Elbow pain both

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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The causes of elbow pain are varied.

A look at the anatomy may be helpful.

The elbow contains three separate places where there is interaction of the bones that make up the elbow. The bones are the humerus (upper arm bone), radius, and ulna (the two lower forearm bones.)The humeroulnar joint is a modified hinge joint that allows flexion and extension. The humeroradial joint is a combined hinge and pivot joint that allows flexion and extension as well as rotation of the head of the radius on the capitellum (end) of the humerus. The radioulnar joint allows rotation during flipping the hand over and back (supination and pronation.)

Stability is provided by the medial and lateral ligament complexes. The annular ligament encircles the head of the radius, stabilizing it. The ulnar and radial collateral ligament provide stability against excessive side to side motion.

Four muscle groups act on the elbow. Flexors (bending the elbow) include the biceps brachii, brachioradialis, and brachialis muscles. The extensors (straightening the elbow) are the triceps and anconeus muscles. The supinators (flippinmg the hand so the palm is facing up) include the supinator and biceps brachii muscles. Pronation (flipping the hand so the palm is facing down)is accomplished by the pronator quadratus, pronator teres and flexor carpi radialis muscles.

The elbow also has a complicated nerve innervation. The median nerve crosses the elbow medially and passes through the two heads of the pronator teres muscle, a site that potentially can lead to entrapment. The ulnar nerve passes along the medial arm and posterior to the medial epicondyle through the cubital tunnel, another site that can cause entrapment.

When a patient presents with elbow pain, the physician should seek information about both occupational and recreational activities involving repetitive activity that could cause trauma and tissue degeneration.

It is important to identify neurologic and mechanical symptoms. Weakness or numbness and tingling are clues to nerve entrapment syndromes or pinched nerves in the neck. Mechanical symptoms, such as clicking with motion as well as locking and catching, may indicate joint pathology.

The tennis elbow test is performed by having the patient make a fist, pronate the forearm and extend the wrist against resistance. The test is positive if pain is elicited in the area of the lateral epicondyle.

Resistance applied to extension of the long finger (third digit) may provoke pain over the extensor muscles in the forearm. This finding is suggestive of radial tunnel syndrome, which is often mistaken for resistant tennis elbow.

The physician can apply force to deviate the elbow from one side to the other to evaluate for medial or lateral laxity, pain, and decreased mobility.

The neck, shoulder and wrist should be examined carefully in the patient with elbow pain.

Magnetic resonance imaging (MRI) can be helpful in identifying soft tissue masses, cartilage abnormalities, and ligament ruptures.

Electromyography and nerve conduction studies are used to evaluate suspected nerve compression syndromes.

Elbow disorders that may affect both elbows are:

Lateral epicondylitis, also know as tennis elbow.This is caused by repeated contractions of wrist muscles located on the outer forearm. The stress causes microscopic tears leading to inflammation at the outer portion of the elbow (the lateral epicondyle). Medial tennis elbow, or medial epicondylitis, is caused by repetitive contractions from muscles located on the inside of the forearm. This overuse injury is common between ages 20 and 40.

People at risk are those in occupations that require strenuous or repetitive forearm movement. Such jobs include mechanics or carpentry. Sport activities that require individuals to twist the hand, wrist, and forearm, such as tennis, throwing a ball, bowling, golfing, and skiing, can cause tennis elbow. Individuals who are not in good physical condition who are exposed to repetitive wrist and forearm movements for long periods of time may be prone to tennis elbow.

Tennis elbow pain originates from a partial tear of the tendon and the attached covering of the bone.

Magnetic resonance imaging (MRI) has been shown to be helpful in diagnosing cases of early tennis elbow because it can detect evidence of swelling and tissue tears in the common extensor muscle group. Diagnostic ultrasound has also been useful for diagnosis.

Heat or ice can be helpful in relieving tennis elbow pain. Once acute symptoms have subsided, heat treatments are used to increase blood circulation and promote healing. The physician may recommend physical therapy. Occasionally, a tennis elbow splint may be useful. Exercises are important to improve flexibility and will help decrease muscle and tendon tightness.

Non-steroidal anti-inflammatory drugs (NSAIDS) may help reduce inflammation and pain. Injections of cortisone or anesthetics are often used if physical therapy is ineffective. Excessive numbers of injections weaken the tendon.

A newer method of treatment for tennis elbow is shock wave therapy, in which pulses of high-pressure sound are directed at the injured part of the tendon. The "shock" breaks down scar tissue and stimulates the regrowth of blood vessels in healthy tissue.

Botulinum toxin, or Botox, is also being tried as a treatment for tennis elbow. Botox appears to relieve pain in chronic tennis elbow by relaxing muscles that have gone into spasm from prolonged inflammation.

Probably the treatment of choice is ultrasound guided needle tenotomy with injection of platelet-rich plasma (PRP). This is a concentrate of a patient's blood that contains a large number of platelets, cells that are packed with growth and healing factors. This creates new good quality tendon tissue in addition to alleviating pain.

Surgical intervention is relatively rare.

Massage therapy has been found to be beneficial if symptoms are mild.

Until symptoms of pain and inflammation subside, activities requiring repetitive wrist and forearm motion should be avoided.

Biceps tendinosis causes anterior elbow pain in a patient who has engaged in activities involving repetitive elbow flexion and forearm supination.

With biceps tendinosis, tenderness of the distal biceps tendon increases with resisted flexion and supination. The patient with advanced biceps tendinosis may develop elbow contracture and may be unable to fully extend the elbow.

Pronator Syndrome. This disorder occurs when the median nerve becomes entrapped at a point just distal to the elbow. The pronator syndrome often occurs in patients who present with elbow pain. Anterior pain and tingling are characteristic symptoms.

Nerve conduction studies may be helpful in making the diagnosis and may also help rule out carpal tunnel syndrome.

Anterior Capsule Strain. Activities requiring repetitive hyperextension of the elbow may strain the anterior capsule. The strain results in anterior pain

Triceps Tendinosis. Posterior elbow pain in the setting of repetitive elbow extension suggests the diagnosis of triceps tendinosis. Resisted extension worsens the pain.

Olecranon Impingement. This injury, which typically occurs in throwing activities, causes clicking or locking of the elbow with extension. The elbow pain worsens with extension.

Olecranon stress fractures produce pain that increases with extension in throwing. MRI is diagnostic.

Olecranon bursitis causes painless swelling of the posterior elbow at the outer tip of the olecranon in a patient complaining of repetitive friction to the elbow.

Septic bursitis should be ruled out in the patient with aspiration and culture of the fluid.

Radial tunnel syndrome is due to compression of the deep branch of the radial nerve at the radial tunnel. It causes pain that radiates into the dorsal forearm and may be mistaken for lateral epicondylitis.

Electrodiagnostic studies may be positive. Radial tunnel syndrome should be considered in the patient with refractory tennis elbow.

Ulnar collateral ligament sprain most commonly occurs in throwing activities (like pitching). The injury is characterized by medial elbow pain that becomes worse with activity. The pain is typically relieved with rest but returns on resumption of throwing.

An ulnar collateral ligament sprain can be demonstrated by pain or instability on valgus stress testing. MRI can identify both partial and complete tears.

Ulnar nerve entrapment is characterized by numbness and tingling along the ulnar aspect of the forearm and extending into the ring and little fingers (fourth and fifth digits). The patient may complain of a weak grip. Ulnar nerve entrapment often occurs in throwing sports.

Tenderness is present over the ulnar nerve within the groove of the medial epicondyle.

Electrodiagnostic tests may be positive. MRI and diagnostic ultrasound are useful.

Many forms of arthritis also affect both elbows. Examples include rheumatoid arthritis, psoriatic arthritis, and crystal-induced arthritis (gout and pseudogout). The diagnosis is made using a combination of history, physical examination, laboratory testing, and joint fluid analysis. Sometimes imaging procedures such as magnetic resonance imaging (MRI) is useful. Synvial biopsy may be necessary.

(For more information on tendonitis, visit our sister site: Tendonitis and PRP)

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