Author(s): Jane Konidis, MD
Originally published: September 20, 2014 Last updated: November 30, 2023
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Disease/Disorder

Definition

Acute

Acute olecranon bursitis: Inflammation of the superficial olecranon bursa, superficial and distal to the triceps tendon insertion. Caused by direct trauma to the bursa. Often seen in sports such as football, wrestling and volleyball. May also be related to an acute inflammatory flare such as pseudogout or gout, or an infection through direct trauma most frequently or immunocompromised state.1,16,24

Distal biceps brachii tendon rupture: uncommon injury located at the distal tendon of the biceps brachii, which ruptures from the bicipital tuberosity of the proximal radius. The most frequent mechanism of injury is a sudden, forceful eccentric contraction, with a flexed elbow at 90 degrees. It is associated with a “pop”, following by intense anterior elbow pain, and bruising. It most frequently occurs in middle aged males. Increased risk factors for tendon rupture includes smoking and obesity.2,16,18,28

Triceps brachii tendon rupture: rare injury that may occur through a forceful eccentric overload of the tendon. Complete tears are usually found with a direct mechanism of injury to the tendon. A palpable defect, swelling or pain over the posterior elbow, and triceps weakness can be seen. A complete rupture of the triceps should be promptly referred for surgical repair.24,28

Olecranon fracture: the mechanism of injury is most often a direct injury to the olecranon process, such as with a fall, resulting in multiple fragments (comminuted fracture). Less frequently, an indirect mechanism of injury, such as a fall onto hand, with a partially flexed elbow, can cause a forceful contraction of the triceps tendon resulting in an olecranon fracture.3,17,24,28

Radial head fracture: most common fracture at the elbow occurring twice as frequently in women. The mechanism of injury usually consists of a fall on outstretched hand, causing an axial load +/- valgus stress, leading to fracture. Pain over the radial head/lateral elbow is expected, with limited motion and loading possible.14

Chronic

Chronic olecranon bursitis: Most common form of olecranon bursitis. Due to repetitive trauma, prolonged compression, or inflammatory conditions. Bursal lining becomes thickened by fibrosis. Inflammatory conditions associated with chronic olecranon bursitis include pseudogout, gout and rheumatoid arthritis. The bursa may become infected especially when related to trauma, prior injection, or in an immunocompromised individual.1

Triceps tendinopathy: The mechanism of injury is typically repetitive overuse of elbow extension as seen in weightlifters or during manual labor. The medial head of the triceps is most frequently affected. Acute tears can occur through indirect mechanisms such as with a fall on an outstretched hand, or less frequently, after a seizure or being struck by lightning. In these cases, it is important to carefully rule out additional injuries at the elbow. Additional risk factors include a history of chronic olecranon bursitis, anabolic steroid use, and diabetes.2,19,24,28

Lateral Elbow Tendinopathy: Also known as lateral epicondylitis and tennis elbow. Typically affecting the dominant arm, it is a degenerative overuse injury (tendinosis) with or without active inflammation near the origin of the common extensor tendon at the lateral epicondyle. Risk factors include repetitive movements involving forceful gripping, wrist and finger extension, as well as smoking and obesity. Affects most frequently the extensor carpi radialis brevis tendon, and secondly, the extensor digitorum communis tendon. It presents with lateral elbow pain and difficulty with activities such as gripping or lifting (extending) with the wrist and forearm pronated. Differential diagnosis especially in recalcitrant conditions includes posterior interosseous nerve syndrome (radial tunnel syndrome). Initial treatment measures include a period of rest, activity and equipment modification, therapeutic exercises and modalities, as well as bracing. Therapeutic exercises can include both eccentric and concentric strengthening as well as stretching of the common extensor tendons. A variety of modalities may be trialed including cryotherapy, therapeutic ultrasound, TENS, and laser therapy. Bracing may include wrist-hand-orthosis, which prevents wrist movement and forceful gripping, or counterforce bracing, using a proximal forearm strap. There is mixed evidence in the literature of one approach being superior to the others and typically a combination of these methods needs to be tailored to the patient’s case.14,15,25,26

Medial Elbow Tendinopathy; Also known as medial epicondylitis and golfer’s elbow. A degenerative overuse injury (tendinosis) with or without active inflammation near the origin of the common flexor tendon at the medial epicondyle. Affects most frequently the flexor carpi radialis and pronator teres tendons. It presents with medial elbow pain and difficulty with activities involving forceful repetitive valgus stress at the elbow or repeated wrist and digit flexion. If the mechanism of injury involves throwing, the medial collateral ligament and ulnar nerve may also be involved.14

Ulnar collateral ligament (UCL) sprain: Caused by a valgus stress to the elbow leading to pain and dysfunction. The greatest stabilizer of the UCL complex is the anterior band. It is primarily affected from overhead throwing, such as in baseball players, but can also be seen in javelin throwers or gymnasts. The mechanism of injury typically consists of repetitive elbow valgus stress, leading to chronic instability at the medial elbow. Risk factors for young pitchers include throwing > 100 innings per year, pitching all year and for multiple teams2,14,20,37

Posterior Interosseous Nerve (PIN) syndrome: typically referred to as radial tunnel syndrome, should be considered in cases of refractory lateral elbow pain. The PIN, a branch from the radial nerve, passes through the supinator muscle through the arcade of Frohse and courses in between the two heads of the supinator muscle. Direct trauma to the PIN can occur from a radial fracture or a Monteggia fracture with a dislocation of the radius. Some persistent lateral elbow pain may be due to compression of the PIN.21

Cubital tunnel syndrome: This is due to compression, traction, or irritation of the ulnar nerve as it passes through the cubital tunnel of the medial elbow, as it courses through the aponeurotic arch between the two heads of the flexor carpi ulnaris muscle, distal to the retroepicondylar groove. Often the term is used to describe all ulnar neuropathy at the elbow. The tunnel spaces reduce by approximately 50% with end of range elbow flexion. Most common in throwing athletes.2,21

Etiology

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

Intrinsic factors

  • Misalignment
  • Muscular imbalance
  • Inflexibility
  • Muscular weakness
  • Poor blood supply
    • Examples include diabetes and smoking

Extrinsic factors

  • Training errors
  • Equipment maladjusted
    • Examples include grip size, weight, tensile strength
  • Environment
  • Poor technique
  • Sports-imposed deficiencies
  • Excessive loads

Elbow injuries are common in throwing athletes. Maximal valgus forces at the elbow are generated during the late cocking and early 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. Risk factors for injuries include diabetes and smoking.

Preventive measures to avoid elbow injuries include ensuring proper biomechanics, posture and equipment use during activities, sports, and work/manual labor. Wearing elbow pads, avoiding repetitive motions, avoiding prolonged pressure on the elbow, warming-up prior to activities, stretching and icing after activities, and rest days from throwing can assist in preventing overuse injuries.

Patho-anatomy/physiology

Injuries typically occur when the elbow is subjected to improper alignment, extreme motions 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 microtrauma from repetitive stress. This can lead to chronic tendinopathies and ligamentous instability.

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, with limited elbow range of motion (ROM).

Specific secondary or associated conditions and complications

  • Olecranon bursitis: can develop chronic bursitis with repetitive injuries.2
  • Triceps tendinopathy can be associated with olecranon bursitis.2
  • Lateral elbow tendinopathy: may be mistaken for PIN syndrome
  • Medial elbow tendinopathy: can be associated with UCL injury or ulnar neuropathy.
  • Ulnar collateral ligament injuries: Associated with ulnar neuritis or subluxation.2
  • Cubital tunnel syndrome: associated with ulnar collateral ligament instability.3

Essentials of Assessment

History

  • 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.
  • 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
  • Cubital Tunnel Syndrome: Medial elbow pain worsened with activity; clumsiness and worsening of grip. Numbness in 4th and 5th digits.
  • Triceps tendinopathy: repetitive concentric elbow extension, posterior elbow pain with elbow extension.
  • PIN 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.
  • 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 medial elbow pain often accompanied by decreased velocity of throwing or feelings of instability or loss of control. Pain is greatest during late cocking and early acceleration phases. There can be associated tingling in the ring and small fingers.

Physical examination

  • Inspection, palpation, range of motion, joint stability, neuromuscular testing, special maneuvers.
  • Olecranon bursitis: swelling in the posterior elbow superficially at the bursa. If acute, it may be tender to the touch, warm and erythematous. If chronic, may be non-tender to the touch without warmth or redness present. Elbow extension and even flexion may be limited at end-of-range.
  • Lateral elbow tendinopathy: tenderness to palpation at the lateral epicondyle and just distal to it at the common extensor tendon. Pain and weakness on resisted supination, wrist and digit extension. Positive special tests include a positive Cozen’s and Mill’s test, as well as a painful resisted extension of the middle finger.
  • Medial elbow tendinopathy: tenderness to palpation at the medial epicondyle and just distal to it at the common flexor tendon. There can be pain and weakness on resisted pronation and wrist flexion. Passive wrist extension with the elbow extended may provoke pain.
  • Cubital tunnel syndrome: Medial elbow tenderness to palpation. Positive Tinel’s sign over the ulnar nerve at the ulnar groove of the elbow. There may be pain with end-of-range elbow flexion/extension, and palpable ulnar nerve subluxation. Paresthesias, tingling and altered sensation to light touch and/or pin prick may be present in the anterior ulnar half of the ring finger and anterior small finger. There may be weakness on testing of the flexor digitorum profundus of the fourth and fifth fingers, first dorsal interosseous, abductor digit minimi and flexor carpi ulnaris. There may be muscle wasting of the intrinsic muscles of the hand.
  • PIN syndrome: there is tenderness over the common extensor tendon near its origin, but typically distal to the usual site of pain in lateral epicondylosis. Maneuvers positive for lateral elbow tendinopathy may also be positive, especially resisted extension of the middle finger.
  • Distal biceps tendon rupture: noticeable weakness in forearm supination (biceps is primary supinator) and weakness in elbow flexion. There is a positive Hook test (lack of a cord that can be palpated with the elbow flexed at 90 degrees). When the examiner passively squeezes the biceps brachii muscle belly with the elbow slightly flexed to 60 degrees and in slight pronation, there is an absence of supination indicating a positive test.
  • Triceps tendinopathy: posterior elbow pain with resisted elbow extension, with typically normal strength or slightly limited due to inhibition from pain. If there is an associated tendon tear, elbow ROM and strength can be reduced. There may be a deformity, atrophy, bruising, or swelling present at the posterior elbow. When squeezing the triceps muscle belly, there should be a passive extension of the elbow unless the tendon is completely ruptured (modified Thompson test).
  • Ulnar collateral ligament elbow injuries: Tenderness to palpation at the medial elbow along the UCL. There may be a slight elbow flexion contracture, when compared to the contralateral elbow. Positive valgus stress test (with the elbow flexed at 30 degrees). Additional stress tests may be positive such as the moving valgus stress test and the milking maneuver. There may be subluxation of the ulnar nerve with elbow ROM. Joint effusion and ulnar nerve tenderness may be present.

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:

  • Windup
  • Early cocking/stride
  • Late cocking
  • Acceleration
  • Deceleration
  • 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. The lumbopelvic core is essential in initiating and generating sufficient power during throwing. A thorough evaluation of the entire kinetic chain is essential to identify any deficiencies, which could result in poor performance or injury at the elbow.29,36,37

Similarly, patients with repetitive motion at work, particularly manual labor, or excessive computer use, should have a work assessment observing their posture, equipment and biomechanics. Adaptations to equipment, posture, and/or duties, are usually necessary to assist in resolving pain and the underlying injury.

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 but is rarely necessary.

Lateral or medial elbow tendinopathy: X-ray of the elbow to rule out arthritis. An ultrasound is useful in assessing tendon integrity, presence of tendon tearing, calcifications, thickening of the tendon and any neovascularity. An MRI can be complementary in assessing instability and for evaluating associated intraarticular injury or for pre-surgical planning.

Cubital tunnel syndrome: X-ray of the elbow to evaluate for spurs or bony changes. An ultrasound can assess for ulnar swelling, areas of compression, and dynamically for subluxation. An MRI can also assess the ulnar nerve, rule out any soft tissue masses and evaluate the ulnar collateral ligament. Electrodiagnostic testing is necessary for confirming and for grading the severity of the neuropathy, especially if there is presence of neurological deficits on physical examination.

PIN syndrome: X-ray of the elbow to evaluate bone and joint integrity. Ultrasound evaluation may show swelling or compression of the PIN, it is important to compare any side-to-side differences.

Triceps tendinopathy: elbow X-ray AP and lateral views to assess for avulsion of the tendon from the olecranon process (fleck fracture) and presence of an olecranon osteophyte. Ultrasound evaluation is useful to assess for integrity of the tendon, calcifications, enthesophytes, and presence of active inflammation. An MRI can be used to assess the extent of triceps tendinopathy and tearing, as well as for surgical planning.

Ulnar collateral ligament injuries: Stress radiographs and dynamic ultrasound studies may show joint widening compared to the contralateral elbow. A difference in joint opening of 1-3 mm suggests UCL injury. MRI can better assess the entire integrity of the UCL and is used for pre-procedural planning.

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 involving manual labor or repetitive motions, 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

These injuries may occur 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 further 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 medical 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.

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 entire kinetic chain including shoulder, spine and hip range of motion and strength, core strength, and overall flexibility. Any abnormalities along the kinetic chain can place undue stress 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 delay/prevent muscle atrophy. ROM should progress from PROM, to AAROM and finally, AROM.

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 flexion, extension, supination and pronation. 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 activity progression 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 at least 70% of the contralateral non-injured extremity. This phase emphasizes robust and eccentric strengthening, high speeds, and plyometric training as appropriate.

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 and strength, no pain or tenderness, and an otherwise normal clinical examination.

Coordination of care

Outcomes are improved if medical attention and treatments are initiated 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 patient needs to be educated regarding the prognosis, treatment options, and length of recovery. It is important to emphasize that they do not return to full activity until proper healing and rehabilitation has occurred, as this may exacerbate the injury and lead to longer recovery times.

Cutting Edge/Emerging and Unique Concepts and Practice

Advanced procedures and experimental regenerative medicine can be utilized for tendinopathies. For acute tendinopathies, corticosteroid injections should be avoided as these can lead to further tendon damage. Tendon fenestration alone, with or without platelet rich plasma (PRP) may be utilized for tendinopathies. PRP has been most studied for common extensor tendinopathy at the elbow. There is promising research indicating that PRP may provide a reduction in pain long-term in cases of lateral epicondylitis.27,31,35,38 Additional benefits of PRP when compared to steroid use, include reducing risks of further tendon injury or tears, skin discoloration, as well as subcutaneous fat and muscle atrophy.33,34 There is limited evidence that PRP, when compared to fenestration alone under ultrasound guidance, may provide no additional benefit in treating tendinopathies.14,22,23 For chronic tendinopathies not responsive to standard treatments such as percutaneous tenotomy, various higher powered ultrasonic systems can provide decreased pain and improved function from 3 months and up to one year post tenotomy.39,40

Gaps in the Evidence-Based Knowledge

Regenerative medicine options, such as PRP or bone marrow aspirate concentrate (BMAC) are classified as experimental and further studies are needed for their use in tendinopathies, ligamentous injuries, and osteoarthrosis.32 For tendinopathies, certain studies have not shown superiority of PRP to fenestration alone.14, 22 Research is ongoing.

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Original Version of the Topic

Barbara Semakula, MD, Reza Taher. Acute Elbow Injuries and Overuse Disorders. 9/20/2014.

Previous Revision(s) of the Topic

Jeffrey Oken, MD, Firas Rafati, DO. Acute Elbow Injuries and Overuse Disorders. 9/6/2018.

Author Disclosure

Jane Konidis, MD
Nothing to Disclose