medial elbow pain differential diagnosis
Radiation of pain from shoulder or wrist injuries. 29. The clinician should attempt to identify changes to hand function, neuropathic pain, weakness, or changes to sensation. Biceps tendinopathy is a relatively common source of pain in the anterior elbow; history often includes repeated elbow flexion with forearm supination and pronation. DIFFERENTIAL DIAGNOSIS OF ELBOW PAIN. 2011;19(1):17–26. Pink MM. Simulation showing injury. Am J … Patients may offer a history of sports activities, including golf, overhead throwing sports, and racket sports. Pattanittum P, Davies GJ. T1-weighted image of the lateral epicondyle demonstrating a partial tear/tendinopathy (arrowhead) of the common extensor tendon (arrow). Clin Sports Med. Walz DM, Clin Sports Med. 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. Differential Diagnosis Elbow Diagnoses Radiograph-Positive. McNally EG. Diagnosis, treatment, and rehabilitation of the thrower's elbow. Ulnar collateral ligament injury in the overhead athlete. Learn about the symptoms, diagnosis and treatments. 2008;19(4):597–608, vi–vii. Nerve injuries about the elbow. This pain may be exacerbated by pronation of the forearm with the elbow extended, resisted supination, and extension of the long fingers. Bones of the elbow: (A) anterior view, (B) posterior view, and (C) lateral view. The examiner then pulls the patient's thumb posteriorly, creating a valgus force (Table 23,7,8,11,13–17). Quismorio FP Jr. Neurol Clin. 5. Soft tissue infections. 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. 2011;19(6):359–367. 27. J Hand Surg Am. Turner T, Also, the tear and pain is more likely to be located in the muscle belly as opposed to the common flexor tendon. J Prolotherapy. Department of Orthopaedic Surgery This high frequency is due to children being less skeletally mature than adults but also usually more active. 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. Giuffre BM. … Meals RA. 26. Pain during resisted pronation is the most sensitive physical examination finding. Nerve injuries about the elbow. Magnetic resonance arthrography may be performed in patients without an effusion to identify ligament tears, osteochondral defects, or loose bodies18,37(Figure 839). Curr Sports Med Rep. Bell SN, Diagnosis and management of ulnar collateral ligament injuries in throwers. Preston DC. Bisset L, Diagnosis and treatment of medial epicondylitis of the elbow. 3.1.1 Radiograph-Positive; 3.1.2 Radiograph-Negative; 3.1.3 Pediatric; 4 Management; 5 Disposition; 6 See Also; 7 References; Background. Drakos MC, Trauma is another cause of elbow pain and need for rehabilitation. The injury is characterized by the insidious onset of vague medial elbow pain … Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. 23. Evaluation of overuse elbow injuries. Aetiology. Drakos MC, Ann Porretto-Loehrke is a skilled clinician and dynamic instructor. Table 1 provides the differential diagnosis of elbow pain by anatomic location. Colorado Joint Replacement. Carpal tunnel syndrome. O'Connor FG, This content is owned by the AAFP. The history should include questions about the onset of pain, what the patient was doing when the pain started, and the type and frequency of athletic and occupational activities. Quismorio FP Jr. Data Sources: A PubMed search was completed in Clinical Queries using the key terms elbow pain, epicondylitis, bursitis, radial tunnel, cubital tunnel, and impingement. Reprinted with permission from Stadnick ME. Most conditions that cause chronic elbow pathology are clinical diagnoses; imaging may be used to confirm the diagnosis before further intervention or referral. 1984;43(1):44–46. Understanding the anatomy and the physical forces of movement will aid in diagnosis.2, Enlarge Curr Sports Med Rep. Clin Sports Med. Tenderness over the UCL has a sensitivity of 81% to 94%, but a specificity of only 22% for UCL tears.11, The most important examination for a possible UCL injury is assessment of the medial joint space laxity or instability against valgus forces. The common flexor tendon provides the origin of the pronator teres, flexor carpi ulnaris, palmaris longus, and flexor carpi radialis (medial to lateral). Hauser MA, Differential diagnosis. Raymond H. Kim, M.D. Sports Med Arthrosc. Address correspondence to Shawn F. Kane, MD, USASOC(A), Attn: AOMD, 2929 Desert Storm Dr. (Stop A), Fort Bragg, NC 28310 (e-mail: firstname.lastname@example.org). Epicondylitis in the athlete's elbow. Weakness and pain when resisting wrist flexion and pain with gripping are also signs of flexor/pronator tendinopathy. 2011;36(4):708–709. Pain is exacerbated with resisted forearm pronation and resisted wrist flexion. In: Bracker MD. Distal biceps tendinopathy. 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). 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 … 3 Differential Diagnosis. Mariscalco MW, 22. It is less common than lateral epicondylitis. Shear force. 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. Coombes BK, The most important examination for a possible UCL injury is assessment of the medial joint space laxity or instability against valgus forces. Hayter CL, 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. Barnsley L, Patients with septic olecranon bursitis present with pain, swelling, warmth, and erythema over the olecranon; roughly one-half will have a fever. Delo M. Ulnar collateral ligament injuries of the elbow. Accessed July 1, 2015. It was initially described by Henry Morris as “lawn tennis arm” in 1882 9 and now most commonly termed as tennis elbow. Mariscalco MW, Most patients will have complete resolution of symptoms with arm rest and nonsteroidal anti-inflammatory drug (NSAID) therapy. Tinel's test may reproduce these symptoms and nerve conduction studies should be completed. Biceps tendon and triceps tendon injuries. Patients with biceps tendinopathy may present with vague anterior elbow pain. Hatch JD. The ‘golfer’s elbow’ and ‘pitcher’s elbow’ are synonyms. Lateral epicondylitis; Medial epicondylitis; Olecranon bursitis (nonseptic) Septic bursitis; Biceps tendon rupture/dislocation; Pediatric. Test. The biceps tendon is a relatively common source of pain in the anterior elbow. 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). Allen AA. Lockman L. Delo M. Ulnar collateral ligament injuries of the elbow. Also searched were the Agency for Healthcare Research and Quality evidence reports, the Cochrane database, Essential Evidence Plus, the Institute for Clinical Systems Improvement, and the National Guideline Clearinghouse database. In addition, an individual with wrist flexor strain is more likely to have acute pain which includes swelling, redness and heat. The poor old anterior elbow … Differential Diagnosis of Knee Pain November 11, 2016. The most common injury in a musculoskeletal physiotherapy practice to the medial elbow would be flexor/pronator tendinopathy (golfers elbow). In: Bracker MD. Peripheral nerve injuries in baseball players. If the patient has a reduced pulse and vascular supply than reduction of the dislocation and medical attention is urgent. The media elbow has many different components and identifying the impaired structure can be tough. Write. Medial epicondylopathy or ‘golfer’s elbow’ is mostly a tendinous overload injury leading to tendinopathy. 2003;2(5):276–280. Information from references 4, 14, 15, 17, and 24 through 36. 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. Clinical Sports Medicine. Newman JS, The latter three clinical entities closely mimic symptoms of plicae and are important to rule out. 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). Anterior elbow pain. Match. The differential diagnosis for plica of the elbow includes radiocapitellar arthritis, osteochondral lesions, radial tunnel syndrome, lateral epicondylitis, loose bodies, instability, and snapping triceps (over the medial epicondyle) (4,5,14,15 and 16). Hatch JD. The MCL is also prone to concurrent injury with me- dial epicondylitis. Engineering, University of Denver. 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]. nadia_babbitt . The Sports Medicine Resource Manual. Assendelft WJ, 2016 Oct. 25 (10):1704-9. Location: medial elbow (3 bands: anterior, posterior, transverse) Pt presentation: hx of "popping" Causes: repetitive valgus overload (throwing), trauma causing valgus stress Kayiaros S, (http://radiopaedia.org/articles/elbow-dislocation). Calfee R. To start off with we will take an anatomy approach of the medial elbow, identifying structures and tests for each. Differential diagnosis of elbow pain can be tricky. If lateral and medial epicondylitis treatments are unsuccessful, ulnar neuropathy and radial tunnel syndrome should be considered. Elbow injuries. Upper extremity injuries account for 65% of injuries in children, of which fractures and dislocations of the elbow are the second most common. The incidence of epicondylitis is highest in the fourth and fifth decades of life. Hariri S, 2010;19(4):508–512. Campbell WW, Porter Adventist Hospital. Further complicating this is a high frequency of referred pain from the nerves exiting the neck. The point of maximal tenderness usually resides over the anterior radial head. J Shoulder Elbow Surg. Static and dynamic valgus stress tests should be performed to identify general and specific ligament damage, respectively. Torralba KD, Lancet. Thereby tendon degeneration appears instead of repair. Created by. Controversial entrapment neuropathies. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. 33. 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. Wartenberg sign (the inability to adduct the little finger), a clawhand deformity, and flexion of the proximal interphalangeal joint and the distal interphalangeal joint of the ring and small fingers may also be present (Table 23,7,8,11,13–17). Nirschl RP. 2000;61(3):692. 1995;77(7):1065–1069. 2010;29(1):33–60. Print. 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). Lateral epicondylitis. 2009;17(4):617–638, v. 6. Scott A, Lateral epicondyle and the origin of the common extensor tendon. The moving valgus stress test (Figure 4) has a 100% sensitivity and a 75% specificity for diagnosing UCL injuries (Table 23,7,8,11,13–17). Walz DM, Newman JS, Konin GP, Ross G. epicondylitis: analysis with more than a 5-year.. 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