#240 Elbow Pain: Straighten it out

November 2, 2020 | By Molly Heublein

A Dabble into Elbow Care with Dr Parks

Returning guest expert Dr Ted Parks helps us get the elbow straight with a simple approach to common causes of elbow pain for primary care.  Listen as he guides Stuart through physical exam techniques (or watch them on YouTube) for epicondylitis and learn what the bursa is there for anyways. Find out what fracture you can treat in your office, why you shouldn’t stab straight into the olecranon bursa and when elbow pain should be referred.  Feel confident when your patient comes in with elbow pain!

Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).

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Credits

• Written and Produced by: Molly Heublein, MD
• Cover Art and Infographic: Edison Jyang
• Hosts: Stuart Brigham MD, Matthew Watto MD, FACP; Molly Heublein, MD
• Editor: Emi Okamoto, MD (written materials); Clair Morgan of Nodderly.com (audio/video)
• Guest: Ted Parks, MD

Sponsor

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VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

How to Claim VCU CME Credit

Time Stamps

• Sponsor – Provider Solutions and Development https://curbsiders.vcuhealth.org/
• Sponsor – VCU Health CE curbsiders.vcuhealth.org
• 00:00 Intro, disclaimer, guest bio
• 04:00 Picks of the Week
• Sponsor – Provider Solutions and Development https://curbsiders.vcuhealth.org/
• 09:50 Medial and lateral epicondylitis case, Elbow anatomy
• 13:00 Pathophysiology of epicondylitis, Epicondylitis exam, Epicondylitis treatment
• 34:11 Olecranon bursitis, Bursitis diagnosis and aspiration
• 46:12 Radial head fracture diagnosis, Radial head fracture treatment
• 55:30 Cubital tunnel nerve entrapment
• 57:45 Platelet rich plasma
• 60:39 Take home points, Plug and Outro
• 64:00 Bonus Pick of the Week
• Sponsor – VCU Health CE curbsiders.vcuhealth.org

Elbow Pearls

It is better to read a little and ponder a lot than to read a lot and ponder a little. – Dr. Ted Parks quoting Dr. Denis Parsons Burkitt

1. Medial and lateral epicondylitis resolve on their own in a few months to a year, treatments are just aimed at symptom control and don’t change overall outcomes.
2. A bursa fully reforms in 6-8 weeks after resection.
3. You can tell the difference between a septic elbow (medical emergency) and septic bursa (important to treat but not emergent) by evaluation of elbow supination/pronation.  A septic joint will be painful with all movements, a bursal infection won’t be painful with elbow rotation.
4. Think of a non-displaced radial head fracture like a sprain- early mobilization reduces adhesive capsulitis.

Elbow Show Notes

Elbow Anatomy:

The olecranon process, the large bony prominence at the posterior elbow, is the proximal ulna.   The medial and lateral epicondyles are parts of distal humerus, slightly more proximal to the olecranon process.  The elbow has dual mobility- flexion/extension and also rotation (supination/pronation).  See our videos on YouTube.

Medial and Lateral Epicondylitis:

History

Age over 20 is the only clear risk factor.  No lifestyle/sports features clearly important.

Pathophysiology is not really clear.  The histologically does not show tendonitis.  Epicondyl myalgia or tendonosis are probably more accurate names for this condition.  Dr Parks suggests perhaps these develop as a consequence of lost elasticity in the tendon attachment.  

Exam: Just 2 quick tests.

First Test: Resisted movement 

Lateral Epicondylitis: extend arms forward with elbows and wrists straight and palms facing down parallel to the floor (like a mummy or Frankenstein).  Push down on top of the affected hand to resist dorsiflexion- if this causes pain in the lateral elbow it suggests lateral epicondylitis (because the tendons that connect wrist and finger muscles of dorsiflexion run over the lateral epicondyle).  Important to keep the elbow straight because you want to test the muscles/tendons under tension.    

To examine for medial epicondylitis, keep the extended arm the same, but turn your palm up (like you’re checking pronator drift).  Resist flexion of the hand/wrist- this will cause pain in the medial elbow.   

Second test: Examine for tenderness to palpation.  Bend elbow 90 degrees and palpate over the epicondyle.  The affected area will be point tender. 

Dr Parks suggests doing a “control” test for the other condition (ie if you think you are looking for lateral epicondylitis, still check the medial epicondyle for tenderness to make sure the patient just doesn’t have pain everywhere).  See our videos on YouTube.

Treatment:

Epicondylitis is not permanent, the majority of patients will improve in months to a year. Treatments are all focused on relieving pain, and probably don’t have long-term impact on recovery since this is a self limited condition. (Johnson 2007)  

Dr Parks suggests the best treatment is stretching, since this is an elasticity problem.  The basic stretch is simple, so most patients can do it without formal physical therapy.  For lateral epicondylitis- get back into Frankenstein/sleepwalker position and then palmar flex wrist/fingers down, repeat this down 30 seconds 10+ times/day.  The opposite stretch (arms extended forward, dorsiflex wrist/fingers and hold) is appropriate for medial epicondylitis.  See our videos on YouTube.

Heat, cold, topical diclofenac (nsaids), bracing on forearm/counterforce brace, wrist brace to prevent wrist cocking, steroid injection all have varying benefits and should be used if effective for pain, but don’t expect that they will heal the condition more quickly (Johnson 2007).  PRP (platelet rich plasma) is advocated by some providers, but there is no evidence that it clearly benefits orthopedic conditions.  (Simental-Mendía 2020) 

Olecranon bursitis

Differential diagnosis for swollen lump over the olecranon includes traumatic/hemorrhagic, septic, gout related, or inflammatory bursitis.  (Khodaee 2017)

When you see a hot, tender, swollen elbow, it is important to rule out septic arthritis.  In both infectious bursitis and septic arthritis, the elbow will be red, hot, painful.  Dr Parks suggests an exam move to easily differentiate from infected olecranon bursitis- flexion/extension hurts in both conditions because flexion will put tension on the bursa.  However, elbow rotation (elbow tucked in to side, flexed 90 degrees, supinate/pronate hand/forearm) will be very painful in septic elbow arthritis (because this is an elbow joint movement) but will not cause pain in olecranon bursitis (because it doesn’t put tension over the bursa). 

Septic bursitis is less acute than a septic joint, but think of it like an abscess– it needs drainage and the patient should generally follow up with ortho urgently but not emergently. 

Technique for diagnostic aspiration–  it is easy to aspirate right over the swollen area, but unfortunately this can cause a chronically draining sinus tract.  Instead, Dr Parks suggests we pick a track superiorly around triceps (1-2cm above the bursa) and pass the needle through skin that’s uninvolved to prevent a sinus tract from developing.  

Infectious or chronic inflammatory (due to scar tissue within causing inflammation) bursitis is  most commonly treated with surgical resection.  In 6 weeks a new bursa will develop on its own.

Radial head fracture

These occur after a traumatic fall on an outstretched arm.  Nondisplaced radial head fractures are treated and behave a lot like an elbow sprain.

Patients should be encouraged to move as soon as they feel comfortable.  With these injuries, there is a lot of bleeding within the joint which can lead to adhesive capsulitis at the elbow if there is immobilization.  Patients should be encouraged to gently move their elbow as tolerated, and start physical therapy when pain is under control.  (Liow 2002) X-ray may show a “sail sign”, or blood from an intra-articular fracture displacing soft tissue in the area.

Cubital Tunnel Syndrome

Ulnar nerve entrapment at the elbow causes lateral hand numbness or pain.  Limiting elbow flexion helps- Dr Parks recommends an elbow pad/brace that will prevent the patient from fully flexing.  In severe/refractory cases or those with atrophy consider surgery (though less effective compared to carpal tunnel surgery).  (Boone 2015)

Take home points:

Medial and lateral epicondylitis will recover in about a year, treatment is just aimed at symptom management.

Olecranon bursitis is  important to differentiate from septic joint.  

Think of a radial head fracture like a sprain- immobilization is worse because it can lead to adhesions.

Links*

1. Molly’s Pick: The Warmth of Other Suns (book) by Isabel Wilkerson 
2. Stuart’s Pick: The Fringe (TV show), JJ Abrams
3. Practical Office Orthopedics (textbook) by Ted Parks, MD

Goals

Listeners will have a working differential of elbow complaints that commonly present in primary care, and understand how to diagnose these and initiate treatment.

Learning objectives

After listening to this episode listeners will…

1. Perform an exam for medial and lateral epicondylitis.
2. Describe treatment options for medial and lateral epicondylitis
3. Identify when further evaluation for clinical olecranon bursitis beyond clinical exam is needed
4. Explain how radial head fractures differ from most other fractures, and why casting or surgery is generally not needed.

Disclosures

Dr Parks reports is the author of Practical Office Orthopedics (McGraw-Hill 2017) . The Curbsiders report no relevant financial disclosures.

Citation

Heublein M, Parks EH, Brigham SK, Okamoto E, Watto MF. “#240 Elbow Pain: Straighten it out. A dabble into elbow care  with Dr Ted Parks”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 02, 2020.

References

Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician. 2007 Sep 15;76(6):843-8. PMID: 17910298.

Simental-Mendía M, et al. Clinical efficacy of platelet-rich plasma in the treatment of lateral epicondylitis: a systematic review and meta-analysis of randomized placebo-controlled clinical trials. Clin Rheumatol. 2020 Aug;39(8):2255-2265. doi: 10.1007/s10067-020-05000-y. Epub 2020 Feb 26. PMID: 32103373.

Parks, Ted.  Practical Office Orthopedics.   McGraw-Hill Education / Medical; 1st Edition (December 29, 2017).  

Khodaee M. Common Superficial Bursitis. Am Fam Physician. 2017 Feb 15;95(4):224-231. PMID: 28290630.

Liow RY, Cregan A, Nanda R, Montgomery RJ. Early mobilisation for minimally displaced radial head fractures is desirable. A prospective randomised study of two protocols. Injury. 2002 Nov;33(9):801-6. doi: 10.1016/s0020-1383(02)00164-x. PMID: 12379391.

Boone S, Gelberman RH, Calfee RP. The Management of Cubital Tunnel Syndrome. J Hand Surg Am. 2015 Sep;40(9):1897-904; quiz 1904. doi: 10.1016/j.jhsa.2015.03.011. Epub 2015 Aug 1. PMID: 26243318.