Acute elbow injuries and overuse disorders

Author(s): Jeffrey Oken, MD and Firas Rafati, DO

Originally published:09/20/2014

Last updated:09/06/2018

1. DISEASE/DISORDER:

Definition

Acute:

1) Acute olecranon bursitis: Inflammation of the superficial olecranon bursa. Caused by direct trauma to the bursa. Often seen in sports such as football, wrestling and volleyball.1

2) Lateral Epicondylitis: inflammation of the Extensor Carpi Radialis Brevis (ECRB)  tendon. The forearm Extensor muscle complex and tendon can become damaged from overuse- repeating the same motions. This leads to pain and tenderness on the lateral side of the elbow.

3) Ulnar collateral ligament (UCL) injuries of the elbow: Sprain or tearing of the UCL due to valgus stress leading to pain and dysfunction. Mostly seen in baseball players, but also seen in javelin throwers and tennis players. Two mechanisms: Chronic deterioration of the UCL owing to repetitive valgus overload or, less commonly, an acute traumatic rupture.2

4) Distal biceps tendon rupture: Rupture of the distal head of the biceps commonly occurs in males ages 40-60 due to repetitive microtrauma or acute traumatic injury.2

5) Olecranon fracture: Nondisplaced: it must be displaced < 2mm, and must not change in position with gentle flexion to 90 degrees. Due to direct trauma, such as a fall onto the tip of the elbow, often an isolated injury. It can also be due to indirect trauma, such as a fall onto the hand with the elbow partially flexed. The olecranon fragments usually displace posteriorly.3

Chronic:

1) Chronic olecranon bursitis: Most common form of olecranon bursitis. Due to repetitive trauma or rubbing of the bursa. Bursal lining becomes thickened by fibrosis. Also can be caused by systemic inflammatory conditions such as rheumatoid arthritis.1

2) Little Leaguer’s elbow: Valgus stress lesion of the medial epicondylar physis. Radiographs may show physeal widening or may show fragmentation or avulsion of the medial epicondyle. MRI will show increased edema of the medial epicondyle apophysis. Seen in pitchers, catchers, infielders, or outfielders.

3) Cubital tunnel syndrome: The elbow is the most common site of injury to the ulnar nerve. This is due to compression, traction, or irritation of the ulnar nerve as it passes through the cubital tunnel of the medial elbow. Most common in overhead throwing athletes.2

4) Triceps tendinitis: Inflammation of the triceps tendon at the olecranon insertion site. Classically an overuse injury due to repetitive extension of the elbow. May result from direct trauma.2

Etiology

Elbow injuries result from intrinsic and/or extrinsic factors.1

Intrinsic factors:

  • Misalignment
  • Muscular imbalance
  • Inflexibility
  • Muscular weakness
  • Poor blood supply

Extrinsic factors:

  • Training errors
  • Equipment
  • Environment
  • Techniques
  • Sports-imposed deficiencies
  • Grip too small
  • Excessive load

Elbow injuries are common in throwing athletes. Extreme valgus during the acceleration phase of throwing results in simultaneous compressive loads to the lateral elbow and tension forces on the medial elbow. Injuries most commonly occur during the eccentric phase of muscle contraction.

Epidemiology including risk factors and primary prevention

Elbow injuries in many instances have a common denominator, including direct trauma, repetitive activity, or weightlifting.

The elbow is especially vulnerable to overuse injuries in young athletes. Other causes of elbow injury that will be discussed include olecranon bursitis/fracture, lateral epicondylitis, cubital tunnel syndrome, ulnar collateral ligament injury and radial tunnel syndrome. In many instances the prevalence is higher in males, as seen in cubital tunnel syndrome, 3-8:1 and triceps tendinitis, 2:1.

Preventive measures to avoid elbow injuries include: wearing elbow pads, avoiding repetitive motions, avoiding prolonged pressure on the elbow, proper stretching prior to activities, icing after activities and weightlifting with proper form.

Patho-anatomy/physiology

Injuries typically occur when the elbow is subjected to irregular motion and unnatural postures and forces, but can also be due to trauma from a fall or direct blow. This can cause damage to the structures surrounding the elbow, including the muscles, tendons, bursae, bones and ligaments. Acute tears occur due to increased overload and tensile force such as seen in distal biceps tendon rupture. Elbow overuse injuries occur due to cumulative micro trauma from repetitive stress and typically involve an inflammatory phase followed by a degenerative phase, involving joint surfaces, ligaments, or tendons about the elbow.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • Acute phase: The athlete might experience discomfort, irritation and pain.
  • Subacute phase: The athlete complains about performance, along with continued pain.
  • Chronic: Chronic elbow pain develops, including at rest, exacerbated with activities, limited elbow range of motion (ROM).

Specific secondary or associated conditions and complications

  • Olecranon bursitis: can develop chronic bursitis with repetitive injuries.2
  • Triceps tendonitis associated with olecranon bursitis.2
  • Little Leaguer’s elbow: Associated with flexion contracture.2
  • Ulnar collateral ligament injuries: Associated with ulnar neuritis or subluxation.2
  • Cubital tunnel syndrome: associated with ulnar collateral ligament instability.3

2. ESSENTIALS OF ASSESSMENT

History

  1. Olecranon bursitis: Acute – history of direct elbow trauma, rapid onset of swelling and pain. Chronic: multiple episodes of trauma, with chronic swelling. May lead to rubbery mobile mass.
  2. Lateral epicondylitis: pain or burning on the outer part of elbow, weak grip strength, worse with forearm activity, such as holding a racquet, turning a wrench, or shaking hands13
  3. Cubital Tunnel Syndrome: Medial elbow pain worsened with activity; clumsiness and worsening of grip. Numbness in 4th and 5th digits.
  4. Triceps tendinitis: Progressive posterior elbow pain; worsens as day progresses; occasional morning stiffness. Improved with rest.
  5. Radial tunnel syndrome: Pain in the lateral elbow that typically radiates distally. Increase in symptoms with repetitive activities such as forearm rotation, elbow extension, and maximum wrist flexion-extension.
  6. Ulnar collateral ligament injuries of elbow: In acute rupture the athlete may experience sudden pain, sometimes with an audible pop and cannot resume play. In chronic injuries there is persistent pain often accompanied by decreased velocity of throwing or hitting.
  7. Little Leaguer’s elbow: Age is important because of the different ages at which each growth center appears and closes. Most commonly the pain is located in the medial epicondyle.

Physical examination

  1. Inspection, palpation, range of motion, joint stability, neuromuscular testing, special maneuvers.
  2. Olecranon bursitis: All forms present with swollen fluctuant fluid collection within the bursa.
    • a) Acute: afebrile, tenderness, range of motion preserved
    • b) Chronic: afebrile, nontender; range of motion preserved
  3. Lateral epicondylitis: lateral elbow tenderness and pain worse with wrist in pronation, radially deviated , extended and finger extension against resistance, called Cozen’s test13
  4. Cubital tunnel syndrome: Medial elbow tenderness; positive Tinels sign, pain with elbow flexion. positive scratch test. Numbness and tingling in the ring finger and little finger are common symptoms, often they come and go, occur more often when elbow is flexed and the ulnar nerve is stretched.
  5. Triceps tendonitis: posterior elbow pain exacerbated by extension/flexion.
  6. Ulnar collateral ligament elbow injuries: Tenderness along the UCL. Joint effusion and ulnar nerve tenderness may be present. Positive valgus stress test (when the athlete has pain, apprehension or instability).
  7. Little Leaguer’s elbow: Pain in medial elbow. Pain accentuated during early and late cocking of throwing motion. Decrease in pitching control.

Functional assessment

Since there is a high correlation between elbow injuries and the throwing athlete, it is imperative to assess throwing biomechanics.

Evaluation of the kinetic chains involved in the pitching motion is also important. This consists of six phases:

  1. Windup
  2. Early cocking/stride
  3. Late cocking
  4. Acceleration
  5. Deceleration
  6. Follow-through

These phases are intricately coupled, resulting in efficient generation and transfer of energy from the body into the arm, ultimately the hand and ball. Breakdown of any phase can lead to elbow injury.

Similarly, patients with repetitive motion at work and elbow pain must have their work motion examined.

Imaging

Olecranon bursitis: Plain films of the elbow to rule out fracture or dislocation. Ultrasound can evaluate the status of the surrounding tendons and illustrate inflammation. MRI can rule out triceps tear, tendinopathy, or stress fracture.

Lateral epicondylitis: x-ray to rule out arthritis of the elbow, MRI to rule out cervical pathology.. However, lateral epicondylitis is a clinical diagnosis.13

Cubital tunnel syndrome: plain films to evaluate for spurs or bony changes. MRI can assess soft tissue masses and the ulnar collateral ligament, electrodiagnostic testing for physiologic correlation.

Triceps tendinitis: plain films – AP/lateral to evaluate for tendon avulsion. Ultrasound can be helpful in showing tears or mixed tendon echogenicity, thickening, calcifications and enthesophythes consistent with chronic triceps tendinopathy.Ulnar collateral ligament injuries: Stress radiographs or dynamic ultrasound may show joint widening compared to the contralateral elbow. A difference in joint opening of 1-3 mm suggests UCL injury. MR arthography is considered the gold standard when ultrasound is equivocal, and can be helpful in assessing intra-articular pathology.Early predictions of outcomes

Early recognition of the injury with rapid medical management, relative rest, physical and occupational therapy, stretching, and posture modification during activities results in a speedy recovery. Poorer prognosis in patients with multiple co-morbidities (such as diabetes, obesity, and alcoholism), and delay in seeking medical intervention.

Environmental

Occupational ergonomic evaluations are key to help prevent recurrence of injuries in occupations such as carpentry where these injuries are common.

Proper athletic training and proper strength and conditioning are key for athletes to prevent recurrence of injuries.

Social role and social support system

Occurs in athletes or occupations subjected to physical, emotional, and psychological stress that in turn can lead to mood disturbance, loss of work hours, and time lost in athletic activities, which can exacerbate their mental health. A multidisciplinary approach is needed to address these issues. Overuse injuries in little league baseball may present in early childhood and  persist  into later in life if the social and mediacl aspects are not addressed, please refer to Baseballhealthnetwork.com for further guidance on age appropriate activity.

Professional Issues

Elbow injuries are common in athletes and occupations that require vigorous physical demands. Occasionally, return to activity prior to complete recovery can lead to chronic complications or other injuries.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Rehabilitation following elbow injury follows a sequential and a progressive multiphase approach. The ultimate goal of rehabilitation is to return the athlete to the previous functional level as quickly and safely as possible.9 Additional attention should be paid to the kinetic chain, shoulder, spine and hip range of motion, core strength, and overall flexibility, since abnormalities can place additional forces on the elbow.

Phase I: Immediate motion

The goals are: to minimize the effects of immobilization, to reestablish non-painful ROM, to decrease pain and inflammation, and to retard muscular atrophy.

Phase II: Intermediate phase

This is initiated when the patient exhibits full ROM, minimal pain and tenderness, and adequate (4/5) manual muscle test of the elbow flexor and extensor muscles. This phase focuses on enhancing elbow and upper limb mobility, improving muscle strength and endurance, and reestablishing neuromuscular control of the elbow complex.

Phase III: Advanced strengthening

This phase focuses on progression of activities to prepare the athlete for sports participation. Criteria that must be met before entering this phase include full non-painful ROM, no pain or tenderness, and strength that is 70% of the contralateral extremity. This phase emphasizes aggressive strengthening, high speed and eccentric contraction and plyometric activities.

Phase IV: Return to activity

Allows the athlete to progressively return to full competition using an interval return to throwing program. Criteria to enter this phase: exhibit full ROM, no pain or tenderness, and an otherwise normal clinical examination.

Coordination of care

Good outcome and prognosis if medical attention and intervention are sought early on. The physiatrist acts as a coordinator between the patient, the primary care physician, the therapist, the coaching staff or employer to speed functional recovery with return to functional activity.

Patient & family education

The individual needs to be educated regarding the prognosis; treatment options; length of recovery; and encouraged not to return to activity while symptomatic, as this may exacerbate the injury.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Platelet rich plasma (PRP) is an emerging treatment for acute/chronic tendinopathies and has been shown to be helpful in healing UCL injuries in baseball players and Lateral Epicondylitis.11 Tenex procedures for tendinopathies has shown functional improvement and sustained relief at 3-year follow ups.12. Further studies need to be done to determine the efficacy of proltherapy.8

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

Results of basic science and pre-clinical trials have not yet been confirmed in large-scale controlled clinical trials regarding other regenerative medicine techniques (like prolotherapy or stem cells,). Clinical use has been promising but inconsistent results in early trials.

REFERENCES

  1. Delee J, Drez D, Miller MD.Orthopaedic Sports Medicine Principles and Practices. Philadelphia, PA, Saunders imprint of Elsevier; 2010:1214-1240.
  2. Vidal AF, Drakos MC, Allen AA. Biceps tendon and triceps tendon injuries.Clinical Sports Medicine. 2004;23:707-722.
  3. Egol KA, Koval KJ, Zuckerman JD.Handbook of Fractures. Philadelphia, PA. Lippincott Williams ans Wilkins.2010;21:257-268.
  4. Gellman H. Compression of the ulnar nerve at the elbow: Cubital tunnel syndrome. Instr course; NY. Demos Medical publishing. 2008;57:187-197.
  5. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachia: Operative vs. non-operative treatment.J Bone Joint Surg Am. 1985;67:414-417.
  6. Keefe DT, Lintner DM. Nerve injuries in the throwing elbow.Clin Sports Medicine. 2004; 23:723-742.
  7. Rand FF. Emergency Medicine. Boston, MA: Little-Brown, 1992.
  8. Podesta L1, Crow SA, Volkmer D, Bert T, Yocum LA.Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma.Am J Sports Med.2013;41(7):1689-1694. doi: 10.1177/0363546513487979. Epub 2013 May 10.
  9. Miller A, Heckert KD, Davis BA. The three-minute musculoskeletal and peripheral nerve exam. New York, Demos Medical publishing. 2009;25-32.
  10. Thompson JC.Netter’s Concise Orthopedic Anatomy. 2nd ed. San Antonio, TX. Elsevier Health science. 2010;4:110-138.
  11. Miller L, (2017, Nov 7). Efficacy of platelet-rich plasma injections for symptomatic tendinopathy: systemic review and meta-analysis of randomized injection-controlled trials. BMJ Sports exercise medicine.(Miller, 2017)
  12. Seng, C (2016, Feb). Ultrasonic Percutaneous Tenotomy for Recalcitrant Lateral Elbow Tendinopathy: Sustainability and Sonographic Progression at 3 years. American Journal of Sports Medicine.
  13. Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391-397.

Original Version of the Topic

Barbara Semakula, MD, Reza Taher. Acute elbow injuries and overuse disorders. Original publication date: 09/20/2014.

Author Disclosure

Jeffrey Oken, MD
Nothing to Disclose

Firas Rafati, DO
Nothing to Disclose

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