elbow pain

causes of lateral elbow pain include:

• tennis elbow
• radial tunnel syndrome
• Medial elbow pain

causes of medial elbow pain include:

• golfer’s elbow
• cubital tunnel syndrome
• medial (ulnar) collateral ligament injury

Golfers elbow 

• Golfer’s elbow is caused by inflammation of the flexor rigin at the medial humeral epicondyle, where there is pain and tenderness. It is far less common than its counterpart tennis elbow.
• It is characterised by pain radiating across the flexor aspect of the arm and there is pain on resisted pronation.
• Medial epicondylitis is an overuse injury affecting the flexor-pronator muscles (i.e. pronator teres, flexor carpi radialis, palmaris longus) at their origin on the anterior medial epicondyle of the humerus
• onset can be related to occupation (e.g. consistent use of a tool such as a hammer, or in baseball when throwing a pitch) 
• examination
  • should reveal point tenderness of the medial aspect of the elbow over the common flexor origin
  • this point can be found by palpating the elbow with the wrist held in resisted palmar flexion
  • discomfort with this manoeuvre is confirmatory
  • neurological examination of the upper limb should be normal
  • joint is not involved so ROM should not be affected
• Investigation: diagnosis is made clinically
  • ultrasound is the investigation of choice if there is any doubt over the diagnosis
  • a nerve conduction study can be useful in excluding cubital tunnel syndrome

Tennis Elbow

• partially reversible but degenerative overuse-underuse tendinopathy
• Risk factors
  • occupational activities and sports which involves repetitive wrist motion or a power grip
    • some examples are plumbing; playing a musical instrument; painting; weaving; raking; using screwdrivers, pliers, and hammers; fishing; engaging in arm wrestling, racket sports, and other twisting movements; and lifting objects with an extended wrist
  • Although the condition is named as tennis elbow, tennis is a direct cause in only 5% of people with lateral epicondylitis.
  • More typically the condition occurs due to overuse of a previously underused and atrophied tendon.
    • This is specially seen in people who begin exercising at the gym, start doing some gardening, painting a room, lifting a new baby, or even just carry heavy luggage on holiday after living a sedentary life style for years
• symptoms
  • gradual, insidious onset pain localized to the front of the lateral epicondyle and often radiates down the forearm
  • pain is made worse by movements such as pouring out tea, shaking hands or lifting the wrist whilst the forearm is pronated.
  • weakness in grip strength or difficulty in carrying objects in hands (2)
• examination
  • there is no swelling
  • the elbow can be flexed and extended without pain
  • tenderness is generally localized to the lateral epicondyle over the extensor mass
  • symptoms are usually reproduced with resisted supination or wrist dorsiflexion, particularly with the arm in full extension 
  • grip strength may be decreased (compared to the unaffected side) or may cause significant discomfort
• Treatment
  • self limiting condition 
  • Non operative procedures:
    • rest, application of ice
    • NSAID’s
    • physical therapy
      • stretching and strengthening exercise – specially eccentric (lengthening only) exercises
    • corticosteroid injections
      • repeating and repeated corticosteroid injections has been reported that repeated injections (average 4.3, range 3 to 6 over 18 months) were associated with poorer outcomes – the suggestion is that steroid injections are more effective in acute and subacute tendonitis (duration <12 weeks
    • orthotic devices
    • extracorporeal shock wave therapy (ESWT)
  • Surgery
  • autologous platelet-rich plasma injections
    • recent high quality randomised controlled trials have shown superior cure rates and pain scores for platelet-rich-plasma (PRP) injections up to two years after treatment when compared to cortisone injections
  • botulinum toxin A injection

Cubital tunnel syndrome

• Entrapment of the ulnar nerve within the cubital tunnel and subsequent inflammation may present with medial elbow pain, hand weakness 
• Patient c/o of  pins and needles radiating down the medial forearm
• Examination
  • positive Tinel’s test (medial elbow pain and 4th and 5th digit pins and needles upon tapping the cubital tunnel over the medial aspect of the elbow (‘funny bone’))
  • positive Froment’s
  • positive Wartenberg’s signs
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• Investigation
  • nerve conduction study
  • a plain x-ray will show if there is bony impingement of the cubital tunnel 
  • ultrasound may show swelling of the ulnar nerve and is useful in confirming the position of the ulnar nerve before surgery
• Management
  • patients with mild sensory symptoms may benefit from ergonomic advice and physiotherapy
  • ultrasound-guided injections of hydrocortisone may offer temporary relief
  • patients presenting with weakness (positive Froment’s and Wartenberg’s) should be referred for surgical decompression