Clinical Pattern Recognition - Elbow Pain

From anatomy to discovering the patient!

• Cubital tunnel syndrome is the second most common neuropathy involving the upper extremity with an estimated incidence of 24.7 cases per 100,000 person-years.

• Approximately 40% of people will experience lateral epicondylalgia (LE) at some point in their life

  • Most common in men and women aged between 35 and 54 years old

•  Up to 50% of all tennis players also experience some type of elbow pain, with 75 to 80% of these elbow complaints attributable to LE

• Approximately 12% of elbow injuries result in contractures requiring surgical release

• See more prevalence information in the Clinical Pattern Recognition: Orthopaedics app here

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Clinical Pattern Recognition

Click on the pain pattern to learn about the patients and develop your clinical patterns!

1. Cubital Tunnel Syndrome - Elbow and forearm radiating pain (1-minute video)

2. Lateral Epicondylalgia - Lateral elbow pain with muscle power deficits (1-minute video)

3. Medial Epicondylalgia – Medial elbow pain with muscle power deficits (1-minute video)

4. Post Traumatic Elbow Stiffness - Elbow pain with mobility deficits (1-minute video)

5. Ulnar Collateral Ligament Sprain - Elbow stability with movement coordination impairments (1-minute video)

6. Pronator Teres Syndrome - Elbow and forearm radiating pain (1-minute video)

7. Supinator Syndrome - Elbow and forearm radiating pain (1-minute video)

Sources: 

Bartels RH, Verbeek ALM. Risk factors for ulnar nerve compression at the elbow: a case control study. Acta Neurochir2007;149:669–74

Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med. 1979;7:234–238.

Myden C, Hildebrand K. Elbow joint contracture after traumatic injury. J Shoulder Elbow Surg2011;20:39-44.

Nirschl R, Tennis. Elbow. Orthop Clin North Am. 1973;4:787–800 

Cubital Tunnel Syndrome

Elbow Pain and Forearm Radiating Pain

• Does your friend or family member have pain or tingling in their ring and pinky finger when they bend their elbow? Do those fingers often fall asleep on them? If either of those statements are true there is a chance that they have Cubital Tunnel Syndrome. This is caused from an irritation of the ulnar nerve as it is being entrapped in the cubital tunnel.

• If you do not know the common clinical findings no problem! Click here

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Anatomy

Image via Complete Anatomy 2018 by 3D4 Medical

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Special Test

A common test to check if your patient has Cubital Tunnel Syndrome is the elbow flexion test. This test puts the ulnar nerve on tension and has the ability to reproduce symptoms. In addition to this test it is also important that you make sure to check all of the other entrapment sites for the ulnar nerve.  (Click image to watch 1-2 minute video)

Treatment

Once the entrapment site is found manual therapy is a good choice to work on mobility in the area. Make sure to watch the video above to figure out how to help your patient! (Click image to watch 1-2 minute video)

Therapeutic Exercise

Once you have worked on the entrapment site it is important to get the nerves moving again. This can be done through nerve sliders. Once the patient has mastered sliders, is not irritable, and only has pain at or near end range make sure to progress them to tensioners! (Click image to watch 1-2 minute video)

Lateral Epicondylalgia

Elbow Pain with Muscle Power Deficits

• Does your friend or family member have pain on the outside of their elbow? Does the pain get worse when they play tennis or golf?  Do they have pain with gripping? Lateral epicondylalgia is an overuse injury and is caused by repetitive motions.

• If you do not know the common clinical findings no problem! Click here

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Anatomy

Image via Complete Anatomy 2018 by 3D4 Medical

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Special Test

A common test to check if your patient has Lateral Epicondylalgia is to stretch and contract the extensor muscle group on the dorsal side of the forearm. This test puts the common extensor tendon on stretch and has the ability to reproduce symptoms. (Click image to watch 1-2 minute video)

Treatment

Soft tissue mobilization of the wrist extensors has the ability to increase flexibility and decrease pain in the extensor muscle group. (Click image to watch 1-2 minute video)

Therapeutic Exercise

Eccentric exercises are a popular treatment used to strengthen the common extensor tendon. Your patients pain should not be over a 5 on the VAS scale while performing this exercise. As always, make sure to look for other associated impairments! (Click image to watch 1-2 minute video)

Ulnar Collateral Ligament Sprain

Elbow Stability and Movement Coordination Impairments

• Ulnar collateral ligament (UCL) pathology often occurs in individuals who perform repeated/forceful overhead movements. If your patient is an overhead athlete complaining of medial elbow pain, check the UCL! 

• If you do not know the common clinical findings no problem! Click here

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Anatomy

Image via Complete Anatomy 2018 by 3D4 Medical

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Key Finding

Palpation of the UCL can help to assess if the UCL is indeed a pathological source tissue. If radicular symptoms are present upon palpation, especially in in the 4th and 5th digits, there could be ulnar nerve involvement as well! (Click image to watch 1-2 minute video)

Movement Fault

In overhead athletes, decreased shoulder external rotation range of motion can result in increased valgus stress directed at the UCL! (Click image to watch 1-2 minute video)

Clinical Pearl: In overhead athletes it is important to assess the entire kinetic chain in order to determine if faulty force transmission is present. For example, research shows that decreased hip internal rotation range of motion can also result in excessive force transmission through the shoulder and the elbow!

Special Test

The moving valgus stress test is excellent for ruling out UCL pathology with a sensitivity of 100! Take a look and see how its done! (Click image to watch 1-2 minute video)

Treatment/Therapeutic Exercise

Research suggests that in overhead athletes, the posterior aspect of the glenohumeral joint capsule can often contracture due to high rates of repetitive movement. This change in tissue can result in limited shoulder range of motion and subpar shoulder arthorokinematics potentially leading to increased strain on structures like the UCL! The patient can also be taught how to perform this exercise at home! (Click image to watch 1-2 minute video)

*Acutely, addressing pain and inflammation around the UCL via techniques such as soft tissue mobilization and activity reduction may prove to be beneficial.

Post Traumatic Elbow Stiffness

Elbow Pain with Mobility Deficits

• Often, after traumatic injury (e.g. fracture) or immobilization, the joints of the elbow along with the joint capsule can become stiff resulting in pain and decreased range of motion! 

• If you do not know the common clinical findings no problem! Click here

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Anatomy

Image via Complete Anatomy 2018 by 3D4 Medical

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Key Finding

If a patient presents to clinic with elbow pain and decreased range of motion, check for history of trauma/immobilization! (Click image to watch 1-2 minute video)

Mobility Assessment

Post immobilization, elbow extension tends to be the most limited. Although the ulnohumeral joint is responsible for the majority of elbow extension, it is imperative to assess the radiohumeral and proximal radioulnar joint as well! (Click image to watch 1-2 minute video)

Treatment

Ulnohumeral distraction mobilization can help improve both flexion and extension range of motion! (Click image to watch 1-2 minute video)

Therapeutic Exercise

Once you have improved joint mobility it is important to follow up with movement in the new found range of motion! (Click image to watch 1-2 minute video)