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  Joint Pain       Elbow      
 
 
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Functional Anatomy

Joints

  • The elbow is a compound synovial joint consisting of three individual joints enclosed within one synovial membrane:-
    • Humero-ulnar Joint - The trochlea of the humerus articulates with the trochlear notch of the ulna .
    • Humero-radial Joint - The round capitulum of the humerus articulates with the dimple in the radial head to form a shallow ball and socket joint.
    • Superior Radioulnar Joint - The edge of the radial head articulates with the side of the olecranon of the ulna .

Movements

  • Functionally the elbow is made up of two joints:-
    • The parts that contribute to flexion (bending) and extension (straightening).
    • The parts that contribute to forearm supination (palm up) and pronation (palm down).
  • Flexion / extension movements take place at the humero-ulnar and humero-radial joints (Normal range 0 - 140 degrees).
    • Full extension of the joint is blocked by the olecranon of the ulna contacting the olecranon fossa on the back of the humerus.
    • Full flexion is blocked by the coronoid process of the ulna contacting the coronoid fossa on the front of the lower humerus, and is also blocked by muscles contacting each other at the front of the joint.
  • Supination / pronation movements take place at the humero-radial and superior radio-ulnar joints. Supination / pronation also involves the inferior radio-ulnar joint at the wrist.
    • With the arm by the side and the elbow flexed to 90 degrees, the full range is nearly 180 degrees (palm up to palm down) .
    • With the arm by the side and the elbow fully straightened, the full range is nearly 360 degrees (palm forwards to palm forwards). This is because additional rotational ability is contributed by the shoulder joint.

Ligaments

  • Medial Collateral Ligament - protects the inside (medial) aspect of the joint and has three parts:-
    1. Anterior part connecting the medial epicondyle to the side of the coronoid process,
    2. Posterior part (triangular) connecting the medial epicondyle to the olecranon,
    3. Oblique part connecting the olecranon and coronoid.
  • Lateral Collateral Ligament - protects the outside (lateral) aspect of the joint. It starts at the lateral epicondyle and blends with the annular ligament and some of the forearm muscles.
  • Annular Ligament - helps to keep the radial head in contact with the side of the olecranon (superior radio-ulnar joint). It forms about 80% of a circle around the radial head. It also blends with the lateral collateral ligament and the joint capsule.

Capsule

  • The elbow is surrounded by a fibrous bag lined with synovial membrane supplying synovial fluid to the joint.
  • There are also three fat pads which line the various holes (fossae) of the humerus - olecranon, coronoid and radial.

Muscles

  • Biceps - The biceps tendon attaches to the radial tuberosity on the inside of the upper radius. With the elbow bent, the biceps contributes to elbow flexion and supination.
  • Triceps - The triceps tendon attaches to the olecranon process of the humerus. Triceps is the main elbow extensor.
  • Common Extensor Origin - Muscles that contribute to extension of the wrist (palm down with wrist bent up) originate from the lateral epicondyle of the humerus and the supracondylar ridge just above it.
  • Common Flexor Origin - Muscles that contribute to flexion of the wrist (palm down with wrist bent downwards) originate from the medial epicondyle of the humerus.
  • Supinator - is a flat muscle with superficial and deep layers, lying over the outer side of the elbow, attaching to the ulna, joint capsule, and outer radius. Along with biceps, it contributes to supination of the forearm (rotating palm up).
  • Pronator Teres - is a muscle with two heads, one originating from the medial epicondyle, and the other from the coronoid process. The muscle inserts in to the outer side of the radius in the mid forearm, contributing to forearm pronation (rotating palm down).

Tennis Elbow

Tennis Elbow is pain in the region where the forearm extensor muscles fasten to the lateral epicondyle of the humerus . It is also known as Lateral Epicondylitis. Common condition seen in the Pain Clinic.

Causes

  • May be caused by sports injuries, overuse of the forearm in pronation / supination movements, or a direct blow to the lateral epicondyle
  • More common in middle aged females and may affect both sides.
  • May be thought of as a type of tendinitis (tendonitis) or enthesitis, caused by repeated micro-trauma to an area that already shows signs of degeneration.
  • Some studies have found osteochondritis affecting the radial head, suggesting that repeated pronation / supination movements may be to blame producing cartilage deterioration.
  • Needs to be differentiated from referred pain from structures in the cervical spine (C6 facet joints, muscle spasm, nerve entrapment).

Clinical Findings

  • Pain is usually felt around the lateral epicondyle region, but may also radiate down the forearm to the middle and ring fingers.
  • Symptoms are aggravated by using the wrist e.g. gripping or shaking hands.
  • Resisted movements are usually painful and reproduced by resisted wrist extension (palm down moving wrist and hand upwards), or resisted radial deviation of the wrist (moving the wrist in the direction of the thumb).
  • Passive movements may also be affected - there may be loss of the last 5 degrees of passive elbow extension, as well as loss of wrist flexion with the elbow straight (shortened extensor muscles).
  • Tenderness to palpation may be found in 4 different sites (most common first) :-
    1. Over the front part of the lateral epicondyle,
    2. Over the supinator / brachioradialis muscles,
    3. Over the radial head,
    4. Over the supracondylar ridge just above the lateral epicondyle.
  • X-rays are either normal for the patient's age or may show calcification at the extensor origin.

Treatment

  • Rest and analgesics initially.
  • LA / steroid injections .
  • Soft tissue massage (deep friction) and mobilisation techniques to the lateral epicondyle and radial head (including Mills Manipulation).
  • Trigger Point Injections to tender muscular points around the outer elbow (brachioradialis and supinator) can give rapid pain relief.
  • Prolotherapy to help repair a torn common extensor origin at the lateral epicondyle or supracondylar ridge.
  • Surgery (last resort)
    • Extensor origin release - releasing the common extensor origin, debridement of granulation tissue, re-attaching the tendon.
    • Release of portion of the annular ligament.

Golfers Elbow

Golfers Elbow is pain in the region where the forearm flexor and pronator muscles fasten to the medial epicondyle of the humerus . It is also known as Medial Epicondylitis. Less common than Tennis Elbow.

Causes

  • May occur in those who have never played golf.
  • Seen in middle aged people whose sporting activity or occupation involves having a strong hand grip and adduction movements (moving the forearm in towards the body).
  • Needs to be differentiated from referred pain from structures in the cervical spine (C8, T1 facet joints, muscle spasm, nerve entrapment).

Clinical Features

  • Pain is usually felt around the medial epicondyle, and is aggravated by gripping and wrist flexion. pain may also radiate down the forearm.
  • Resisted wrist flexion whilst gripping the examiners fingers with the elbow straight and usually reproduces the pain.
  • Pain can also be reproduced by resisted pronation (palm down).
  • Stretching the flexor muscle group by extending the wrist with the elbow straight also reproduces the pain.

Treatment

  • Rest and analgesics initially.
  • LA / steroid injections .
  • Soft tissue massage (deep friction) and mobilisation techniques to the medial epicondyle.
  • Trigger Point Injections to tender muscular points around the inner elbow.
  • Prolotherapy to help repair a torn common flexor origin at the medial epicondyle (beware injury to the ulnar nerve).
  • Surgery (last resort)
    • Flexor origin release - releasing the common flexor origin, debridement of granulation tissue, re-attaching the tendon.

Bicipital Tendinitis

An uncommon condition with pain in the middle of the front of the elbow.

Clinical Features

  • Pain in the front of the elbow may reproduced by a combination of resisted elbow flexion with supination (palm up).
  • Pain may also be reproduced by passively stretching the biceps tendon with full elbow extension combined with forearm pronation (palm down).
  • A tender spot over the tuberosity of the radius can be palpated with the elbow bent at 90 degrees.

Treatment

  • Rest and analgesics initially.
  • LA / steroid injections .
  • Soft tissue massage (deep friction) and mobilisation techniques to the tuberosity of the radius.

Triceps Tendinitis

A rare condition with pain over the triceps insertion on the back of the elbow. Caused by sudden severe strains to the triceps e.g. javelin throwers. Pain is reproduced by resisted elbow extension and by passive elbow flexion.

Treatment

  • Rest and analgesics initially.
  • LA / steroid injections .
  • Prolotherapy to the triceps insertion (beware the ulnar nerve behind the medial epicondyle).
  • Surgical debridement and tendon re-attachment.

Olecranon Bursitis

A condition where bursa (fluid filled sac) at the tip of the elbow becomes inflamed and painful . The olecranon bursa is a fluid filled sac allowing the skin of the elbow to slide easily over the bone without causing friction. When inflamed, the sac fills with synovial fluid becoming tense and painful. The bursa may become secondarily infected if the skin has been breached during an injury, in which case the bursa fills with pus rather than synovial fluid.

Causes

  • Direct blow to the tip of the elbow from a hard surface.
  • Spending too much time leaning on the tip of the elbow.
  • More common in those with Gout and Rheumatoid Arthritis

Clinical Features

  • A red tender fluctuant lump forms at the tip of the elbow.

Treatment

  • Rest and analgesics initially.
  • If there is a suspicion of an infected bursa (broken skin, fever, chills, feeling unwell), the bursa should be drained with a needle and syringe, and the fluid sent for analysis at the laboratory, followed by the appropriate antibiotic orally.
  • In the absence of infection, a LA / steroid injection can greatly help to reduce the pain and inflammation.
  • In recurrent cases, surgical removal of the bursa is necessary.

Osteoarthritis

Pain and stiffness in the elbow can occur due to osteoarthritis (arthritis pain) and traumatic synovitis. Elbow movements become painful in all directions and there may be an effusion (joint fluid) palpable between the olecranon and lateral epicondyle behind the elbow joint.

Rarely trauma can cause bleeding into the front of the joint capsule or the brachialis muscle producing a lump at the front of the elbow joint. If left untreated, the injury causes severe restriction of elbow extension with a fixed flexion deformity. The lump can become calcified and then it shows up on an X-ray as myositis ossificans.

Treatment

  • Rest and analgesics initially.
  • Think about trying the Pain Gone Pen - a simple low-cost non-drug self-help pain device for home use.
  • Intra-articular LA / steroid injection in the acute cases.
  • Mobilisation techniques (I prefer to combine these with the intra-articular injection above).
  • Viscosupplementation with Ostenil in the chronic cases.
  • Surgical replacement for severely affected joints.

Pulled Elbow

A common source of elbow pain in children. Occurs when a young child's arm is pulled causing a subluxation of the superior radioulnar joint.

Clinical Features

  • Occurs usually before the age of 8 years with a peak incidence at 2-3 years. The left arm in girls is more commonly affected.
  • The injury can occur with harmless movements like lifting a child out of the bath using one arm, or being swung round by an adult.
  • The injury produces a click, after which the child refuses to use the arm due to severe pain.
  • X-rays may show a slightly downward displaced radial head.
  • The suggested mechanism is that the head of the radius slips out through a tear in the annular ligament . All movements of the elbow are then impeded due to pain.

Treatment

  • The head of the radius can be usually quite easily be manipulated back into place, without the need for sedation or a general anaesthetic.
  • The child needs to be watched afterwards for recurrent subluxations.
  • As the child grows the strength of the annular ligament increases so that further subluxations are unlikely beyond the age of 8 years.
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