscle stretching7. Muscle strengthening8. Treat other components of pain9. Correct predisposing factors10. Corticosteroid injection11. Surgery12.Graduated return of activity

Sustained myofascial tension

Applied to the injured area from proximal to remove fibrous irregularities

Massage techniques

Massage techniques

Transverse friction with extensor tissue under tension(wrist and hand flexion)

Stretching of ERCB tendon

Muscle stretching

Strengthening exercises for elbow

Concentric and eccentric

Treat other components of pain

Cervical mobilization

Back hand technique

CorrectIncorrect

Correct predisposing factors

Steroid Injection

Posterior interosseous nerve entrapment

Possible entapments @

fibrous bands in front of the radial head

Recurrent radial vessels

Arcade of Frhose

Tendinous margin of the ECRB muscle

Lateral elbow pain

Neural stretch

Posterior interosseous nerve entrapment

Medial elbow painCommon

Flexor tendinopathy

medial collateral ligament sprain

acute

chronic

Less common

Ulna nerve compression

avulsion of medial epicondyle

traction apophysitis of medial epicondyle

Referred pain

Medial elbow pain- Flexor tendinopathy

Clinical features

Repeated strain

Localized tenderness just below medial epicondyle

Pain on resisted wrist flexion and pronation

Test – reverse Mills’ test

Treatment – Same liens as lateral tendinopathy

Medial elbow Pain – Flexor tendinopathy

Pain is reproduced with resisted wrist flexion and forearm pronation

Stretching exercises for forearm flexors and pronators

Medial elbow pain Medial collateral ligament pain

Acute injury

Chronic injury

Clinical featureslocalized tendernessinstability in valgus strain

Treatmentactivity modificationlocal electrotheraputic modalitiesulrtasoundmuscle strengtheningstrapping

Assessment of the integrity of the medial collateral ligament

Medial elbow pain- Ulna nerve compression

Ulna nerve entrapment

Traction injuriesInflammatory adhesionsRecurrent subluxation of nerveIrregularities in the bony grove

Clinical featuresposteromedial elbow painneurological symptomstender nerve

TREATMENT

Local massage therapyNeural strechingNerve transposition

Nural streching – ulna nerve

The strech can be increased by further shoulder abduction,Forearm supination and wrist extension

Posterior elbow pain

1. Olecranon bursitis

2. Triceps tendinopathy

3. Posterior impingement

Olecranon bursitis