Evaluation of Elbow Pain in Adults



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2014 Apr 15;89(8):649-657.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

The elbow is a complex joint designed to withstand a wide range of dynamic exertional forces. The location and quality of elbow pain can generally localize the injury to one of the four anatomic regions: anterior, medial, lateral, or posterior. The history should include questions about the onset of pain, what the patient was doing when the pain started, and the type and frequency of athletic and occupational activities. Lateral and medial epicondylitis are two of the more common diagnoses and often occur as a result of occupational activities. Patients have pain and tenderness over the affected tendinous insertion that are accentuated with specific movements. If lateral and medial epicondylitis treatments are unsuccessful, ulnar neuropathy and radial tunnel syndrome should be considered. Ulnar collateral ligament injuries occur in athletes participating in sports that involve overhead throwing. Biceps tendinopathy is a relatively common source of pain in the anterior elbow; history often includes repeated elbow flexion with forearm supination and pronation. Olecranon bursitis is a common cause of posterior elbow pain and swelling. It can be septic or aseptic, and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary. Plain radiography is the initial choice for the evaluation of acute injuries and is best for showing bony injuries, soft tissue swelling, and joint effusions. Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. Musculoskeletal ultrasonography allows for an inexpensive dynamic evaluation of commonly injured structures.

Determining the underlying etiology of elbow pain can be difficult because of the complex anatomy of this joint and the broad differential diagnosis. As with other musculoskeletal problems, the keys to diagnosing elbow pain are a history to include mechanism of injury or exacerbating movements, and a focused physical examination. The patient's occupation and recreational activities can be important clues to diagnosis. Table 1 provides the differential diagnosis of elbow pain by anatomic location.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

If an ulnar collateral ligament injury is suspected, the medial joint space of the symptomatic elbow should be compared with the asymptomatic side for the amount of opening, the subjective quality of the end point while a valgus force is applied across the joint, and pain.

C

7, 8, 12

In patients with signs of compressive ulnar neuropathy at the cubital tunnel, a physical examination of the upper extremities and cervical spine is essential to rule out other compressive neuropathies.

C

14, 20, 21

To avoid introducing infection, aspiration of olecranon bursitis should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases.

C

24

Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain.

C

37, 38


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

If an ulnar collateral ligament injury is suspected, the medial joint space of the symptomatic elbow should be compared with the asymptomatic side for the amount of opening, the subjective quality of the end point while a valgus force is applied across the joint, and pain.

C

7, 8, 12

In patients with signs of compressive ulnar neuropathy at the cubital tunnel, a physical examination of the upper extremities and cervical spine is essential to rule out other compressive neuropathies.

C

14, 20, 21

To avoid introducing infection, aspiration of olecranon bursitis should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases.

C

24

Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain.

C

37, 38


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1.

Differential Diagnosis of Elbow Pain Based on Anatomic Location

Anterior

Anterior capsule strain

Biceps tendinopathy

Gout

Intra-articular loose body

Osteoarthritis

Pronator syndrome

Rheumatoid arthritis

Lateral

Lateral epicondylitis

Osteochondral defect

Plica

Posterolateral rotatory instability

Radial tunnel syndrome/posterior interosseous nerve syndrome

Medial

Cubital tunnel syndrome

Medial

The Authors

SHAWN F. KANE, MD, is a staff family physician/primary care sports medicine physician at Womack Army Medical Center in Fort Bragg, N.C.

JAMES H. LYNCH, MD, MS, is a staff family physician/primary care sports medicine physician at Womack Army Medical Center.

JONATHAN C. TAYLOR, MD, is a staff family physician at Womack Army Medical Center.

Address correspondence to Shawn F. Kane, MD, USASOC(A), Attn: AOMD, 2929 Desert Storm Dr. (Stop A), Fort Bragg, NC 28310 (e-mail: shawn.f.kane.mil@mail.mil). Reprints are not available from the authors.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department, the U.S. Army at large, the Department of Defense, or the U.S. government.

REFERENCES

1. Chumbley EM, O'Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. 2000;61(3):691–700.

2. Bryce CD, Armstrong AD. Anatomy and biomechanics of the elbow. Orthop Clin North Am. 2008;39(2):141–154, v.

3. Vidal AF, Drakos MC, Allen AA. Biceps tendon and triceps tendon injuries. Clin Sports Med. 2004;23(4):707–722, xi.

4. Bain GI, Durrant AW. Sports-related injuries of the biceps and triceps. Clin Sports Med. 2010;29(4):555–576.

5. Hayter CL, Giuffre BM. Overuse and traumatic injuries of the elbow. Magn Reson Imaging Clin N Am. 2009;17(4):617–638, v.

6. Gabel GT, Morrey BF. Operative treatment of medical epicondylitis. Influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. 1995;77(7):1065–1069.

7. Freehill MT, Safran MR. Diagnosis and management of ulnar collateral ligament injuries in throwers. Curr Sports Med Rep. 2011;10(5):271–278.

8. McCall BR, Cain EL Jr. Diagnosis, treatment, and rehabilitation of the thrower's elbow. Curr Sports Med Rep. 2005;4(5):249–254.

9. Mariscalco MW, Saluan P. Upper extremity injuries in the adolescent athlete. Sports Med Arthrosc. 2011;19(1):17–26.

10. Salyapongse A, Hatch JD. Advances in the management of medial elbow pain in baseball pitchers. Curr Sports Med Rep. 2003;2(5):276–280.

11. Hariri S, Safran MR. Ulnar collateral ligament injury in the overhead athlete. Clin Sports Med. 2010;29(4):619–644.

12. Cummins CA, Schneider DS. Peripheral nerve injuries in baseball players. Neurol Clin. 2008;26(1):195–215, x.

13. Scott A, Ashe MC. Common tendinopathies in the upper and lower extremities. Curr Sports Med Rep. 2006;5(5):233–241.

14. Garg R, Adamson GJ, Dawson PA, Shankwiler JA, Pink MM. A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. J Shoulder Elbow Surg. 2010;19(4):508–512.

15. Kaw P, Deu R. Radial tunnel syndrome. In: Bracker MD. The 5-Minute Sports Medicine Consult. 2nd ed. Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011:502–503.

16. Slabaugh MA. Elbow injuries. In: Seidenberg PH, Beutler AI, eds. The Sports Medicine Resource Manual. Philadelphia, Pa.: Saunders Elsevier; 2008:226–232.

17. Pattanittum P, Turner T, Green S, Buchbinder R. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database Syst Rev. 2013;(5):CD003686.

18. Shapiro BE, Preston DC. Entrapment and compressive neuropathies. Med Clin North Am. 2009;93(2):285–315, vii.

19. Hariri S, McAdams TR. Nerve injuries about the elbow. Clin Sports Med. 2010;29(4):655–675.

20. Neal SL, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010;81(2):147–155.

21. Cleland J. Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical Therapists. 1st ed. Philadelphia, Pa.: Saunders Elsevier; 2005:434–436.

22. Van Hofwegen C, Baker CL III, Baker CL Jr. Epicondylitis in the athlete's elbow. Clin Sports Med. 2010;29(4):577–597.

23. Campbell WW, Landau ME. Controversial entrapment neuropathies. Neurosurg Clin N Am. 2008;19(4):597–608, vi–vii.

24. Aaron DL, Patel A, Kayiaros S, Calfee R. Four common types of bursitis: diagnosis and management. J Am Acad Orthop Surg. 2011;19(6):359–367.

25. Torralba KD, Quismorio FP Jr. Soft tissue infections. Rheum Dis Clin North Am. 2009;35(1):45–62.

26. Herrera FA, Meals RA. Chronic olecranon bursitis. J Hand Surg Am. 2011;36(4):708–709.

27. Bell S. Elbow and arm pain. In: Brukner P, Khan K, eds. Clinical Sports Medicine. 3rd ed. Sydney, Australia: McGraw-Hill; 2006:302–303.

28. Ellenbecker TS, Pieczynski TE, Davies GJ. Rehabilitation of the elbow following sports injury. Clin Sports Med. 2010;29(1):33–60.

29. Young CC, Walrod B. Lateral epicondylitis. In: Bracker MD. The 5- Minute Sports Medicine Consult. 2nd ed. Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011:356–357.

30. Buchbinder R, Johnston RV, Barnsley L, Assendelft WJ, Bell SN, Smidt N. Surgery for lateral elbow pain. Cochrane Database Syst Rev. 2011;(3):CD003525.

31. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751–1767.

32. Hauser RA, Hauser MA, Baird NM. Evidence-based use of dextrose prolotherapy for musculoskeletal pain: A scientific literature review. J Prolotherapy. 2011;3(4):765–789.

33. Delo M. Ulnar collateral ligament injuries of the elbow. In: Bracker MD. The 5-Minute Sports Medicine Consult. 2nd ed. Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011:616–617.

34. Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis. 1984;43(1):44–46.

35. Lockman L. Treating nonseptic olecranon bursitis: a 3-step technique. Can Fam Physician. 2010;56(11):1157.

36. Maxwell DM. Nonseptic olecranon bursitis management. Can Fam Physician. 2011;57(1):21.

37. Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in athletes. Clin Sports Med. 2010;29(4):521–553.

38. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics. 2010;30(1):167–184.

39. Stadnick ME. Lateral epicondylitis. MRI web clinic–November 2003. http://www.radsource.us/clinic/0311. Accessed March 12, 2014.


Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

More in Pubmed

Navigate this Article