Acute Elbow Pain

== Taxonomy ==
*	best is lateral /medial elbow pain
*	nerve compression syndromes only if focal neurological abnormalities and nerve conduction abnormalities proven
== Clinical Assessment ==
=== Red Flag Conditions ===
Red Flag Condition 	Features
Fractures 	
* history of trauma is cardinal indicator
* risk factors –visual & balance impairment
* underlying osteoporosis - [ # in 56% of women , 29% of men > 60yrs]
* 11% in humerus, [mainly surgical neck- not elbow]
* FOOSH- usually # wrist not elbow
* Pathological #- Pagets, Ca, osteomalacia etc
Neoplasia 	
*	risk factors are: age > 50; past history of ca; unexplained weight loss >4.5 kg, pain non-responsive to treatment > 1month- stronger viewed as negative predictors
*	palpable mass/ deformity
*	bone tenderness with no incriminating features of any other cause of pain
Infection 	
*	pre-test probability not tested –but likely to be low
*	cardinal indicator is fever
*	portal of entry penetration by object, surgery, catheter etc
*	underlying joint abnormalities or immunosuppression increased risk
*	joint swelling/ bursal swelling/ bone tenderness
inflammatory arthropathies	
*	caused by crystal, psoriatic, rheumatoid & reactive
*	joint effusion
*	can be difficult to diagnose
Referred pain & visceral 	
*	MI [referred to arm in 30% of cases]
*	Usually affects area greater than elbow in typical dermtomal/sclerotomal distribution
=== History ===
Circumstance of onset
*	?trauma- no valid features to rule out #
*	repetitive strain- cardinal condition involves throwing/swinging- strain of MCL and common flexor origin
*	spontaneous- ? red flag
Radiation
*	tends to be well localised
No historical feature is diagnostic- NB patient’s general medical history & system review
=== Examination ===
Inspection
*	superficial joint- rewarding
*	swellings/oedema/skin changes in colour, trophic changes etc
Palpation
*	tenderness cannot be validly ascribed to any specific structure
Range Of Movement
*	no data re diagnostic value of range of movement
*	Mill’s manoeuvre – pain pronation/wrist flexion/ elbow extension- lateral epicondylitis
*	Resisted extension of 3rd metacarpal- [ insertion of ECRB]- ? lateral epicondylitis – no data
== Imaging ==
*	cardinal role detection of #- increased risk if –significant force/immediate loss of function/bony swelling & tenderness/compression of joint causes pain
*	rare - cancer/osteomyelitis/osteonecrosis/osteochondritis
*	first xray ? bone scan
*	otherwise not indicated.- especially in lat/med epicondylitis; biceps & triceps tendonitis–are all purely clinical diagnosis [even if test 100% sensitivity /specificity – nothing added]
==Differential Diagnosis==
== Specific Conditions ==
=== Neurological Conditions ===
*	CNS/ cord/ radiculopathy/peripheral neuropathy- pain over area greater than elbow and symptoms & signs of numbness/weakness/parasthesiae/allodynia
Radial tunnel syndrome
*	entrapment of radial nerve passing through the arcade of Frohse in supinator muscle- ? a cause of refractory lateral elbow pain
*	EMG studies – no evidence of radial nerve compression found
*	Surgery to release nerve- 13 obtained relief out of 37 [16 rtw]
*	Another study- 2 ops- nerve release in tarsal tunnel & lengthening of ERCB muscle- both groups did as well- both ops released extensor tendon and this was presumed to be the mode of improvement , not decompression of tunnel.
Posterior interosseus nerve entrapment
*	weakness of wrist & finger extension
Ulnar neuropathy
*	pain & aching over medial elbow and prox forearm with tingling /parasthesiae in 4&5th fingers.
=== Lateral Epicondylitis ===
*	No accepted definition
*	Most common cause of pain around elbow
*	Swedish study- prevalence 1-3%- peak incidence 10% women in 5th decade
*	Tennis players prevalence 50%
Risk factors
*	no prospective/case-controlled studies
*	increased incidence in strenuous occupations
natural history 
*	no prospective cohort study with a no treatment arm- therefore natural history uncertain but recurrence rate of 50% over 1 year
pathology 
*	only in chronic lateral epicondylitis 
*	hyaline degradation with chronic repair with vascular & fibroblastic proliferation*	very little inflammation
*	mainly affecting common extensor tendon and surrounding tissues
*	recent high resolution ultrasound shows thickening of tendon & peri tendon suggestive of inflammation
treatment with corticosteroid injections
class 1 evidence
*	not many papers of adequate methodological quality- but best paper showed large benefit for steroid over saline/lignocaine
*	pooled odds ratio-0 .15 at 6 weeks- definite benefit for injections but after 6 weeks- no statistical benefit but better outcomes.
*	Side effects- pain in 50% and skin atrophy in 20-30%
*	Technique and dosage are varied- no one best way- use 1ml cortisone +- lignocaine- target site is point of maximal tenderness- usually in prox end of extensor tendon rather than epicondyle
Treatment with rest
*	avoidance of usual activities or splinting [not counterforce brace]
*	rationale- caused by excessive loads 
*	efficacy- no class 1 & 2 evidence
*	class 3- two studies showing no benefit for rest
*	class 4- most authorities recommend rest for the first 2 weeks
treatment with exercise
*	stretching or resisted isometric or isotonic contractions of forearm extensors
*	rationale [based on evidence in knee] lateral epicondylitis causes disuse – extensors become weaker wit reduced muscle resistance and increased forces on the common extensor tendon.
*	Evidence- no class 1 or 2
*	Class 3 – one study- significant difference in favour of active stretching vs counterforce brace.
*	Class 4 – virtually universally prescribed by experts – no consensus on type, frequency duration etc
Treatment with passive modalities
*	ultrasound/interferential/ laser- supposed to heat and increases blood flow
*	evidence
*	class 1
*	- ultrasound [US] review- initially US significantly > placebo but 3rd arm using sham US vs real US- no difference – showing power of hands on placebo
*	second review showed no difference at 3 & 12 months followup
*	laser - no real benefit
*	class 2
*	pulsed electromagnetic field therapy [PEMF]- no real benefit
*	extracorporeal shockwave thereapy- [same as lithotropsy]- shows significant improvement in grip & pain at 3,6 24 weeks in refractory cases due for surgery
*	Rebox- low current electrical treatment – minor but significant effect- poor study.
Treatment with NSAID’s
*	class 1- no real benefit beyond analgesia
treatment with topical NSAID
*	no real benefit
treatment with SURGERY
*	only for chronic
*	3 aims;- 
*	dissect common extensor tendon off epicondyle -to get a better ‘join’ from scarring
*	denervation of epicondyle
*	excise aberrant tissue
*	No controlled data.- best is class3
*	Results largely positive- but not indicated for acute lateral epicondylitis 
=== Medial Epicondylitis ===
*	less common that lateral epicondylitis ratio 1:6
*	seem to be lumped in with lateral epicondylitis – same treatment criteria probably apply
*	diagnosis entirely clinical
treatment 
*	no class 1 trial
*	class 2 – improved pain relief at 6 weeks for local cortisone shot- [major risk is injecting into ulnar nerve]
*	class 4- surgical – showed tear in common origin with varying degrees of inflammation
=== Distal Biceps and Triceps Tendonitis ===
*	no studies on these entities
*	treatment as for other tendonitis- rest then graded exercise with stretching + ?cortisone
*	avoid expensive investigations
=== Fibromuscular Impairment ===
*	tenderness usually over the common tendon insertion distal to the lateral epicondyle 
*	other structures possibly involved are radiohumeral joint with capsule & annular ligament and fibrous tissue derived from fascia overlying the extensor muscles. - [no independent radial collateral ligament exists]
*	clinical examination cannot determine which structure is involved
*	- therefore use lateral fibromuscular impairment
*	possible pathologies- tears or sprains of extensor muscles near origin [no formal studies done] , capsule tears [no formal studies] , synovitis, meniscoid entrapment [ joint has a fibrous meniscoid- fibrous extension of capsule covered by synovium. If joint distracted, meniscoid could be trapped outside joint under the capsule and act as a FB- increased tension in capsule causing pain.- no formal studies done but reports claiming relief from excising these structures – also treatment could use distraction, varus bending and replacing of meniscoid] , radio-humeral arthropathy [this may resolve or progress]
*	None of these have been proven
=== Medial Fibromuscular Impairment ===
*	joint covered by ulnar collateral ligament and common flexor muscles
*	treatment with rest and time
Follow diagnostic algorithm
==References==
Category:Elbow and Forearm
Category:Elbow and Forearm Conditions
Category:Presenting Complaints