Aggressive therapy may worsen shoulder inflammation, stiffness, and pain. Operative treatment, especially in the older patient, may lead to stiffness. Axillary nerve injury may result from surgery on the inferior portion of the labrum. Traction injuries to the bra- chial plexus can occur when arthroscopic surgery is done using arm traction.
Mild cases of impingement will often respond favorably to therapy, but patients must continue the rotator cuff strengthening exercises.
Because impingement is a degenerative process, gradual worsen- ing of symptoms is expected over time. Surgical treatment can have profound results, but some patients will continue with inflammation and pain despite surgery. A good postoperative therapy program improves results. Occasionally, a postoperative injection of steroid is needed to decrease residual inflammation. Surgical treatment for instability will usually improve symp- toms, but a careful postoperative therapy course and continued maintenance of rotator cuff strength are essential.
Some patients fail to respond to all reasonable treatment meth- ods. Various modalities, including trigger point injection and acu- puncture, can prove useful.
CONCLUSION
Shoulder pain is a common presenting complaint. Many cases are self-limited or respond to conservative treatment methods. If con- servative treatment fails to provide relief, surgical treatment is effec- tive, but accurate diagnosis is essential. A careful postoperative therapy course, administered by an experienced therapist, is essen- tial for good surgical results.
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U G G E S T E DR
E A D I N G SMcFarland EG, Selhi HS, Keyurapan E. Clinical evaluation of impingement: what to do and what works. J Bone Joint Surg Am 2006;88:432–441.
Meislin RJ, Sperling JW, Stitik TP. Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. Am J Orthop 2005;34(12 suppl):5–9. Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of shoulder
pain in the community: the influence of case definition. Ann Rheum Dis 1997;56:308–312.
Swanson GDG. The upper extremities. In Cocchiarella L, Anderson GBJ (eds): Guides to the Evaluation of Permanent Impairment, 5th ed. Chicago: AMA Press, 2000; pp 474–479.
Yamaguchi K, Ditsios K, Middleton WD, et al. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am 2006;88:1699–1704.
Table 19^2.Current Therapy for Shoulder Pain
Diagnosis ConservativeTreatment Surgical Treatment
Fracture Closed reduction, sling Open reduction, internal fixation
Dislocation Closed reduction Arthroscopic labral repair
Impingement Therapy (rotator cuff strengthening) NSAIDs
Steroid injection
Acromioplasty (open or arthroscopic)
AC arthritis Steroid injection Distal clavicle resection (open or arthroscopic)
Biceps tendinitis Therapy (ultrasound, strengthening) Steroid injection (may lead to rupture)
Acromioplasty (with or without biceps tenodesis)
Rotator cuff tear Therapy Steroid injection
Surgical repair (open or arthroscopic) Instability Therapy (rotator cuff strengthening) Arthroscopic labral repair
SLAP lesion Therapy (rotator cuff strengthening) NSAIDs
Arthroscopic repair (<40 yr old) or de´bridement (>40 yr old)
Frozen shoulder Therapy (stretching) Manipulation
Arthroscopic release of capsule
Cervical disk Therapy
NSAIDs Cervical traction Cervical epidural
Cervical decompression
AC, acromioclavicular; NSAIDs, nonsteroidal anti-inflammatory drugs; SLAP, superior labrum anterior posterior.
151 V CHRONIC PAIN: NONCANCER PAIN
Chapter 20
ELBOW
PAIN
Richard L.Uhl
INTRODUCTION
The elbow is inherently more stable than the shoulder. The majority of elbow problems come from lateral and medial epicondylitis, olecranon bursitis, and ulnar neuropathy. Less common causes of elbow pain include instability, synovitis, and arthritis. Many pro- blems are the result of overuse and can be addressed with rest, activity modification, and conservative treatment.
TAXONOMY
Epicondylitis: Lateral or medial epicondylitis is an avascular necro- sis of the common extensor or flexor tendon origins rather than a true inflammatory process, as the name would suggest. Olecranon bursitis: Inflammation of the bursa at the tip of the
olecranon, causing an unsightly swelling at the posterior aspect of the elbow. Olecranon bursitis rarely has functional implica- tions unless it becomes infected.
Intra-articular loose body: When a fragment of bone or cartilage is floating freely within the joint, it can become lodged between the articular surfaces, causing intermittent locking and pain with joint motion.
EPIDEMIOLOGY
Of 60,131 new patient visits (or old patients with a new problem) seen in a general orthopedic practice over a 2-year period, 2219 patients (3.7% of patients seen) had elbow-related diagnoses (acute fractures excluded). The most common diagnoses were lat- eral epicondylitis (918 patients; 41% of patients with elbow pro- blems), olecranon bursitis (307 patients; 14%), medial epicondylitis (214 patients; 10%) and ulnar neuropthy (194 patients; 9%).
PATHOPHYSIOLOGY
The elbow is made up of the ulnohumeral joint, which is a hinge- type joint, and the radiocapitellar joint, which allows rotation. The elbow has considerably more bony stability than the shoulder, but it still requires ligamentous support, especially from the medial col- lateral ligament (MCL). The radiocapitellar joint acts as a secondary stabilizer of the ulnohumeral joint. Normal elbow range of motion is from full extension (08) to 1408 of flexion.
The annular ligament of the elbow wraps around the radial head, allowing rotation while preventing translation. Normal supination is 808, and normal pronation is 808. Fractures of the radial head and arthritis of the radiocapitellar joint may limit this motion.
The lateral epicondyle gives origin to the common extensor tendon (extensor carpi radialis brevis and the extensor digitorum communis). Repeated wrist extension (such as flicking the wrist in a poorly executed tennis backhand stroke) leads to microtears in the muscle origin. Decreased blood flow to the area is common with aging ( 40 yr), and this decreases the healing potential once the microtears occur. A similar condition can affect the common flexor origin at the medial epicondyle (Fig. 20–1).
The ulnar nerve crosses the elbow posterior to the medial epi- condyle through the cubital tunnel. After it crosses the elbow, the ulnar nerve passes between the ulnar and the humeral heads of the flexor carpi ulnaris. The nerve can be compressed at the medial epicondyle or the flexor carpi ulnaris, leading to pain and numbness in the ulnar nerve distribution.
The radial nerve passes between the brachialis and the brachior- adialis muscles proximal to the elbow joint before splitting into the superficial radial nerve and the posterior interosseous nerve (PIN). The PIN passes between the superficial and the deep heads of the supinator muscle into the dorsal forearm and can be compressed at this location.
The MCL is the major stabilizer of the elbow. The ligament can be injured by acute trauma such as elbow dislocation, or by chronic stretching of the ligament, which is common in throwing athletes. Fractures of the elbow are usually the result of a fall on the outstretched arm and may include supracondylar fractures of the humerus, an avulsion fracture of the olecranon, and fracture of the radial head (Fig. 20–2).
Arthritis of the elbow is usually a result of fracture or chronic insta- bility (Fig. 20–3). Synovitis may occur from chronic instability, from inflammatory arthritis (such as rheumatoid arthritis [RA]), and from repeated intra-articular bleeding seen in patients with hemophilia.
Olecranon bursitis occurs from local trauma to the bursa over- lying the olecranon. The process is usually self-limiting, but the bursa may become infected after skin trauma or aspiration to drain the bursa. A spur may develop on the tip of the olecranon in chronic cases (Fig. 20–4).
CLINICAL FEATURES
Lateral epicondylitis and medial epicondylitis present as local ten- derness at the muscle origins. The pain is often worse in the morn- ing, with patients describing a tearing sensation when they first move the wrist after awakening (Table 20–1).
Ulnar neuropathy often presents with medial elbow pain and tenderness and associated hand numbness in the ulnar nerve dis- tribution (ulnar half of the ring finger and the little finger). More advanced cases of ulnar neuropathy have weakness and atrophy of the hand’s intrinsic muscles. With subluxation of the ulnar nerve, patients complain of a snapping sensation as the nerve crosses over the medial epicondyle with elbow flexion and extension. The snap- ping is accompanied by an electric shock sensation along the course of the ulnar nerve in the forearm and into the hand.
Compression of the PIN causes a deep aching pain in the dorsal forearm muscles. Symptoms of PIN compression can coexist with lateral epicondylitis and may account for continued symptoms after treatment of lateral epicondylitis.
Instability of the elbow results in an increase in motion in the varus/valgus plane that leads to inflammation, pain, and eventually degeneration of the joint. Chronic instability can be difficult to detect because of the inherently stable bony architecture of the 152 Chapter 20 ELBOW PAIN
elbow joint and because the symptoms often occur under extreme loading circumstances (such as pitching a fastball).
Fractures about the elbow will present with pain and swelling. Most fractures are easily discernible on plain radiographs, but occult fractures of the radial head and neck may not be apparent on the initial radiographs. Diagnosis in this case is made by the history of elbow trauma and local tenderness at the radial head.
Arthritis of the elbow causes pain with elbow motion and a restriction of motion as osteophytes begin to form about the joint. Patients with an intra-articular loose body will complain of intermittent locking of the joint as the fragment moves in and out of the joint space.
EVALUATION
Examination of the elbow begins with visual observation, looking for areas of swelling, deformity, atrophy, and discoloration.
The patient is asked to extend and flex the elbow, and the motion is noted.
Next, the elbow is systematically palpated over the lateral and medial epicondyle, along the ulnar nerve at the cubital tunnel and the tip of the olecranon, noting areas of tenderness. To evaluate the radial head and radiocapitellar joint, the examiner places a finger over the lateral aspect of the joint, 2 to 3 cm distal to the lateral epicondyle, while pronating and supinating the wrist. The motion of the radial head should be free without popping or grinding.
Passive wrist flexion while the patient attempts to extend the wrist will exacerbate the pain of lateral epicondylitis. Passive wrist extension while actively resisting will increase the pain of medial epicondylitis.
Examination of the ulnar nerve includes palpation along course of the nerve and sensory and motor examination of the hand. Tinel’s sign may be elicited by light percussion on the skin over the nerve. Flexion of the elbow produces tension along the nerve, which can reproduce the symptoms in cases of ulnar neuritis. Lateral epicondyle Medial epicondyle Radial head Tip of the olecranon Figure 20^1. Anteroposterior(AP)(left)andlateral(right)radiographs ofanormalelbow.Thelateralandmedialepicondylesarebony
prominencesonthehumerus.Thelateralepicondyleservesas the origin to thecommonextensor tendon.Themedialepicondyleis the originof thecommonflexor tendon.The otherreadilypalpablebonylandmarkis the tip of the olecranon.Theradialheadisdistalto thelateralepicondyle.
Figure 20^3. Severe diffuse arthritis of the elbow joint shows multiple osteophyte formation (arrows) without significant narrowing of the joint space. Arthritis in this patient was due to previous trauma. Severe narrowing of the joint space may indicate rheumatoid arthritis, hemophilia, infection, and other causes.
Figure 20^4. Bone spur formation at the tip of the olecranon after repeated episodes of olecranon bursitis. At this point, the spur is likely to cause additional irritation of the bursa, and surgical removal should be considered. Radial head fracture Free fragment
Figure 20^2. AP and lateral radiographs demonstrate a fracture of the radial head after a fall on the outstretched arm. In this patient, approximately 40% of the radial head is depressed, and there is a loose fragment in the anterior portion of the elbow joint. Surgery would usually be performed to remove the loose fragment and to repair the large depressed portion of the radial head.
153 V CHRONIC PAIN: NONCANCER PAIN
The diagnosis of radial nerve/PIN entrapment is made by con- firming deep aching pain in the dorsal musculature, tenderness to deep palpation along the course of the nerve (between the extensor carpi radialis brevi and extensor digitorum communis muscle bel- lies), and increased pain with attempted supination while the exam- iner holds the wrist in pronation.
Instability due to laxity of the MCL is tested in 308 of elbow flexion, by applying a valgus stress while the examiner’s fingers are on the medial joint line at the MCL.
Evaluation for an intra-articular loose body is difficult if the symptoms are very intermittent, but sometimes the patient can reproduce the locking (and unlocking) maneuvers, and on rare occasion, the fragment can be palpated at the joint surface.
Patients presenting with elbow pain should have anteroposterior (AP) and lateral radiographs of the elbow to evaluate for fractures, arthritis, and radiopaque fragments (loose bodies) within the joint.
MANAGEMENT
Lateral and medial epicondylitis are initially treated in a similar fashion (Table 20–2). Conservative treatment includes rest, nonster- oidal anti-inflammatory drugs (NSAIDs), and therapy including gentle stretching and ultrasound with or without phonophoresis, followed by gentle strengthening. Steroid injections usually provide substantial relief, which can last weeks to months. When injecting steroid around the superficial epicondyles, care should be taken to avoid subcutaneous injection. Because these conditions are usually self-limited, steroid injections can provide relief while waiting for the condition to heal over time.
The standard surgical procedure for both lateral and medial epicondylitis has been de´bridement, partial epicondylectomy, and repair of the tendon. Medial epicondylectomy may be combined with ulnar nerve decompression if the patient also has symptoms of ulnar neuropathy. A newer procedure for lateral epicondylitis uses a radiofrequency (RF) probe to provide a controlled burn to the tendon. This injury stimulates neovascularization and healing.
Early cases of ulnar neuropathy (several weeks to several months duration) can initially be managed conservatively if there is no profound numbness or intrinsic muscle atrophy. Initial treatment in early and mild cases of ulnar neuropathy includes rest, avoiding pressure on the nerve from resting the elbow on desks and unpadded armrests, and sleeping with a pillow to avoid flexing the elbow when asleep. Formal therapy with ulnar nerve gliding and phonophoresis can provide relief in mild cases. If conservative treatment is not effective, or if there is evidence of intrinsic muscle weakness or atrophy, operative treatment should be considered. In situ decompression, medial epicondylectomy, subcutaneous trans- position, and submuscular transposition all have an essentially equivalent success rates according to published reports.
In acute cases of ulnar nerve subluxation, an initial period of rest, while avoiding flexion, may allow the nerve to heal within the cubital tunnel. For chronic ulnar nerve subluxation, medial epicondylectomy, subcutaneous transposition, or submuscular transposition should be considered. Chronic ulnar neuritis not responding to these measures may require medication (pregabalin, gabapentin, or amitriptyline) or alternative treatments such as acupuncture.
Radial nerve/PIN entrapment is initially treated conservatively. Repetitive activities involving supination should be avoided. Therapy should include radial nerve gliding to help mobilize the nerve. If there has been no improvement after 3 months of therapy, surgical decompression should be considered.
Instability from acute MCL injury can heal with early protected motion. If instability remains, ligament reconstruction can restore stability. In chronic cases, strengthening of secondary stabilizers (flexor/pronator group) can restore stability. In a competitive thrower, surgical reconstruction, using a tendon graft, may be needed.
Minimally displaced radial head fractures, including depressed fractures involving 30% of the articular surface or less, are treated with a short period of immobilization followed by early motion. Displaced fractures of the elbow benefit from open reduction and internal fixation with early motion.
Table 20^1.Current Diagnosis for Elbow Pain
Diagnosis History Examination
Lateral epicondylitis Repetitive wrist extension Tender over lateral epicondyle
Pain with passive wrist flexion while the patient resists Medial epicondylitis Repetitive wrist flexion Tender over medial epicondyle
Pain with passive wrist extension while the patient resists Ulnar neuropathy Aching pain along the medial forearm
Tender along the ulnar nerve Ulnar-sided hand numbness
Tinel’s sign over the ulnar nerve
Numbness with pressure over the ulnar nerve Numbness with elbow flexion
Radial nerve/PIN entrapment
Deep aching pain over the extensor musculature
Tender along PIN
Pain with attempted supination against resistance Instability History of dislocation (traumatic)
Repetitive injury (throwing)
Pain and laxity with valgus stress
Fracture Trauma Localized tenderness
Pain with attempted motion
Synovitis Swelling
Painful ROM
Crepitus, popping with ROM
Arthritis Trauma
History of inflammatory arthritis (RA)
Generalized swelling Restricted painful motion
Intra-articular loose body History of locking while moving the elbow Elbow may lock and pop during examination Olecranon bursitis/cellulitis Swelling
Pain
History of scrape over elbow
Soft, fluctuant mass Red streak up the arm
PIN, posterior interosseous nerve; RA, rheumatoid arthritis; ROM, range of motion. 154 Chapter 20 ELBOW PAIN
Synovitis is treated with rest, therapy, steroid injection, and then arthroscopic, or open, synovectomy if conservative treatment fails. Arthritis may respond to NSAIDs and steroid injection. Occasionally, de´bridement may help with pain, but it usually will not restore motion. Total elbow replacement is occasionally indi- cated but has a high complication rate, especially in younger, high- demand patients.
Intra-articular loose bodies will usually require removal because continued incarceration of the fragment within the joint can lead to arthritis.
Olecranon bursitis is usually a self-limiting process. Attempts at aspiration are rarely successful and may lead to infection. If infected, surgical drainage and intravenous antibiotics are needed. Chronic, painful olecranon spurs benefit from surgical removal.
COMPLICATIONS/OUTCOMES
Therapy that is too aggressive can worsen inflammation, stiffness, and pain.
Steroid injections can cause atrophy of the overlying skin if given in the subcutaneous layer.
Ulnar nerve fibrosis can occur after transposition if the support- ing neural tissue is stripped from the nerve during mobilization.
Aspiration of an olecranon bursitis can result in infection, requiring operative drainage and intravenous antibiotics.
Most elbow problems will improve with rest, activity modifica- tion, therapy, and steroid injection. Surgical treatment of lateral and medial epicondylitis will usually result in improvement, but pro- blems may recur if the patient does not modify her or his activity. Ulnar nerve decompression, medial epicondylectomy, and trans- position all have a success rate ranging from 80% to 90%. A small
percentage of patients will develop a chronic ulnar neuritis requir- ing pain management treatment methods.
Outcomes after procedures for arthritis are less successful. Joint de´bridement with removal of osteophytes may help pain at the end- points of motion, but this rarely improves motion.
CONCLUSIONS
Careful diagnosis and appropriate conservative treatment, com- bined with activity modification, will help most patients with lateral or medial epicondylitis. Ulnar neuropathy often requires surgical treatment.
Conservative and surgical treatment results for synovitis and arthritis of the elbow are less successful than results for the other elbow conditions.
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U G G E S T E DR
E A D I N G SBriggs CA, Elliott BG. Lateral epicondylitis: a review of structures associated with tennis elbow. Surg Radiol Anat 1985;7:149–153. Coleman SH, Altchek DW. Arthropscopy and the thrower’s elbow. In
Green DP, et al (eds): Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier Churchill Livingtone, 2005; pp 959–972. Field LD, Altchek DW. Chronic elbow pain, overuse, and tendinitis. In
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Swanson GDG. The upper extremities. In Cocchiarella L, Anderson GBJ (eds): Guides to the Evaluation of Permanent Impairment, 5th ed. Chicago: AMA Press, 2000; pp 470–474.
Table 20^2.Current Therapy for Elbow Pain
Diagnosis ConservativeTreatment Surgical Treatment
Lateral epicondylitis Rest, ice, splinting, NSAIDs, therapy Steroid injection
Lateral epicondylectomy Extensor tendon origin release RF ablation therapy (Topaz) Medial epicondylitis Rest, ice, splinting, NSAIDs, therapy
Steroid injection
Medial epicondylectomy Flexor origin release
Ulnar neuropathy Rest, therapy, ulnar nerve gliding Ulnar nerve decompression
Ulnar nerve transposition Medial epicondylectomy Radial nerve/PIN entrapment Rest, therapy, radial nerve gliding Radial nerve/PIN decompression