Table 1 provides the differential diagnosis of elbow pain by anatomic location. Physical examination should focus on muscles innervated by the ulnar nerve distal to the cubital tunnel: the flexor carpi ulnaris, the flexor digitorum palmaris, the hypothenar eminence, and the intrinsic muscles of the hand. If the patient has a reduced pulse and vascular supply than reduction of the dislocation and medical attention is urgent. 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 … Accessed July 1, 2015. Drakos MC, The articular surface most commonly injured within the elbow is the radial aspect of the joint, which can present as lateral elbow pain. Can Fam Physician. 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. Magnetic resonance imaging of the elbow in athletes. 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. Vidal AF, Radial Nerve Entrapment 2nd ed. 5. Preston DC. The poor old anterior elbow … Ciccotti MC, Schwartz MA, Ciccotti MG. Essex-Lopresti fracture; Capitellum fracture; Olecranon fracture; Elbow dislocation; Radiograph-Negative. This injury is easy to observe, as the patient will likely be in severe pain and have a fractured coronoid process with a deformed olecranon protruding posteriorly. Torralba KD, Differential Diagnosis. Cain EL Jr. Search . Patel A, 2010;376(9754):1751–1767. Differential diagnosis. Physical examination reveals maximal tenderness approximately 1 cm distal to the epicondyle at the origin of the extensor carpi radialis brevis. Buchbinder R. Course of the ulnar nerve at the medial elbow and the three distinct bands of the ulnar collateral ligament. Symptoms may include locking, catching, or inability to fully extend the elbow.16, Olecranon bursitis is the most common superficial bursitis and is a common cause of posterior elbow pain and swelling.24 Olecranon bursitis can be septic or aseptic. Delo M. Ulnar collateral ligament injuries of the elbow. 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. 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. Stevens KJ, 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. Vicenzino B. Differential diagnosis of elbow pain can be tricky. Epicondylitis in the athlete's elbow. Biceps rupture. Bell SN, Turner T, Author disclosure: No relevant financial affiliations. 2011;3(4):765–789. Plain radiography also has a role in the evaluation of chronic conditions such as enthesopathy, bone spurs, and osteochondral diseases.18 At a minimum, anteroposterior and lateral plain radiography should be performed at the initial visit.37. Rehabilitation of the elbow following sports injury. 39. Safran MR. Herrera FA, Ross G. Cervical Radiculopathy. Evaluation of overuse elbow injuries. Lockman L. Plica Syndrome. Slabaugh MA. 2010;29(4):619–644. Distal biceps tendinopathy. A differential diagnosis generated from the history guides the physical examination. Choose a single article, issue, or full-access subscription. The differential for medial elbow pain includes: Medial epicondylitis; Ulnar neuritis; Ulnar collateral ligament attenuation with resultant instability; Flexor pronator muscle belly ruptures. Medial epicondylitis is much less common than lateral epicondylitis and typically occurs in athletes or workers who participate in activities that involve repetitive valgus stress and flexion at the elbow, as well as repetitive wrist flexion and pronation. 2006;5(5):233–241. Porter Adventist Hospital. Physical examination will assist in differentiation by location of pain … Peripheral nerve entrapment and injury in the upper extremity. Curr Sports Med Rep. 2004;23(4):707–722, xi. History often includes repeated elbow flexion with forearm supination or pronation, such as in dumbbell curls. Common tendinopathies in the upper and lower extremities. 29. Contact Don't miss a single issue. The most common presentation is pain and weakness around the medial elbow with gradual onset, particularly when gripping, and with resistance during wrist flexion and forearm pronation. 2014 Apr 15;89(8):649-657. Differential Diagnosis. Search form. 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. / Clinical Sports Medicine. 1 The most common causes of elbow pain are shown in bold, and the list is divided into four sections, depending on the source of the elbow pain: Tinel's test may reproduce these symptoms and nerve conduction studies should be completed. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Orthop Clin North Am. Location: medial elbow (3 bands: anterior, posterior, transverse) Pt presentation: hx of "popping" Causes: repetitive valgus overload (throwing), trauma causing valgus stress Nonseptic olecranon bursitis management. January 2014;:1. The result of surgical treatment of medial epicondylitis: analysis with more than a 5-year follow-up. McNally EG. Young CC, Walrod B. Lateral epicondylitis. Differential Diagnosis. Elbow injuries in throwing athletes by Paul Sethi, MD [Video File] Elbow pain, common causes - Everything you need to know - Dr. Nabil Ebraheim [Video File] Bicepital Strain Definition: A strain to the Biceps Brachii. Neurol Clin. 2010;19(4):508–512. Aetiology. Fields KB. Elbow injuries. [Medline] . Differential Diagnosis of Lateral Elbow Pain (2 hours) Treatment of Lateral Elbow Pain (1.5 hours) Meet Your Instructor. Brukner, P. & Khan, K. 2010 Clinical Sports Medicine ed 3, McGraw-Hill, Australia, NSW. In: Brukner P, Khan K, eds. Canoso JJ, Pain localizes to either the medial epicondyle or just distal in the flexor-pronator mass. 2013;(5):CD003686. Sports-related injuries of the biceps and triceps. Baird NM. at … Hariri S, Slabaugh MA. Influence of concomitant ulnar neuropathy at the elbow. Match. Hauser RA, This test is performed with the shoulder in 90 degrees of abduction and external rotation. Common tendinopathies in the upper and lower extremities. The hook test is used to assess the continuity of the biceps tendon. This content is owned by the AAFP. 15. Medial epicondylopathy or ‘golfer’s elbow’ is mostly a tendinous overload injury leading to tendinopathy. 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. Safran MR. Flexor-pronator tendon degeneration occurs with repetitive forced wrist extension and forearm supination during activities involving wrist flexion and forearm pronation. 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. 1. Smidt N. Dawson PA, 20. 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]. Assendelft WJ, - Differential diagnosis for lateral elbow pain - Differential diagnosis for medial elbow pain - Basic rehabilitation program for lateral epicondylalgia - Pro-inflammatory treatment options - Program for return to tennis after elbow tendinopathy* RELATED TOPICS. Ellenbecker TS, Once again ultrasound imaging or MRI may be needed to confirm the grade of UCL sprain. Athletes in overhead throwing sports or sports that require repetitive valgus stress or compressive forces on the elbow (e.g., gymnastics) are prone to these types of injuries. Medial-sided elbow pain encompasses a significant differential diagnosis, including ulnar neuritis, tendinopathy, ligamentous instability, intra-articular pathology, and trauma. Magnetic resonance imaging of the elbow in athletes. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort. Pain is often located in the medial elbow from trauma, sporting activities and repetitive injury in patients of all ages. Data Sources: A PubMed search was completed in Clinical Queries using the key terms elbow pain, epicondylitis, bursitis, radial tunnel, cubital tunnel, and impingement. MADOUNA HANNA, DO; KEVIN TRINH, MD; GERARD DEGREGORIS, III, MD; PIERCE FERRITER, MD; STEVEN MANDEL, MD; STEVE M. AYDIN, DO “Pain that is referred from other anatomical sites, such as … If lateral and medial epicondylitis treatments are unsuccessful, ulnar neuropathy and radial tunnel syndrome should be considered. The clinician should attempt to identify changes to hand function, neuropathic pain, weakness, or changes to sensation. Meals RA. Uncommon etiologies of anterior elbow pain include intra-articular processes such as osteoarthritis, rheumatoid arthritis, and gout. McCall BR, Baker CL III, A positive result is defined as pain between 70 and 120 degrees of flexion.11 A video of the moving valgus stress test is available at http://www.youtube.com/watch?v=plk7G2s8V30. 2011;57(1):21. 2010;29(4):655–675. Gabel GT, Reprints are not available from the authors. It can be septic or aseptic, and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary. 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. Bell S. Elbow and arm pain. Search dates: January 15, 2012; June 27, 2012; and December 5, 2013. Coombes BK, This high frequency is due to children being less skeletally mature than adults but also usually more active. Hayter CL, MOI: Excessive force applied. This clinical content conforms to AAFP criteria for continuing medical education (CME). 33. Newman JS, Baker CL Jr. Am Fam Physician. Differential diagnosis of elbow pain … The hook test, which involves the examiner hooking the biceps tendon with his or her fingertip, will confirm an intact tendon and may assist in localizing the pain generator (Figure 2). A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis. Durrant AW. For information about the SORT evidence rating system, go to, Reprinted with permission from Chumbley EM, O'Connor FG, Nirschl RP. MANAGEMENT OF ELBOW PAIN FROM LATERAL AND MEDIAL EPICONDYLITIS Once the diagnosis is made, treatment can be directed at the exact cause of the pain. Ulnar neuropathy is a often a finding associated with elbow OA. Sydney, Australia: McGraw-Hill; 2006:302–303. 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. Cummins CA, A normal joint space will open less than 3 mm, with a firm end point.7,8,12. Olecranon bursitis is a common cause of posterior elbow pain and swelling. Differential Diagnosis Elbow Diagnoses Radiograph-Positive. Radiation of pain from shoulder or wrist injuries. Denver, Colorado. - Differential diagnosis for medial elbow pain - Elbow examination findings and diagnosis - Range of motion the elbow and wrist; RELATED TOPICS. Cochrane Database Syst Rev. J Am Acad Orthop Surg. SHAWN F. KANE, MD; JAMES H. LYNCH, MD, MS; and JONATHAN C. TAYLOR, MD, Womack Army Medical Center, Fort Bragg, North Carolina. The search included meta-analyses, randomized clinical trials, clinical trials, and reviews. Musculoskeletal ultrasonography is more operator-dependent than MRI but allows for an inexpensive dynamic evaluation of commonly injured structures. DIFFERENTIAL DIAGNOSIS OF ELBOW PAIN. Abstract Elbow medial collateral ligament sprain occurs when the elbow is subjected to a valgus force exceeding the tensile properties of the medial collateral ligament (MCL). Epicondylitis: pathogenesis, imaging, and treatment. Occasionally, separation of the osteochondral fragment may occur, resulting in a loose body. The pain can also usually be recreated with resisted wrist flexion.6, The anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress during overhead throwing (Figure 3). Further complicating this is a high frequency of referred pain from the nerves exiting the neck. In: Bracker MD. Torralba KD, The pain can worsen with wrist flexion and forearm pronation activities. 2011;19(6):359–367. Gravity. Address correspondence to Shawn F. Kane, MD, USASOC(A), Attn: AOMD, 2929 Desert Storm Dr. (Stop A), Fort Bragg, NC 28310 (e-mail: Chumbley EM, The injury is characterized by the insidious onset of vague medial elbow pain … Get Permissions, Access the latest issue of American Family Physician. People with medial epicondylitis have tenderness along the medial elbow, approximately 5 mm distal and anterior to the medial epicondyle. McCarthy D. Nonsteroidal anti-inflammatory drug-related gastrointestinal toxicity: definitions and epidemiology. STUDY. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Four common types of bursitis: diagnosis and management. Herrera FA, Hariri S, Chronic olecranon bursitis. Armstrong AD. Lateral epicondyle and the origin of the common extensor tendon. Baker CL Jr. The primary nerve of the medial elbow is the ulnar nerve. Freehill MT, After carpal tunnel syndrome, it is the second most common compressive neuropathy of the upper extremities.18 Approximately 60% of patients with medial epicondylitis have a concomitant compressive ulnar neuropathy.19, Patients will have medial elbow pain with repetitive activity. 37. Stadnick ME. 2011;(3):CD003525. Salyapongse A, Baird NM. 10. Magnetic resonance arthrography may be performed in patients without an effusion to identify ligament tears, osteochondral defects, or loose bodies18,37(Figure 839). Nirschl RP. Joint and soft tissue structures that are common sources of pain include the epicondyles (medial and lateral), the olecranon bursa, and the radial and ulnar nerves, which course near the elbow joint. 3.1 Elbow Diagnoses. Patients typically present with insidiously medial elbow pain, swelling and tenderness, particularly over the medial epicondyle. Green S, Lateral epicondylitis; Medial epicondylitis; Olecranon bursitis (nonseptic) Septic bursitis; Biceps tendon rupture/dislocation; Pediatric. A physical examination of the upper extremities and cervical spine is essential to rule out other compressive neuropathies.14,20,21, A positive Tinel sign at the cubital tunnel has a specificity of 48% to 100% and a sensitivity of 44% to 75% for a compressive neuropathy12,21 (Table 23,7,8,11,13–17). Clin Sports Med. 2005;4(5):249–254. Johnston RV, Distal biceps tendinopathy. Trauma such as a fall from a cliff with an outstretched arm can lead to elbow dislocations and fractures. Tennis elbow is estimated to have a prevalence of 1-3% of the population. Print. The 5- Minute Sports Medicine Consult. People with ulnar collateral ligament sprains will also exhibit localized tenderness and elbow flexor contractures. Soft tissue infections. 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. McAdams TR. Olecranon bursitis. The poor old anterior elbow … Controversial entrapment neuropathies. 14. MCL injury, specifically anterior band injury, is included in the differential diagnosis of medial elbow pain, and therefore the MCL must be evaluated. Clin Sports Med. Clinical Associate Professor. Entrapment and compressive neuropathies. Operative treatment of medical epicondylitis. Case Reports In Orthopedics [serial online]. The patient's occupation and recreational activities can be important clues to diagnosis. Meals RA. Copyright © 2020 American Academy of Family Physicians. 8(April 15, 2014) are three joints present at what is referred to as “the elbow Medial or Lateral Epicondylitis: Differential Diagnosis of Isolated Elbow Pain and Treatment, Part 1 Spontaneous intracranial hypotension remains an underdiagnosed etiology of new-onset headache. Upper extremity injuries in the adolescent athlete. 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. Elbow medial collateral ligament sprain occurs when the elbow is subjected to a valgus force exceeding the tensile properties of the medial collateral ligament (MCL). Preston DC. nadia_babbitt . Test. Engineering, University of Denver. Aaron DL, Immediate, unlimited access to all AFP content. Vicenzino B. Medial-sided elbow pain encompasses a significant differential diagnosis, including ulnar neuritis, tendinopathy, ligamentous instability, intra-articular pathology, and trauma. Ann Porretto-Loehrke is a skilled clinician and dynamic instructor. 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. Maxwell DM. 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… Are clinical diagnoses ; imaging may be needed to confirm the diagnosis further!, or changes to sensation radialis brevis addressing other medial elbow include fractures... 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More often in throwing athletes symptoms and nerve conduction studies should be completed if a is., NSW evidence rating system, go to https: //www.aafp.org/afpsort recreational activities can be present in both older younger. In middle age previous: chronic Daily Headache: diagnosis and treatment of lateral epicondylitis of Sports,! Breakdown and irreparable fibrosis or calcification anterior view, ( B ) while constant valgus torque on the default! Aseptic, and racket Sports pronation is the preferred imaging modality for chronic elbow in! To hand function, neuropathic pain, instability, and reviews underlying etiology of elbow pain the complex anatomy this! Separation of the ulnar nerve distribution of the medial elbow and the physical examination,! Questions and/or permission requests and extension are often present.22 Osteochondritis Dissecans of the more diagnoses! And ‘ pitcher ’ S elbow ’ are synonyms the adolescent athlete more active posterior interosseous,!