ELBOW PAIN & PATHOLOGY

a. Lateral

i. Tendinopathy

Tennis Elbow – Wrist Extensor Tendinopathy

Tennis elbow (Lateral elbow tendinopathy) is a tendon overloading injury, where micro-tearing of the tendon and subsequent degeneration occurs. This condition affects the wrist extensors, that orgonite at the lateral epicondyle of the humerus. Tennis elbow is the most common elbow overuse injury, account for 80-90% of elbow epicondyle related pain. Computer use has been associated with the condition. The condition may affect any age, however commonly 35-50 years, and often affects non-tennis players, despite the name.

Presents like this to us: A history of pain on repeated gripping/ wrist extension activities, reduced grip strength, tenderness on palpation of tendon closest (proximal) to the elbow. Pain may be replicated on palpation and referred down the forearm. Biomechanical factors have recently change, with the presentation including new equipment, load, change to technique, or shoulder injury.

It feels like this at rest and with sport to you: Depending on the severity, symptoms may be present at rest, and will typically be present in the morning or during the initial phase of warming up for a task. If acute, symptoms may vary throughout the day. Commonly an onset of pain 24 to 72 hours following an aggravating activity including wrist extension is experienced.

We look for this in the physical assessment: We look for reproduction of symptoms on palpation of the lateral epicondyle and tendon, pain and weakness on grip strength, wrist extension and/ or third digit extension, weak elbow extensors/ flexors, and any contribution of shoulder and neck to condition.

We initially manage these by implementing this: Initial management of this condition involves education, manual therapy, ice, exercise and de-load of aggravating activities. Taping or tennis elbow specific brace may be useful for management.

Longer term we look to do this to aid prevention and performance: Restore grip strength, wrist range of motion, and return to activity and sport.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.

ii. LCL


b. Medial

i. Tendinopathy

Golfer’s Elbow – Wrist Flexor Tendinopathy 

Golfer’s Elbow (Medial epicondyle tendinopathy) is a tendon overloading injury, where micro-tearing of the tendon and subsequent degeneration occurs.   The condition affects the wrist flexors, which all originate at the medial epicondyle of the humerus.  Golder’s elbow is less common than tennis elbow (lateral epicondyle tendinopathy), account for 10-20% of epicondyle related pain.  Individuals who participate in throwing sports are more likely to develop the condition due to the forces created during overhead throwing.  A history of repetitive wrist and elbow movements is a common report in symptomatic individuals.  Symptoms may develop after an acute overload or trauma, or over time with chronic dysfunctional response to repetitive loading.

You can expect to feel pain on the inner side of the elbow, with possible referral down the arm along the ulna side, with occasional referral to the fingers.   You may also feel localised pain over the medial epicondyle (inner elbow) and the wrist flexor muscles.   Elbow stiffness, weakness in the wrist and hand, and altered sensation may also be reported.  Grip strength is commonly reduced compared to the unaffected side.

We initially manage the condition by reducing any aggravating activities.  Ice and compression, in addition to tape/ brace can be worn for symptomatic relief, with hands on manual therapy commenced during this time.  Once improvement is noted, the introduction of strengthening exercises is introduced to gradually load the affected tendon.

Longer term we look to gradually return you to activity begins as symptoms dictate.   Finally, a review of activities or techniques are assessed to ensure optimal movement and reduction in re-injury is achieved.

If you are experiencing these symptoms, feel free to email Sean at sean@evokerpps.com.au

ii. MCL

Medial collateral ligament sprain may occur in an acute or chronic environment (repetitive throwing). This condition is common amongst pitchers and throwing athletes. Repetitive stress on the medial collateral ligament generates a greater valgus load leading to micro-tearing and inflammation of the ligament, later leading to calcification and potential tearing.

Presents like this to us: A history of repetitive throwing, change in technique or load, recent development of pain and/ or weakness

It feels like this at rest and with sport to you: During and after throwing, pain at the medial elbow along the ligament will be experienced. There may be pain at rest if severe or acutely aggravated.

We look for this in the physical assessment: Localised pain over the ligament and mild instability when stressed. There may also be associated forearm muscle contracture, synovitis or damage to the radopcaitellar joint.

We initially manage these by implementing this: Initial management of this condition involves education, manual therapy, ice, exercise and de-load of aggravating activities. Taping may be applied to offload the ligament.

Longer term we look to do this to aid prevention and performance: Restore strength, range of motion, and return to activity and sport.

For a 100% return to sport clearance we need to see this: Pain free range of motion, strength equal to unaffected limb/ pre-injury level.


c. Posterior

i. Olecranon bursitis

Olecranon bursitis may be caused by a single or repeated trauma, often occurring during a fall onto the elbow on a hard surface. This condition is commonly seen in students who rest their elbow on hard desks for long periods. The olecranon bursa is filled with fluid and blood, becoming inflamed due to trauma.

We look for marked tenderness over the olecranon bursa coupled with visible swelling around the posterior elbow. Treatment initially involves the use of rest, ice, compression and NSAIDs. Aspiration may be required if conservative management does not resolve the issue.

ii. Triceps tendinopathy

Triceps tendinopathy is a less common condition seen at the tendon attaching to the olecranon. The condition can be as a result from change in training or activity load, technique changes, and shoulder injuries leading to capular dysfnction.

We look for marked tenderness at triceps tendon, and pain and weakness on elbow and shoulder extension. Treatment initially involves education, manual therapy, rest, ice and dry needling. Longer term we look to add exercises to strengthen the tendon and surrounding musculature.

iii. Impingement

Posterior impingement is the most common cause of elbow pain at the back of the elbow. In older individuals, early osteoarthritis may lead to the development of osteophytes and consequently a fixed flexion deformity and posterior pain in forced extension. In younger individuals, repetitive hyperextension valgus stress leads to impingement of the olecranon tip on the fossa. With the time, this may lead to osteophyte formation, further aggravating the issue and development of a fixed flexion deformity.

Management is focused at decreasing hyperextension loads through taping or bracing, in addition to flexibility and strengthening. Longer term progressions to sport and activity are implemented.

 


d. Acute injuries

i. Fracture

X-ray will be used to determine the severity of an acute fracture. Early intervention is important for elbow fractures due to the higher rates of complications in the area compared to other joints. Unstable fractures will require an orthopaedic review. Symptoms often include stiffness and loss of elbow extension during early onset or during immobilisation. Management of mobility and strength, couple with hands on manual therapy are standard treatment. Progression to return to activity and sport protocols are introduced later in rehabilitation.

ii. Dislocation

Elbow dislocations present acutely from direct trauma in contact sport or following a fall. There is commonly fracture of the coronoid process or radial head. Vascular supply may be compromised in this condition and should be cleared on initial assessment, surgical intervention may be required. X-ray may be performed following reduction to assess for fracture and stability of the elbow. Depending on the severity of dislocation and associated fractures/ stability, surgical review may be recommended. Management includes initial immobilisation if required, taping, strength, mobility, and a graduated return to sports protocol longer term.

iii. Tendon

Tendon rupture of the biceps tendon insertion to the forearm seen largely in younger individuals during strength exercise. Partial ruptures are typically more symptomatic than complete rupture, largely due to the aggravation of a partially connected tendon. Surgical intervention in the initial stages of a complete rupture are associated with better long-term results. Rupture of the triceps tendon is seen during excessive deceleration forces during a direct impact or fall. Partial tears generally recover without surgery, while complete ruptures require surgically intervention. Long term, strength and mobility exercise followed by return to activity and sports protocols are implemented.

iv. Medial collateral ligament rupture

Medial collateral ligament rupture may appear during an extreme valgus stress or to a previously injured ligament acutely. Rupture of the ligament is often associated with elbow dislocation. If unstable, surgical intervention is required. Partial tears may be managed with immobilisation in a brace, in addition to strengthening for 3 – 6 weeks. Longer term return to activity and sport protocols may be commended.

 


e. Forearm

i. Fracture

Fractures in the forearm to the radius or ulnar may vary in severity and will often require medial and orthopaedic review. Typically, a fracture occurs due to a fall onto an outstretch hand/ arm. X-ray is a standard form of imaging used to assess fracture severity. A period of immobilisation is required and may include time in a sling to eliminate movement if required. Standard immobilisation for 4 to 6 weeks is recommended depending on the age or severity of fracture. In severe or complex cases, reduction and fixation of the fracture may be required. Longer term we look to regain strength and mobility, before progress to return to activity and sports protocols.

ii. Radial tunnel syndrome

Radial tunnel syndrome (entrapment of the posterior interosseous nerve) is the result of compression of the posterior interosseous nerve at one of four locations (fibrous brands in front of the radial head, recurrent radial vessels, arcade of Froshe, or tendinous margin of the extensor carpi radialis brevis muscle). The radial nerve divides into the superficial radial and the posterior interosseus nerve at the radiocapitellar joint. Symptoms are often similar to extensor tendinopathy and radial tunnel syndrome in early stages. Commonly individuals who complete repetitive pronated and supinated forearm movements, in comparison to extensor tendinopathy associated with repetitive wrist extensor movements. Symptoms often include parasthesia in the lateral forearm and hand, pain over the wrist extensors, wrist aching and pain in the middle/ upper third of the humerus.

We often look for pain on resisted supination with the elbow flexed at 90 degrees, tenderness on palpation of the supinator, and pain on resisted third digit extension. Neural tests may reproduce symptoms, with nerve conduction studies sometimes used to confirm diagnosis. Treatment includes soft tissue release, neural mobilisation, exercise for strength and mobility, and graduated return to activity. Decompression surgery may be required in severe cases.

iii. Compartment pressure syndrome

Compartment pressure syndrome is seen in canoeists, motor cyclists and kayakers particularly, where the flexor compartment is affected. Common symptoms include activity related pain decreased with rest. Management involves soft tissue therapy, although surgical fasciotomy may be required if conservative management is unsuccessful.

 


f. Humerus

i. Stress reaction

Stress reactions are a less common condition, seen in ball throwing sports, tennis players, bodybuilders and weightlifters. The majority of fractures occur during adolescence and associated with an increase in activity. Management of stress reactions follows standard guidelines for simple stress fractures, including the reduction and cessation of aggravating factors until asymptomatic, before a gradual return to activity and sport.