elbow shoulder hand pain symptoms

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.

Click here: Second Opinion Arthritis Treatment Kit

There are a number of conditions that may affect all three regions.

Sometimes these are distinct problems and sometimes they are interrelated. This page will discuss the many problems that may occur.

One problem that can tie together all these areas is a neck disorder where there is nerve root irritation. The pain may radiate into the shoulder, elbow, and hand. When pain begins in the neck but is felt in the shoulder and arm, it is called “referred pain.”

Other types of nerve irritation or inflammation such as brachial plexus inflammation (Parsonage-Turner Syndrome), and entrapment of nerves in the elbow and wrist may also cause pain in the arm. Parsonage-Turner is a rare idiopathic inflammation of the nerves of the brachial plexus. It causes severe pain and weakness in the affected arm.

Nerve entrapment of the ulnar and radial nerves near the elbow may also cause significant discomfort in the arm. Entrapment may occur as a result of trauma or arthritis.

Nerve entrapment involving the median and ulnar nerve in the wrist may cause proximal referred pain.

Many patients seek medical attention for shoulder pain, and a diagnosis given is 'shoulder bursitis,' or 'shoulder tendonitis.' The doctor will often mention that identifying which of these diagnoses is the real cause of pain is not important because the treatment is the same.

Shoulder bursitis and rotator cuff tendonitis both indicate there is inflammation of a particular area within the shoulder joint that is causing a common set of symptoms. The best terminology for these symptoms is 'impingement syndrome.' Impingement syndrome occurs when there is inflammation of the rotator cuff tendons and the bursa that surrounds these tendons.

Impingement syndrome, or shoulder bursitis, occurs when there is inflammation between the top of the humerus (arm bone) and the acromion (tip of the shoulder). Between these bones lies the tendons of the rotator cuff, and the bursa that protects these tendons.

Normally, these tendons slide effortlessly within this space. In some people this space becomes too narrow for normal motion, and the tendons and bursa become inflamed. Inflammation leads to thickening of the tendons and bursa, and contributes to the loss of space in this location. Eventually, this space becomes too narrow to accommodate the tendons and the bursa, and every time these structures move between the bones they are pinched--this is the impingement.

Impingement syndrome is a descriptive term of pinching of the tendons and bursa of the rotator cuff between bones. In many individuals with this problem, the shape of their bones is such that they have less space than most others. Therefore, small thickenings of the tendons or bursa can cause symptoms.

Often there is an initial injury that sets off the process of inflammation. Thereafter, the problem can become a vicious cycle. Once there is an initial injury, the tendons and bursa become inflamed. This inflammation causes a thickening of these structures. The thickening then takes up more space, and therefore the tendons and bursa become are pinched upon even more. This causes more inflammation, and more thickening of the tendons and bursa, and so on.

Common symptoms include:

o Pain with overhead activities (arm above head height)
o Pain while sleeping at night
o Pain over the outside of the shoulder/upper arm

Impingement syndrome and a rotator cuff tear are different problems; the treatment is different. Impingement syndrome is a problem of inflammation around the rotator cuff tendons. A rotator cuff tear is an actual tear within the tendons. The best signs that differentiate these problems area the strength of the rotator cuff muscles. Your physician will be able to specifically isolate these muscles to better determine if a rotator cuff tear is present. An MRI can also show the tendons of the rotator cuff and help determine if a tear is present.

The rotator cuff is the name for the tendons that surround the shoulder joint. The rotator cuff aids in allowing the shoulder to function as the most unique joint in the body. Due to the rotator cuff, the shoulder joint can move and turn through a wider range than any other joint in the body. This motion of the shoulder joint allows an amazing variety of tasks with the arms.

Unfortunately, a rotator cuff injury is a common problem, and these injuries make many routine activities difficult and painful. The rotator cuff is part of this mechanism that, when healthy functions very well, but when injured can be a difficult and frustrating problem.

The rotator cuff is actually a group of four muscles and their tendons that wraps around the front, back, and top of the shoulder joint.

Together the rotator cuff muscles help guide the shoulder through many motions, and also lend stability to the joint. The ends of the rotator cuff muscles form tendons that attach to the arm bone (humerus). It is the tendinous portion of the muscle that is usually involved in a rotator cuff injury.

The most common mechanisms of a rotator cuff injury are separated into 'repetitive use' and 'traumatic.'

In repetitive use injuries to the rotator cuff, repeated activities cause damage to the rotator cuff tendons. Over time, the tendons wear thin and a tear can develop within the tendons of the rotator cuff. Patients with repetitive use injuries to the rotator cuff often have complaints of shoulder bursitis prior to developing a tear through the rotator cuff tendons.

Traumatic injuries to the rotator cuff are seen after events such as falling on to an outstretched hand. The traumatic event can cause a rotator cuff injury by tearing the rotator cuff tendons. This mechanism is much less common than repetitive use injuries, but when a rotator cuff tear occurs in a patient younger than 60 years old it is usually a traumatic injury.

A rotator cuff injury is much more common in the older population. Usually in younger patients, there is either a traumatic injury, or the patient is involved in demanding unusual use of their shoulder, as seen in professional athletes.

As people age, the muscle and tendon tissue of the rotator cuff loses some elasticity, becomes more susceptible to injuries, and is often damaged while performing everyday activities. This is the reason that rotator cuff tears are more commonly seen in older patients.

Not every rotator cuff injury causes significant pain or disability. In fact, autopsy studies have shown rotator cuff tears in up to 70% of people over the age of 80 and 30% of the population under the age of 70. Clearly, all of the people with rotator cuff tears are not complaining of painful symptoms. However, in many individuals, a rotator cuff injury can cause significant disability, and prompt diagnosis and treatment can have a profound improvement in symptoms.

Frozen shoulder, or adhesive capsulitis, is a condition that causes loss of motion in the shoulder joint. The diagnosis of frozen shoulder is often used for any painful shoulder condition associated with a loss of motion, but it is important to understand the cause of the symptoms in order for treatment to proceed effectively.

Other conditions can also cause restricted motion and a stiff joint--the diagnosis of a frozen shoulder includes specific symptoms. Often people experience trauma to the shoulder prior to the onset of the frozen shoulder, and sometimes there is no known cause for developing a frozen shoulder.

Frozen shoulder is also called adhesive (scarred) capsulitis (inflamed joint capsule).

The shoulder joint is a ball and socket joint. The ball is the top of the arm bone (the humeral head), and the socket is part of the shoulder blade (the glenoid). Together these bones form the glenohumeral joint; this is the ball (humerus) and socket (glenoid)--the glenohumeral joint.

Normally, the shoulder joint allows more motion than any other joint in the body. When frozen shoulder sets in, however, the limits in motion can make this a stiff and useless joint.

The condition is characterized by a decrease in motion, primarily seen in lifting the arm and turning it inwards. Frozen shoulder is most common in the 40-60 year old age group and it is twice as common in women as men. People usually experience pain as the first symptom of frozen shoulder, followed by the loss of motion and a decrease in pain. Normally a gradual return of motion will follow; however, the length of time for recovery from frozen shoulder can be prolonged, with an average duration of 18 months.

Calcific tendonitis is a condition that causes the formation of a small, usually about 1-2 centimeter size, calcium deposit within the tendons of the rotator cuff. These deposits are usually found in patients at least 30-40 years old, and have a higher incidence in diabetics. The calcium deposits are not always painful, and even when painful they will often spontaneously resolve after a period of 1-4 weeks.

The cause of calcium deposits within the rotator cuff tendon is not entirely understood. Different ideas have been suggested, including blood supply and aging of the tendon, but the evidence to support these conclusions is not clear.

Calcific tendonitis usually progresses predictably, and almost always resolves eventually without surgery.

The typical course is:

• Precalcification Stage: Patients usually do not have any symptoms in this stage. At this point in time, the site where the calcifications tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.
• Calcific Stage: During this stage, the calcium is excreted and then coalesces into calcium deposits. When seen, the calcium looks chalky; it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins, this is not a painful time and may last a varied length of time. After the resting phase, a resorptive phase begins--this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit appears like toothpaste.
• Postcalcific Stage: This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing tissues.

Patients usually seek treatment during the painful resorptive phase of the calcific stage, but some patients have the deposits found incidentally as part of impingement syndrome.

Nonoperative treatment is nearly always the first line of treatment for calcific tendonitis. The treatment protocol is similar to the treatment for impingement syndrome of the shoulder. This includes physical therapy, exercises, anti-inflammatory medications, and steroid injections. There is a good success rate with treatment. The calcific deposit will often remain, but the goal of treatment is to control the symptoms caused by this condition.

Surgery is recommended in the following situations:

o When symptoms continue to progress despite treatment
o When constant pain interferes with routine activities (dressing, combing hair)
o When symptoms do not respond to conservative care

Available treatment options include aspiration of the calcium deposit with a needle and excision of the calcium deposit.

Needling is a procedure that is done under sedation or general anesthesia. Your surgeon will direct a large needle into the calcium deposit and attempt to aspiration, or suck out, as much of the calcium deposit as possible. Injections of saline, novocaine, or sometimes cortisone, is then performed into the calcium deposit. Patients can resume activity shortly after the procedure.

Excision of the deposit is a larger procedure, but may be necessary, especially is cases of chronic calcific tendonitis. Either through a small incision or through the use of an arthroscope, the calcium deposit is identified and removed. Physical therapy is usually necessary after this procedure to help regain strength and motion in the affected shoulder.

Shoulder instability is a problem that occurs when the structures that surround the glenohumeral (shoulder) joint do not work to maintain the ball within its socket. If the joint is too loose, is may slide partially out of place, a condition called shoulder subluxation. If the joint comes completely out of place, this is called a shoulder dislocation. Patients with shoulder instability often complain of an uncomfortable sensation that their shoulder may be about to slide out of place--this is what physicians call apprehension.

Shoulder instability tends to occur in three groups of people:

• Prior Shoulder Dislocators: Patients who have sustained a prior shoulder dislocation often develop chronic instability.
In these patients, the ligaments that support the shoulder are torn when the dislocation occurs. If these ligaments heal too loosely, then the shoulder will be prone to repeat dislocation and episodes of instability. When younger patients (less than about 35 years old) sustain a traumatic dislocation, shoulder instability will follow in about 80% of patients.
• Young Athletes: Athletes who compete in sports that involve overhead activities may have a loose shoulder or multidirectional instability (MDI). These athletes, such as volleyball players, swimmers, and baseball pitchers, stretch out the shoulder capsule and ligaments, and may develop chronic shoulder instability. While they may not completely dislocate the joint, the apprehension, or feeling of being about to dislocate, may prevent their ability to play these sports.
• "Double-Jointed" Patients: Patients with some connective tissue disorders may have loose shoulder joints. In patients who have a condition that causes joint laxity, or double-jointedness, their joints may be too loose throughout their body. This can lead to shoulder instability and even dislocations.

Treatment of shoulder instability depends on several factors, and almost always begins with physical therapy and rehab. If patients complain of a feeling that their shoulder is loose or about to dislocate, physical therapy with specific strengthening exercises will often help maintain the shoulder in proper position. Shoulder strengthening is most likely to help the second group of patients--athletes with multi-directional shoulder instability. Other treatments sometimes used to treat shoulder instability include cortisone injections and anti-inflammatory medications.

If therapy fails, there are surgical options that can be considered. Depending on the cause of the instability, the surgical treatments may be quite different.

If the cause of the shoulder instability is a loose shoulder joint capsule, then a procedure to tighten the capsule of the shoulder may be considered. This can be done with an arthroscope in a procedure called a thermal capsular shrinkage. In this surgery, a heated probe shrinks the shoulder capsule to tighten the tissue. The more standard method of this procedure is called an open capsular shift. In this surgery, the shoulder joint is opened through a larger incision, and the capsule is tightened with sutures. The advantage of the open capsular shift is that the results are more predictable. The advantage of the arthroscopic procedure is that the recovery is faster and the incision is smaller. Sometimes a particular problem is better suited to one procedure than the other.

If the problem is due to a tearing of the ligaments around the shoulder, called the labrum, then a procedure called a Bankart repair can be performed to fix this ligament. A Bankart repair can also be done either through an incision or an arthroscope. Again, the results of the open procedure are more predictable (more patients get better), but the arthroscopic procedure does not leave as large an incision.

A shoulder dislocation is an injury that occurs when the top of the arm bone (humerus) loses contact with the shoulder blade (scapula). This injury is often confused with a shoulder separation, but these are two very different injuries! It is important to distinguish between these two problems because the issues with management and treatment are different.

The shoulder joint is made of three bones which come together at one place. The arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle) all meet up at the top of the shoulder (see the pictures!). A shoulder separation occurs when there is an injury to the joint between the scapula and clavicle--this is called an acromioclavicular (or A-C) separation. A shoulder dislocation occurs when there is an injury to the joint between the humerus and scapula.

The joint between the humerus and scapula, also called the glenohumeral joint, is a ball-and-socket joint--the ball is on the top of the humerus, and this fits into a socket of the shoulder blade called the glenoid. This joint allows us to move our shoulder though an amazing arc of motion--no joint in the body allows more motion than the glenohumeral joint. Unfortunately, by allowing this wide range of motion, the shoulder is not as stable as other joints. Because of this, shoulder dislocations are not uncommon injuries.

A shoulder dislocation generally occurs after an injury such as a fall or a sports-related injury. About 95% of the time, when the shoulder dislocates, the top of the humerus is sitting in front of the shoulder blade--an anterior dislocation. In less than 5% of cases, the top of the humerus is behind the shoulder blade--a posterior dislocation. Posterior dislocations are unusual, and seen after injuries such as electrocution or after a seizure.

When the dislocation is diagnosed, the shoulder must be "reduced," or put back in place. It is possible to treat a shoulder dislocation at the scene of the injury, but if transportation to a hospital is available, then this is a much safer option. There are potential complications of dislocated shoulder, and there are complications of reducing a dislocated shoulder.

An x-ray usually shows the dislocation, but can x-rays can be misleading--good quality studies must be obtained. In order to return the joint to proper position, some anesthesia is given, and the physician performs specific maneuvers to pop the joint in place. Some patients are able to have the dislocated shoulder reduced with local anesthesia, others require general, and many fall somewhere in between.

Once the joint is in place, repeat x-rays are performed to ensure it is indeed in the correct position, and to evaluate for other injuries such as fractures. One of the most common problems following a shoulder dislocation is called shoulder instability. Shoulder instability often follows a dislocated shoulder and is due to tears of the ligaments that help support the shoulder. If these ligaments heal too loosely, the shoulder may not be held in place adequately, and the shoulder may become prone to repeat dislocations. The following page contains more information on shoulder instability.

A shoulder separation is almost always the result of a sudden, traumatic event that can be attributed to a specific incident or action. The two most common descriptions of a shoulder separation are either a direct blow to the shoulder (often seen in football, rugby, or hockey), or a fall on to an outstretched hand (commonly seen after falling off a bicycle or horse).

Pain is the most common symptom of a separated shoulder, and is usually severe at the time of injury. Evidence of traumatic injury to the shoulder, such as swelling and bruising, are also commonly found. The injury is graded by severity from Grade I (minimal joint disruption) to Grade III (severe injury). If the injury is more severe, Grade III, a bump caused by the separated joint may be seen or felt at the tip of the shoulder bones. The diagnosis of shoulder separation is often quite apparent from hearing a story that is typical of this injury, and a simple physical examination. An x-ray should be performed to ensure there is no fracture of these bones. If the diagnosis is unclear, an x-ray while holding a weight in your hand may be helpful. When this type of x-ray is performed, the force of the weight will accentuate any shoulder joint instability and better show the effects of the separated shoulder.

The Bankart lesion is a specific injury to a part of the shoulder joint called the labrum. The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable.

To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within. This cuff of cartilage makes the shoulder joint much more stable, yet allows for a very wide range of movements (in fact, the range of movements your shoulder can make far exceeds any other joint in the body).

When the labrum of the shoulder joint is torn, the stability of the shoulder joint is compromised.

A specific type of labral tear is called a Bankart lesion. A Bankart lesion happens when an individual sustains a shoulder dislocation. As the shoulder pops out of joint, it often tears the labrum, especially in younger patients. The tear is to part of the labrum called the inferior glenohumeral ligament.

Typical symptoms of a Bankart lesion include a catching, aching, and susceptibility to dislocation; often patient will complain that they cannot "trust" their shoulder. Diagnosis can be difficult as these injuries do not always show up well on MRI scans. This is more of a clinical diagnosis with the definitive diagnosis of a Bankart lesion made at the time of surgery. Patients who sustain a Bankart injury are at much higher risk for dislocating their shoulder again. Treatment of a Bankart lesion often depends on whether or not a patient has recurrent episodes of shoulder instability.

When there is suspicion for a Bankart lesion, attempts at physical therapy to strengthen the shoulder may help to reduce the risk of repeat dislocation. If strengthening does not help the problem, shoulder arthroscopy can be performed, and the injury can be definitively diagnosed and treated. A Bankart repair is surgery to repair the torn ligament back to the shoulder socket. The actual Bankart repair can either be performed through an arthroscope or through an incision over the front of the shoulder.

Whether or not a Bankart repair is done arthroscopically or through an incision (a so-called open Bankart repair) depends on several factors. An open Bankart repair is still widely considered the "best" repair. However, as arthroscopy continues to develop, an arthroscopic Bankart repair is becoming more widely accepted. You should discuss with your surgeon which procedure is best for your situation.

The SLAP lesion is an injury to a part of the shoulder joint called the labrum. The shoulder joint is a ball and socket joint, similar to the hip; however, the socket of the shoulder joint is extremely shallow, and thus inherently unstable. To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within.

A specific type of labral tear is called a SLAP lesion; this stands for Superior Labral tear from Anterior to Posterior. The SLAP lesion occurs at the point where the tendon of the biceps muscle inserts on the labrum. The mechanism of this injury is usually a fall onto an outstretched arm.

Typical symptoms of a SLAP lesion include a catching sensation and pain with movement, most typically overhead activities such as throwing.

Diagnosis can be quite difficult, as these injuries do not show up well on MRI scans. Usually, the diagnosis is made at the time of surgery. A typical course of action when there is suspicion for a SLAP lesion is to try physical therapy, resting the shoulder, anti-inflammatory medication, and cortisone injections. If these treatments do not help the problem, shoulder arthroscopy can be performed, and the injury can be definitively diagnosed and treated.

Osteoarthritis is the most common type of shoulder arthritis. Also called wear-and-tear arthritis or degenerative joint disease, osteoarthritis is characterized by progressive wearing away of the cartilage of the joint. As the protective cartilage is worn away by shoulder arthritis, bare bone is exposed within the joint.

The other type of shoulder arthritis that is not uncommon is rheumatoid arthritis. Rheumatoid arthritis is a systemic condition that causes an inflammation of the lining of a joint. This inflammation can, over time, invade and destroy the cartilage and bone.

Shoulder arthritis typically affects patients over 50 years of age. It is more common in patients who have a history of prior shoulder injury.

There is also a genetic predisposition of this condition, meaning shoulder arthritis tends to run in families.

Shoulder arthritis symptoms tend to progress as the condition worsens. What is interesting about shoulder arthritis is that symptoms do not always progress steadily with time. Often patients report good months and bad months or symptom changes with weather changes. This is important to understand because comparing the symptoms of arthritis on one particular day may not accurately represent the overall progression of the condition.

The most common symptoms of shoulder arthritis are:

o Pain with activities
o Limited range of motion
o Stiffness of the shoulder
o Swelling of the joint
o Tenderness around the joint
o A feeling of grinding or catching within the joint

Evaluation of a patient with shoulder arthritis should begin with a physical examination and X-Rays. These can serve as a baseline to evaluate later examinations and determine progression of the condition.

Treatment of shoulder arthritis should begin with the most basic steps, and progress to the more involved, possibly including surgery. Not all treatments are appropriate in every patient, and you should have a discussion with your doctor to determine which treatments are appropriate for your shoulder arthritis.

• Activity Modification: Limiting certain activities may be necessary, and learning new exercise methods may be helpful. Shoulder exercises are excellent for patients who have a weak shoulder.
• Physical Therapy: Stretching and strengthening of the muscles around the shoulder joint may help decrease the burden on the shoulder. Preventing atrophy of the muscles is an important part of maintaining functional use of the shoulder.
• Anti-Inflammatory Medications: Anti-inflammatory pain medications (NSAIDs) are prescription and nonprescription drugs that help treat pain and inflammation.
• Cortisone Injections: Cortisone injections may help decrease inflammation and reduce pain within a joint.
• Joint Supplements (Glucosamine): Glucosamine appears to be safe and might be effective for treatment of arthritis, but research into these supplements has been limited.
• Shoulder Arthroscopy: Exactly how effective shoulder arthroscopy is for treatment of arthritis is debatable. For some specific symptoms, it may be helpful
• Total Shoulder Replacement Surgery: In this procedure the cartilage is removed and a metal & plastic implant is placed in the shoulder.

The biceps tendon is the structure that connects the biceps muscle to the bone. There is a proximal biceps tendon at the shoulder joint, and a distal biceps tendon at the elbow.

Rupture of the proximal head of the biceps tendon involves one of two heads of the biceps tendon. This condition usually occurs in older individuals and is caused by degenerative changes within the tendon leading to failure of the structure. Most patients have preceding shoulder pain consistent with impingement syndrome. The proximal biceps tendon rupture may then occur during a trivial activity, and some patients may experience some pain relief once the damaged tendon ruptures.

The proximal biceps tendon may rarely rupture in a younger patient with activities such as weight-lifting or throwing sports, but this is quite unusual.

Usually patients will have sudden pain associated with an audible snap in the area of their shoulder.

The pain is usually not significant, and, as mentioned previously, some patients may experience pain relief after the rupture. After the ruptured tendon retracts, patients may notice a bulge in their arm at the biceps muscle. This is the retracted muscle bunched up in the arm, and is sometime referred to as a "Popeye Muscle," because it is more pronounced than normal.

Patients usually do not notice any loss of arm or shoulder function following a proximal biceps tendon rupture. A slight bulge in the arm, and some twitching of the retracted muscle are usually the most significant symptoms. Surgical repair of the proximal biceps tendon is usually only considered in the rare case of a young patient who works as a heavy laborer.

The reason there is little functional loss following a proximal biceps tendon rupture is that there are actually two tendinous attachments of the biceps at the shoulder joint (that is why the muscle is named "bi-ceps," meaning two heads). When the rupture occurs at the distal biceps tendon at the elbow, where there is only one attachment, surgical repair is much more commonly needed.

If pain persists following a proximal biceps tendon rupture, other causes of shoulder pain should be considered. These include impingement syndrome (rotator cuff bursitis), rotator cuff tears, or fractures around the shoulder.

Rupture of the distal biceps tendon at the elbow joint is much less common and accounts for less than 5% of biceps tendon ruptures. This injury is also usually found in elderly patients, although not always. There is usually some degree of tendinosus, or degenerative changes within the tendon, that predisposes the patient to rupture of the tendon.

The significance of a distal biceps tendon rupture is that without surgical repair, patients who experience complete rupture of the distal biceps tendon will notice loss of strength at the elbow. The strength will affect both the ability to bend the elbow against resistance, and the ability to turn the forearm to the palm-up position against resistance (for example, turning a doorknob).

Distal biceps tendon rupture is characterized by sudden pain over the front of the elbow after a forceful effort against a flexed elbow. Usually the patient will hear a snap and have pain where the tendon rupture occurs. Swelling and bruising around the elbow are also common symptoms of distal biceps tendon rupture.

Most patients will experience benefit if the biceps tendon is repaired surgically. If the tear is incomplete, or if the patient is very low-demand, then surgery may not be needed. However, most patients who want more normal use of their arm will benefit from surgery to repair the ruptured tendon to the bone.

Lateral epicondylitis, also known as tennis elbow, is characterized by pain in the back side of the elbow and forearm, along the thumb side when the arm is alongside the body with the thumb turned away. The pain is caused by damage to the tendons that bend the wrist backward away from the palm. A tendon is a tough cord of tissue that connects muscles to bones.

If you bend your arm, you can feel three bumps at your elbow joint. The most common type of elbow pain, known as 'tennis elbow', is associated with the two bumps that lie on either side of the elbow's main bump. Injury to the tendons that anchor muscles to these bumps are the cause of tennis elbow. Overuse of the elbow joint, or continuously making the muscles take heavy loads, can cause small tears to form in the soft tissue, particularly where the tendons anchor to the bony bump. Eventually, enough tears accumulate to cause pain and reduced movement of the elbow joint. Depending on the location and severity of the injury, full recovery can take up to six months.

The following are the most common symptoms of tennis elbow. However, each individual may experience symptoms differently.

Initially, the pain may be felt along the outside of the forearm and elbow. The pain may increase down to the wrist, even at rest, if the person continues the activity that causes the condition. Pain may also persist when the arm and hand are placed palm-down on a table and the person tries to raise the hand against resistance.

The symptoms of tennis elbow may resemble other medical problems or conditions. Always consult your physician for a diagnosis.

The diagnosis of tennis elbow usually can be made based on a physical examination. However, in some cases, an x-ray of the elbow is necessary.

Pain in the elbow joint, especially when straightening the arm
Dull ache when at rest
Pain when making a fist (medial epicondylitis)
Pain when opening the fingers (lateral epicondylitis)
Soreness around the affected elbow bump
Weak grip
Difficulties and pain when trying to grasp objects, especially with the arm stretched out.

The parts of the elbow associated with tennis elbow include:

• Lateral epicondyle - the bump on the outer side of the elbow. The muscles on the back of your forearm, responsible for curling your wrist backwards, are anchored to this bony point. Pain localized to this bump is referred to as lateral epicondylitis. This area is particularly susceptible to tennis elbow because it has a poor blood supply.
• Medial epicondyle - the bump on the inner side of the elbow. The muscles on the front of your forearm, responsible for curling your wrist up, are anchored to this bony point. Pain localized to this bump is referred to as medial epicondylitis. Sometimes this area becomes sore from playing golf.

Tennis elbow, as the name implies, often is caused by the force of the tennis racket hitting balls in the backhand position. The forearm muscles, which attach to the outside of the elbow, may become sore from excessive strain. When making a backhand stroke in tennis, the tendons that roll over the end of the elbow can become damaged. Tennis elbow may be caused by the following:

• improper backhand stroke
• weak shoulder and wrist muscles
• using a too tightly strung or too short tennis racket
• hitting the ball off center on the racket or hitting heavy, wet balls
• painting with a brush or roller
• operating a chain saw
• frequent use of other hand tools on a continuous basis

Specific treatment for tennis elbow will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the condition
• your tolerance for specific medications, procedures, and therapies
• expectation for the course of the condition
• your opinion or preference

Treatment for tennis elbow includes stopping the activity that produces the symptoms. Treatment may include:

• ice pack application (to reduce inflammation)
• strengthening exercises
• anti-inflammatory medications
• surgery

Some of the many conditions and events that may contribute to tennis elbow include:

• Lack of strength in the forearm muscles.
• Lack of flexibility in the forearm muscles.
• Lack of strength in the shoulder muscles.
• Instability of the elbow joint.
• Poor technique during sporting activities (especially tennis and golf) that puts too much strain on the elbow joint.
• Inappropriate sporting equipment, such as using a heavy tennis racquet, or having the wrong sized grip on a tennis racquet or golf club.
• Repetitive movements of the hands and arms, such as working an assembly line.
• Continuously making the muscles and joint take heavy loads.
• Other factors such as neck symptoms or nerve irritation.

Suggestions for tennis elbow include:

• Stop whatever you are doing.
• Rest your elbow for a few days.
• Use icepacks every two hours, applied for 15 minutes.
• Massage and stretch the muscles after 48 hours to relieve stress and tension.
• See your doctor or physiotherapist for diagnosis and further treatment, if necessary.

If the symptoms don't improve, or if you are prone to recurring bouts of tennis elbow, see your doctor or physiotherapist. Treatment options may include:

• Soft tissue massage
• Ice massage
• Acupuncture
• Joint mobilization
• Flexibility and strengthening exercises prescribed by your physiotherapist
• Tape
• Anti-inflammatory medication
• Electrotherapy modalities
• Corticosteroid injections
• Pain-killing drugs
• Bracing
• Surgery, in severe cases.

Some of the exercises suggested by your doctor or physiotherapist may include:

• Stand facing a wall with your arms stretched out straight in front of you at shoulder height, palms facing upwards. Bend your wrists so you can place your palms on the wall until you feel a stretch in your forearm, but no pain. Hold for 10 seconds, relax, and repeat five times.
• Hold a stick horizontally with both hands and curl the wrists up and down, once again maintaining each position for around 10 seconds.
• Squeeze and release a small firm ball, such as a tennis ball, with your arm stretched out straight in front of you.

Ways to reduce the risk of tennis elbow include:

• Always warm up and cool down thoroughly when playing sport.
• Make sure you use good technique and proper equipment when playing your chosen sports.
• Do strengthening exercises with hand weights - your physiotherapist can prescribe the correct exercises for you.
• Regularly stretch relevant muscles before beginning any potentially stressful activity - your physiotherapist can prescribe the correct exercises for you.

While tennis elbow is the most common cause of elbow pain, other conditions can include:

• Radiohumeral bursitis - bursitis is inflammation of a bursa. Bursae are small sacs that contain fluid to lubricate moving parts such as joints, muscles and tendons.
• Osteoarthritis - the joint cartilage becomes brittle and splits. Some pieces of cartilage may even break away and float around inside the synovial fluid. This can lead to inflammation.
• Referred pain - injuries to the bones of the spine (vertebrae) can irritate the nerves servicing the arm and cause referred pain around the elbow joint.
• Nerve entrapment - the radial nerve is the main nerve of the arm. If this nerve can't move freely, it can cause pain when the arm is stretched out. The radial nerve can be pinched by vertebrae or the elbow joint. There is evidence to suggest that nerve entrapment contributes to the pain of tennis elbow in some cases.
• Ligament sprain - joints are held together and supported by tough bands of connective tissue called ligaments. A sprain is a type of joint injury characterised by tearing of the ligaments.
• Bone fracture - a heavy fall or blow to the elbow may cause one of the bones to break or crack.
• Avulsion fracture - a powerful muscle contraction can wrench the tendon free and pull out pieces of bone.
• Osteochondritis dissecans - in younger people, a piece of cartilage and bone can become loose in the joint.

Medial epicondylitis, also known as golfer's elbow, baseball elbow, suitcase elbow, or forehand tennis elbow, is characterized by pain from the elbow to the wrist on the palm side of the forearm. The pain is caused by damage to the tendons that bend the wrist toward the palm. A tendon is a tough cord of tissue that connects muscles to bones.

Medial epicondylitis is caused by the excessive force used to bend the wrist toward the palm, such as swinging a golf club or pitching a baseball. Other possible causes of medial epicondylitis include the following:

• serving with great force in tennis or using a spin serve
• weak shoulder and wrist muscles
• using a too tightly strung, too short, and/or too heavy tennis racket
• throwing a javelin
• carrying a heavy suitcase
• chopping wood with an ax
• operating a chain saw
• frequent use of other hand tools on a continuous basis

The following are the most common symptoms of medial epicondylitis. However, each individual may experience symptoms differently.

The most common symptom of medial epicondylitis is pain along the palm side of the forearm, from the elbow to the wrist, on the same side as the little finger. The pain can be felt when bending the wrist toward the palm against resistance, or when squeezing a rubber ball.

The symptoms of medial epicondylitis may resemble other medical problems or conditions. Always consult your physician for a diagnosis.

The diagnosis of medial epicondylitis usually can be made based on a physical examination. The physician may rest the arm on a table, palm side up, and ask the patient to raise the hand by bending the wrist against resistance. If a person has medial epicondylitis, pain usually is felt in the elbow.

Specific treatment for medial epicondylitis will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the condition
• your tolerance for specific medications, procedures, and therapies
• expectation for the course of the condition
• your opinion or preference

Treatment for medial epicondylitis includes stopping the activity that produces the symptoms. Treatment may include:• ice pack application (to reduce inflammation)
• strengthening exercises
• anti-inflammatory medications
• surgery

The hand is composed of many different bones, muscles, and ligaments that allow for a large amount of movement and dexterity. There are three major types of bones in the hand itself, including the following:

• phalanges - the 14 bones that are found in the fingers of each hand and also in the toes of each foot. Each finger has three phalanges (the distal, middle, and proximal); the thumb only has two.
• metacarpal bones - the five bones that compose the middle part of the hand.
• carpal bones - the eight bones that create the wrist. The carpal bones are connected to two bones of the arm, the ulnar bone and the radius bone.

Numerous muscles, ligaments, and sheaths can be found within the hand. The muscles are the structures that can contract, allowing movement of the bones in the hand. The ligaments are fibrous tissues that help bind together the joints in the hand. The sheaths are tubular structures that surround part of the fingers.

There are many common hand problems that can interfere with activities of daily living (ADLs), including the following:

Arthritis is joint inflammation and commonly occurs in the fingers and at the base of the thumb. The pain associated with arthritis may be from many different sources, including inflammation of the following:

• synovial membrane - a clear, sticky fluid that is released by the synovial membrane and acts as a lubricant for joints and tendons.
• tendons - the tough cords of tissue that connect muscles to bones.
• ligaments - a white, shiny, flexible band of fibrous tissue that binds joints together and connects various bones and cartilage.
Osteoarthritis, a degenerative joint disease, is the most common type of arthritis in older people. It is a slow-progressing disease that primarily affects the hands and the large weight-bearing joints of the body, such as the knees and hips.

Osteoarthritis in the hands or hips may run in families, or be caused by injuries, overuse, muscle strain, or fatigue.

• Heberden nodes, bony abnormal enlargements of the distal interphalangeal joints.
• Bouchard nodes – bony enlargement of the proximal interphalangeal joints

Rheumatoid arthritis, psoriatic arthritis, gout, and pseudogout may also affect the hands.

Carpal tunnel syndrome is a condition in which the median nerve is compressed as it passes through the carpal tunnel in the wrist, a narrow confined space. Since the median nerve provides sensory and motor functions to the thumb and three middle fingers, many symptoms may result.

The following are the most common symptoms for carpal tunnel syndrome. However, each individual may experience symptoms differently. Symptoms may include:

• difficulty making a fist
• difficulty gripping objects with the hand(s)
• pain and/or numbness in the hand(s)
• "pins and needles" feeling in the fingers
• swollen feeling in the fingers
• burning or tingling in the fingers, especially the thumb and the index and middle fingers

The symptoms of carpal tunnel syndrome may resemble other conditions such as tendonitis, bursitis, or rheumatoid arthritis. Always consult your physician for a diagnosis.

• splinting of the hand (to help prevent wrist movement and decrease the compression of the nerves inside the tunnel)
• oral or injected (into the carpal tunnel space) anti-inflammatory medications (to reduce the swelling)
• surgery (to relieve compression on the nerves in the carpal tunnel)
• changing position of a computer keyboard, or other ergonomic changes

Soft, fluid-filled cysts can develop on the front or back of the hand for no apparent reason. These are called ganglion cysts - the most common, benign (non-cancerous), soft-tissue tumor of the hand and wrist.

The following are the most common symptoms for ganglion cysts. However, each individual may experience symptoms differently. Symptoms may include:

• wrist pain that is aggravated with repeated use or irritation
• a slow growing, localized swelling, with mild aching and weakness in the wrist
• an apparent cyst that is smooth, firm, rounded, and/or tender

The symptoms of ganglion cysts may resemble other medical conditions or problems. Always consult your physician for a diagnosis.

Initially, when the cyst is small and painless, treatment is usually not necessary. Only when the cyst begins to grow and interferes with the functionality of the hand is treatment usually necessary. Treatment may include:

• rest
• splinting
• non-steroidal anti-inflammatory medications
• aspiration
• cortisone injections
• surgery

Two major problems associated with tendons include tendonitis and tenosynovitis. Tendonitis, inflammation of a tendon (the tough cords of tissue that connect muscles to bones) can affect any tendon, but is most commonly seen in the wrist and fingers. When the tendons become irritated, swelling, pain, and discomfort will occur.

Tenosynovitis is the inflammation of the lining of the tendon sheaths which enclose the tendons. The tendon sheath is usually the site which becomes inflamed, but both the sheath and the tendon can become inflamed simultaneously. The cause of tenosynovitis is often unknown, but usually strain, overuse, injury, or excessive exercise may be implicated. Tendonitis may also be related to disease (i.e., diabetes or rheumatoid arthritis).

DeQuervain's tenosynovitis - the most common type of tenosynovitis disorder characterized by the tendon sheath swelling in the tendons of the thumb.

Trigger finger/trigger thumb -a tenosynovitis condition in which the tendon sheath becomes inflamed and thickened, thus preventing the smooth extension or flexion of the finger/thumb. The finger/thumb may lock or "trigger" suddenly.

• activity modification
• splinting or immobilization
• steroid injections
• anti-inflammatory medications
• surgery

Elbow shoulder hand pain symptoms