tendons of back of the forearm as they insert onto the lateral epicondyle of the elbow. The
condition occasionally can become chronic. The extensor muscles of the forearm attached to
the tendon, are used for twisting the hand, extending the wrist, turning the hand. Tennis is a
sport commonly associated with the tearing of this tendon, but repetitive motions as in factory
assembly line work with high torque wrist twisting can produce the same symptoms. The pain
produced is located on the outside of the elbow (lateral) and is worsened by twisting the hand
or extending the wrist. The tendons become inflamed and transmit some pain into the muscle
itself in the forearm.
Tennis elbow develops during playing tennis due to use of too heavy a racket and by using the
elbow to lead instead of keeping the elbow straight during backhand shots. There may be
decreased grip strength, inability to hold a coffee cup, and thickening of the tendons of the
forearm. The diagnosis is usually made by placing the elbow and hand face down on a table,
having the patient extend the wrist, and the doctor tries to push the hand back down to the
table. Tennis elbow results in pain at the elbow during this process. Other diagnoses which
may be confused with tennis elbow are radial tunnel syndrome (see below) and C6-7 cervical
radiculopathy.
Treatment of tennis elbow is by using massage over the tendon, use of an elastic band around
the tendon, avoidance of the offending motions or activities for 1-2 months. NSAIDS may be
useful and if the pain is severe, a low dose steroid injection into the area over the inflamed
tendon may be useful. In less than 5% of the cases, surgery is required to repair the tendon.
Arthritis of the elbow, especially osteoarthritis, is a very common cause of chronic elbow pain.
Often inflammation of the bursa lubricating sac, tendonitis, and arthritis occur together at the
elbow. Arthritis (osteoarthritis) causes erosion of the cartilage in the joint with subsequent
narrowing of the joint. The pain may become so severe around the elbow and the forearm that
it prevents simple tasks such as holding a coffee cup, typing, or drying the hair with a portable
hairdryer. The causes of the arthritis are usually osteoarthritis but occasionally rheumatoid
arthritis is a cause. Generally, activity makes osteoarthritis of the elbow worse and the pain
from the arthritis is an "aching" pain which is present constantly. Sometimes there is a grinding
or popping sensation when moving the forearm. The diagnosis is made by plain xrays of the
elbow which often reveal irregularities of the joint surface with joint space narrowing.
Treatment is usually rest of the joint, reduction of activity, application of heat or cold, topical
gels containing ketoprofen or other analgesics such as menthol containing ointments or gels,
NSAIDS, COX2 inhibitors, and in extreme cases injection of local anesthetics plus steroids.
Elbow joint replacement is performed in some centers with moderately good results, but it is
not a routine operation performed by orthopedic surgeons.
Golfer's elbow (also known as medial epicondylitis) is an acute inflammation or tearing of the
flexer tendons of the forearm as they insert onto the inside of the elbow. Chronic overuse or
misuse of the flexers of the forearm may lead to chronic scarring and tearing of these ligaments.
Playing golf or other activities such as repetitive throwing or balls, carrying heavy objects by
handles, etc. cause inflammation of the tendon resulting in pain. The pain is usually over the
inside aspect of the elbow. Testing for golfers elbow is by placing the elbow on a table palm of
the hand turned upward. Then with the wrist flexed off the table, pressure is applied onto the
hand trying to force it back to the table. Pain at the medial epidcondyle on the inside of the
elbow is produced during this procedure. Another test is the praying hands test...place the
hands together in front of you with the palms of the hands pressed against one another. Pain
in the area of the red dot on the figure to the right denotes possible golfers elbow.
Non-medical therapies for golfers elbow include: A short period of wrist and elbow
immobilisation in a resting splint to allow damaged tissues to start healing, Ice Packs,
Ultrasound , Low Level Laser, Deep tissue massage to the forearm muscles, Gentle mobilising
and stretching of the forearm to avoid scar tissue build-up, Deep transverse frictions if scar
tissue present, A flexibility and strengthening program when pain subsides, Suggestion about
the use of an epicondyle brace (to decrease loading on the epicondyle insertion), Changing
clubs to graphite shafts, Thickening grips on the clubs by two or three layers.
Medical Therapies include: 1. Non steroidal anti inflammatory drugs (NSAID'S)
2. Corticosteroid injections to decrease chronic inflammation 3. Surgery to strip away scar
tissue in the tendon or relocate the tendon insertion
Without any therapy the pain of golfer's elbow may persist for up to a year.
Ulnar nerve entrapment at the elbow (also known as cubital tunnel syndrome) produces
pain and numbness from the inside back of the elbow down to the wrist and into the inside 2
fingers (ring and little finger) of the hand. The entrapment may be due to an acute trauma or
as a chronic fibrosis of a band running over the ulnar nerve. The nerve lies in a groove around
the back of the elbow and when struck traumatically, results in pain down the arm into the hand
(hitting the "funny bone") but when chronic results in the same symptoms which do not
resolve. There may occasionally be pain transmitted into the shoulder blade on the same side.
When untreated, there may develop weakness in the hand, atrophy of the hand muscles, and
ultimately permanent flexion contractures of the fingers. While diabetics and alcoholics have a
higher risk for ulnar neuropathy (the symptoms produced from ulnar nerve entrapment), it can
occur in anyone with repeated compression of the nerve. The diagnosis is made by tapping on
the nerve as it crosses the elbow (Tinels sign) which reproduces the pain, tenderness over the
point of entrapment, and muscle wasting in the hand muscles. EMG is used to confirm the
diagnosis and differentiate the condition from other commonly confused conditions such as
golfer's elbow and cervical radiculopathy.
Treatment consists of avoidance of trauma (avoid leaning on the elbows or using the elbows
to assist in rising from bed), use of a protective wrap when trauma is possible due to work,
NSAIDS, and occasionally injections. The injection consists of steroids plus local anesthesia
which is used to reduce the inflammation of the entrapped nerve. Ultimately surgery may be
required. Failure to address this condition results in permanent muscle wasting and weakness
in the hands.
Olecranon bursitis is the inflammation and swelling of the lubricating bursa sac located
directly over the middle of the back of the elbow. Usually it is induced by trauma to the elbow
such as a fall onto the elbow or a blow to the back of the elbow. With trauma, the blood
vessels over the sac are broken and may cause blood to leak into the sac. The sac swells,
becomes increasingly tender, and the patient may find it difficult to flex the elbow due to pain.
It is difficult for the patient to have the elbow rest on a hard surface. Over time the bursa sac
develops a scar tissue or thickening which results in chronic deformity of the tip of the elbow
soft tissues. The thickening of the bursa results in a protrusion from the elbow which is tender.
Occasionally the inflamed bursa becomes infected which causes extreme redness and swelling
(click here to see another section of our website demonstrating infected bursa). The
treatments for olecranon bursitis depend on whether the condition is acute or chronic.
Treatments for acute bursitis include Rule out fracture or ligamentous injury with xray, apply
ice, aspirate under local anesthesia, wrap with compressive dressing, apply splint or immobilizer,
return to full activity with padding when swelling is controlled, consider surgical excision for
recurrence. Steroid injections are not indicated for treatment of acute bursitis and certainly not
for infected bursitis. Chronic bursitis treatments include application of ice frequently, administer
nonsteroidal anti-inflammatory drugs, add padding over bursa during activity, consider night
splints if previous treatment brings no response, use corticosteroid injection only if symptoms
persist despite treatment, and advise patient to watch for signs of infection. Some olecranon
bursitis does not result in any pain but only in swelling. Usually in these patients padding only is
used.
Pronator syndrome is an uncommon clinical syndrome which appears to mimic many of the
symptoms of carpal tunnel syndrome (see above). It refers to compression of the median
nerve to the hand by the pronator teres muscle resulting in pain in the forearm, complaints of
"tiredness" in the foream, clumsiness and weakness of the hand muscles, and pain and
numbness in the hand in the same pattern as carpal tunnel syndrome. The median nerve runs
under the pronator teres muscle in the forearm and is the same nerve involved in carpal tunnel
syndrome when entrapped at the wrist. However, as opposed to carpal tunnel syndrome, there
is a negative Tinel's sign over the wrist (reproduction of pain by tapping over the wrist), a
positive Tinel's sign in the forearm, and less pain at night compared with carpal tunnel
syndrome in which there is more pain at night. The syndrome is caused by inflammation of the
muscle of the forearm responsible for rotating the hand from palm up to palm down position.
Activities such as repetitive elbow movements in chopping wood, rowing a boat, etc. lead to the
onset of the pain although in some patients there is no specific triggering activity. There may be
tenderness over the forearm, enlargement of the pronator muscle, and a positive pronator test
sign. The pronator test is placing the elbow on a table and turning the palm down. The patient
is instructed to resist the examiner rotating the palm upwards. If pain is produced in the
forearm during this process, there is a positive pronator sign. Treatment of this syndrome
involves NSAIDS, rest of the arm and elbow, avoidance of the repetitive triggering activity, and
occasionally steroid injections may be used to improve the symptoms. Surgery is rarely
required.
Cubital bursitis is an increasingly common disorder due to weight lifting and other exercise
equipment use resulting in pain in the front of the elbow. The use of dumbells to perform bicep
curls has resulted in increased incidence of this disorder which is characterized by pain and
swelling in the antecubital area (the front bend of the elbow), with pain increased by any
movement of the elbow. There is tenderness over the antecubital area and referred pain to the
forearm and hand. Extension of the forearm at the elbow worsens the pain significantly.
The cubital bursa (bcipitalradial bursa in the figure to the right) is a lubricating sac
overwhich passes the biceps tendon and the radial nerve and under which is bone.
Inflammation of the bursa by lifting repetitively using weights or in construction labor causes
some compression of the radial nerve which results in weakness in the triceps muscle of the
forearm. This produces some wrist extension weakness. In most patients with cubital tunnel
syndrome, there is a palpable mass in the front of the elbow in the antecubital area in the bend
of the forearm. Diagnosis is made on clinical grounds and via MRI which demonstrates bursa
inflammation and thickening. Treatment is by altering the load placed on the biceps by reducing
the amount of weight during weight training and reducing the number of repetitions.
Non-steroidal anti-inflammatory medications may be useful. Injection of the bursa with steroids
is indicated if more conservative measures are insufficient to reduce pain.
Radial tunnel syndrome is an uncommon cause of elbow pain which is often misdiagnosed
as tennis elbow. This is an entrapment neuropathy of the radial nerve at the level of the elbow
which produces mild to moderate deep aching pain just below the elbow with a tingling pain in
the back of the hand and thumb. The pain often develops after direct trauma to the area over a
small branch of the radial nerve (posterior interosseous branch) or after a twisting injury. The
pain is worsened by the act of turning the palm forward (supination) and involves sleep
disturbances due to the pain. There are three signs which distinguish this uncommon condition
from tennis elbow: tenderness to pressure below the radial head (as opposed to tenderness
over the area above the radial head), increasing pain on trying to turn the palm up against
applied resistance to such rotation, and extension of the middle finger and wrist which produces
the pain at the lateral elbow.
The syndrome is produced by entrapment of a small branch of the radial nerve as it passes
close to the elbow or through compression of the radial nerve itself. Sometimes the entrapment
is by muscle (extensor carpi radialis muscle) or fibrous bands which cross over the nerve.
Other diagnoses which must be evaluated which have similar symptoms include cervical
radiculopathy and tennis elbow (as above). Gout of the elbow sometimes mascarades as radial
tunnel syndrome. Treatment of the syndrome is by injection with steroids and local anesthetic
around the area of suspected entrapment at the elbow. Such injections are diagnostic as well
as therapeutic. Other conservative measures which may be useful include physical therapy, use
of NSAIDS, use of oral anticonvulsants (eg. Neurontin), heat/cold, and avoidance of activities
which trigger the syndrome. Rarely surgery is indicated as a treatment.
