medial elbow pain differential diagnosis

A differential diagnosis generated from the history guides the physical examination. Sports-related injuries of the biceps and triceps. Hariri S, 26. A normal joint space will open less than 3 mm, with a firm end point.7,8,12. Drakos MC, 2004 Oct. 23(4):693-705, xi. Lockman L. Differential Diagnosis. Drakos MC, Department of Orthopaedic Surgery J Bone Joint Surg Am. Buchbinder R. Walz DM, S&S: Decrease elbow ROM, pain @ radiocapitellar joint, pain increase w/ active/resisted pronation and supination, may complain of locking, catching, clicking. Kayiaros S, Lateral epicondylitis. In: Brukner P, Khan K, eds. Magn Reson Imaging Clin N Am. In: Bracker MD. Safran MR. 2011;19(6):359–367. Diagnosis, treatment, and rehabilitation of the thrower's elbow. 2003;2(5):276–280. Light up the elbow section of your brain and master the assessment, diagnosis and clinical reasoning of elbow pain with Part 1 in this elbow … Hauser RA, Musculoskeletal ultrasonography is more operator-dependent than MRI but allows for an inexpensive dynamic evaluation of commonly injured structures. Mariscalco MW, The history should include questions about the onset of pain, what the patient was doing when the pain started, sports played, and the frequency of participation. Pain is often located in the medial elbow from trauma, sporting activities and repetitive injury in patients of all ages. Bell SN, In the athlete, this condition is typically associated with overhead throwing, golf, or tennis; however, in the literature, it has been associated with other sports, including football, weightlifting, and bowling.13,14 Medial epicondylit… Differential Diagnoses Lateral Elbow Pain. Rehabilitation of the elbow following sports injury. Neurol Clin. 7. 2010;29(4):577–597. The distal biceps tendon is ruptured if the examiner's finger does not meet resistance. Wohlgethan JR. Removal from activity Rehabilitation: RICE. Patient education: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics) The most sensitive region is located near the origin of the wrist flexors on the medial epicondyle of the hum… McNally EG. O'Connor FG, J Shoulder Elbow Surg. Fields KB. Radial Nerve Entrapment A person with medial epicondylitis typically experiences pain when they bend the wrist toward the forearm. … 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). Patients with a UCL injury will have pain, instability, and apprehension.11. Distal biceps tendinopathy. Diagnosis and treatment of medial epicondylitis of the elbow. Chronic olecranon bursitis. / Vol. Diagnosis is confirmed by bursal fluid analysis.25 By contrast, patients with aseptic olecranon bursitis may present with a history of minor trauma to the elbow and a boggy, nontender mass over the olecranon without redness, warmth, limited range of motion, or other signs of infection.26 Because aspiration of bursae can be associated with complications such as introducing infection, this should be performed only when the diagnosis is uncertain or to relieve symptoms in refractory cases.24, Tendinopathy at the triceps insertion occasionally occurs in weight lifters or industrial workers in whom repetitive elbow extension against resistance is required. The Sports Medicine Resource Manual. Entrapment and compressive neuropathies. Finally the ulnar nerve passes through the ulnar sulcus between the medial epicondyle and olecranon and then between the humerus and ulnar heads of the flexor carpi ulnaris muscle. The patient's occupation and recreational activities can be important clues to diagnosis. Most patients will have complete resolution of symptoms with arm rest and nonsteroidal anti-inflammatory drug (NSAID) therapy. Peripheral nerve injuries in baseball players. Mariscalco MW, Sign up for the free AFP email table of contents. The primary nerve of the medial elbow is the ulnar nerve. Elbow injuries. Philadelphia, Pa.: Saunders Elsevier; 2008:226–232. Anatomy and biomechanics of the elbow. A thorough history and physical examination is critical to determine the likelihood of medial epicondylitis. Calfee R. Biceps tendon and triceps tendon injuries. 2008;19(4):597–608, vi–vii. Diagnosis is fairly straightforward in the setting of a suggestive history. 2014 Apr 15;89(8):649-657. Nonseptic olecranon bursitis management. Evidence-based use of dextrose prolotherapy for musculoskeletal pain: A scientific literature review. 31. Common tendinopathies in the upper and lower extremities. 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. Elbow part 5 - Anterior & medial elbow pain assessment & diagnosis with David Pope When we think of elbow pain, the lateral aspect is the one that springs to mind first. Am Fam Physician. To clinically identify a wrist flexor strain, individual muscles of the wrist flexors would need to be assessed for strength, length and pain by knowing origins, insertions and actions of the each muscle. Surgery for lateral elbow pain. 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. Common tendinopathies in the upper and lower extremities. MRI is the preferred imaging modality for chronic elbow pain.37,38 MRI can identify pathologic conditions such as bone marrow edema, tendinopathy, nerve entrapments, and joint effusions. Overuse syndrome affecting the wrist and digit flexors; Also seen in pitchers and rock-climbers; Also known as "Golfer's elbow" Clinical Features. Hauser RA, 3 Differential Diagnosis. Pattanittum P, Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011:502–503. The search included meta-analyses, randomized clinical trials, clinical trials, and reviews. The point of maximal tenderness usually resides over the anterior radial head. . Calfee R. Stevens KJ, In: Bracker MD. Nerve injuries about the elbow. Medial epicondylitis therefore perhaps deserves a less prominent place on the “default” list of causes of medial elbow pain. Anatomy, Epiphyseal Development and Elbow Ossification The elbow joint is articulated proximally by the humerus and distally by the r… Carpal tunnel syndrome. Radial tunnel syndrome/posterior interosseous nerve syndrome, The elbow is primarily a hinged joint, but possesses the unique ability to rotate the distal arm in pronation and supination (Figure 11). Clin Sports Med. Overuse and traumatic injuries of the elbow. 20. STUDY. Engineering, University of Denver . In: Seidenberg PH, Beutler AI, eds. In the milking maneuver, (A) the elbow is flexed to 90 degrees while a valgus force is applied to the elbow by (B) gently pulling the patient's thumb in the posterior direction. Aetiology. Morrey BF. UCL injuries commonly occur in athletes participating in sports that involve overhead throwing, such as baseball, javelin, and volleyball.7-9 Injury to the UCL results in significant valgus elbow instability and may predispose an athlete to secondary injuries.8,10. Pain and decreased strength with resisted gripping and with wrist supination and extension are often present.22. This content is owned by the AAFP. Elbow pain may be due to disorders involving the joint itself, the surrounding soft tissue structures, or a referred source (eg, neck, shoulder, or wrist). Buchbinder R. Baker CL III, When evaluating the elbow, division of the examination into specific anatomic areas is critical. Curr Sports Med Rep. The information on differential diagnosis is based on the National Institute for Health and Care Excellence (NICE) clinical guideline Suspected cancer - recognition and referral [], expert opinion in review articles on tennis elbow [Ahmad, 2013; Tosti, 2013] and on elbow pain [Kane, 2014; Javed, 2015; Descatha, 2016]. For information about the SORT evidence rating system, go to, Reprinted with permission from Chumbley EM, O'Connor FG, Nirschl RP. 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. 23. Determining the underlying etiology of elbow pain can be difficult because of the complex anatomy of this joint and the broad differential diagnosis. Saluan P. Adjunct Associate Professor of Bioengineering, Department of Mechanical and Materials . Treating nonseptic olecranon bursitis: a 3-step technique. Med Clin North Am. The pain is usually associated with numbness and tingling in the ulnar border of the forearm and hand, and in the ring and little fingers. Magnetic resonance arthrography may be performed in patients without an effusion to identify ligament tears, osteochondral defects, or loose bodies18,37(Figure 839). Conditions that the physician should consider include lateral epicondylitis, medial epicondylitis, radial tunnel syndrome, intra-articular pathology including radiocapitellar chondral lesions, cervical radiculopathy, ulnar neuropathy, elbow overuse as a compensatory mechanism, inflammation/edema of the anconeus, and inflammatory or degenerative art… The elbow is a complex joint designed to withstand a wide range of dynamic exertional forces. Ultrasonography is less expensive than MRI and, in skilled hands, has a sensitivity of 64% to 82% for the diagnosis of medial and lateral elbow tendinopathy, compared with a sensitivity of 90% to 100% with MRI.38, Electrodiagnostic studies, such as nerve conduction studies and electromyography, are helpful in confirming the diagnosis of a peripheral compressive neuropathy and ruling out conditions such as plexopathies and cervical radiculopathies. Engineering, University of Denver. These unique motions, along with a wide range of dynamic exertional forces, predispose the elbow and its structures to significant injuries, particularly with repetitive motions. Dawson PA, In contrast, radial tunnel syndrome typically presents as a pure pain syndrome without any objective clinical muscular weakness.15,19,23. History often includes repeated elbow flexion with forearm supination or pronation, such as in dumbbell curls. Physical examination reveals maximal tenderness approximately 1 cm distal to the epicondyle at the origin of the extensor carpi radialis brevis. The medial elbow consists of skin, ulnar collateral ligaments (anterior, posterior and transverse components), joint capsule (filled with synovial fluid), coronoid process of the ulna, trochlea of the humerus, coronoid fossa and medial epicondyle. Cubital tunnel syndrome is a compressive or traction neuropathy of the ulnar nerve as it passes through the cubital tunnel of the medial elbow (Figure 3). Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011:616–617. Wohlgethan JR. Surgery for lateral elbow pain. Nursemaid’s Elbow (Subluxation of the Radial Head) Nursemaid’s elbow is the most common elbow injury in children under 5 years of age and is unique to young children. The medial epicondylitis physical exam should look for increased carrying angle (greater than 10° in males, 15° in females); pain with point tenderness over the tip of the medial epicondyle extending distally 1 to 2 inches along the common flexor origin (usually PT and FCR); pain/weakness of wrist flexors and pronators with elbow extended and possible loss of full extension of elbow. Sydney, Australia: McGraw-Hill; 2006:302–303. If the patient has a reduced pulse and vascular supply than reduction of the dislocation and medical attention is urgent. Porter Adventist Hospital. Stadnick ME. 1995;77(7):1065–1069. Bell S. Elbow and arm pain. Available from: Publisher Provided Full Text Searching File, Ipswich, MA. Am Fam Physician. 30. This clinical content conforms to AAFP criteria for continuing medical education (CME). Cummins CA, 5. On physical examination, the patient will have posterior elbow pain when forced into full elbow extension.27, Table 3 summarizes key aspects of the diagnosis and treatment of selected causes of elbow pain.4,14,15,17,24–36, Vague anterior elbow pain; history of repeated elbow flexion with forearm supination and pronation, Resisted supination recreates pain deep in the antecubital fossa, Relative rest, ice, short course of NSAIDs, physical therapy, Lateral epicondylitis (tennis elbow)14,29–32, Much more common than medial epicondylitis; insidious onset of pain because of increase in occupational or recreational activities; tenderness to palpation over the common extensor tendon, Pain and decreased strength with resisted gripping and with wrist supination and extension; pain at the lateral elbow with isolated resisted extension of the middle finger, Relative rest and watchful waiting, ice, bracing, short course of NSAIDs, Stretching and strengthening with or without formal physical therapy, Bracing (consider wrist extension brace instead of commonly used counterforce traction brace), Injections of corticosteroids, autologous blood, or platelet-rich plasma; prolotherapy; dry needling, Painless loss of the ability to extend the middle finger against resistance, Positive result on the middle finger test (the inability to actively extend the middle finger against resistance), Splinting to maintain forearm supination and wrist extension, Physical therapy focusing on ergonomics, stretching, and then strengthening, Surgery may be considered for refractory cases, Pain in the lateral aspect of the forearm in the absence of any motor symptoms, Same treatment as for posterior interosseous nerve syndrome, Insidious onset of pain and paresthesias down the medial aspect of the forearm into the ring and little fingers, Positive Tinel sign at the cubital tunnel; may feel the ulnar nerve subluxate over the medial epicondyle with flexion and extension, Conservative treatment: cessation of inciting activity, night splint to keep arm in extension, physical therapy with nerve gliding exercises, Surgery for recalcitrant cases that fail to respond to four to six months of treatment, Medial epicondylitis (golfer's elbow)17,29, Insidious onset of pain because of increase in occupational or recreational activities; tenderness to palpation of flexor-pronator mass, Pain with resisted wrist flexion and pronation, Relative rest, ice, bracing, short course of NSAIDs (topical or oral), Injections with corticosteroids (may be more effective than NSAIDs in the short term), autologous blood, or platelet-rich plasma; dry needling, Positive result on moving valgus stress test or milking maneuver; lack of end point with valgus stress, Grade 1 and 2 partial tears should be treated with relative rest and prolonged guided rehabilitation, Surgery should be considered early on for elite level/professional athletes, History of minor trauma to the elbow; boggy, nontender mass over the olecranon, Bursal fluid analysis; absence of redness, warmth, limited range of motion, or other signs of infection, Ice, compressive dressings, avoidance of aggravating activity, For failed conservative treatment, aspiration of the bursa followed by two weeks of compressive dressing, Surgical bursectomy may be required for refractory cases persisting longer than three months, Intrabursal corticosteroid injection may be considered but can be complicated by infection and skin atrophy, Pain, swelling, warmth, and erythema over the olecranon; approximately 50% of patients have fever, Aspiration, mechanical rest, systemic oral or intravenous antibiotics directed by bursal fluid culture, Pain at the posterior elbow, especially at full extension, Posterior elbow pain when forced into full elbow extension; radiography to evaluate for osteophyte formation, If conservative treatment fails, arthroscopic osteotomy of osteophytes on the posterior elbow is effective, Pain at the posterior elbow, especially with extensor use (pushing motions), Pain at the posterior elbow with resisted extension; tenderness at the triceps insertion, Relative rest, ice, short course of NSAIDs, refer for physical therapy. Van Hofwegen C, Presentation History may include acute traumatic blow to elbow causing avulsion of CFT repetitive elbow use, repetitive gripping, repetitive valgus stress /- numbness or tingling in ulnar digits Symptoms insidious onset pain over medial epicondyle worse [orthobullets.com]. Giuffre BM. Neurosurg Clin N Am. Kayiaros S, The location and quality of elbow pain can generally localize the injury to one of the four anatomic regions: anterior, medial, lateral, or posterior. Author disclosure: No relevant financial affiliations. Lateral epicondylitis. 2009;35(1):45–62. 2010;29(4):521–553. / afp Pink MM. There is some controversy about whether radial tunnel syndrome and posterior interosseous nerve syndrome are two separate entities or a continuum of the same condition. The poor old anterior elbow … While maintaining constant valgus torque on the elbow, the elbow is quickly flexed and extended. 3rd ed. MRI web clinic–November 2003. http://www.youtube.com/watch?v=plk7G2s8V30, Chronic Daily Headache: Diagnosis and Management. General Components and Differential Diagnosis of the Elbow. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. 27. Vidal AF, This would need to be confirmed with x-ray, CT or MRI and medical management. Elbow injuries. McCall BR, Pain that is referred from other anatomical sites, such as cervical radiculopathy, thoracic outlet syndrome and remote arthritis can be sent to the appropriate specialty for treatment. Medial elbow pain is uncommon when compared with lateral elbow pain.Medial epicondylitis is an uncommon diagnosis and can be confused with other sources of pain.Overhead throwers and workers lifting heavy objects are at increased risk of medial elbow pain.Differential diagnosis includes ulnar nerve disorders, cervical radiculopathy, injured ulnar collateral ligament, altered distal triceps anatomy or joint disorders.Children … Both radial tunnel syndrome and lateral epicondylitis are primarily a clinical diagnosis. Biceps rupture. Hatch JD. The MCL is also prone to concurrent injury with me- dial epicondylitis. Durrant AW. Pattanittum P, Khan K, eds ( 8 ):649-657 MRI web clinic–November 2003. http: //www.youtube.com/watch?,!, 2013 valgus force ( table 23,7,8,11,13–17 ) & Wilkins ; 2011:502–503 initially described by Henry Morris as lawn! Vascular supply than reduction of the elbow is maintained, the prudent practitioner must consider various diagnoses can! 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