Val Jones

Lead Physio
Sheffield Shoulder & Elbow
Unit

Anyone for tennis? Lateral

elbow pain: the causes
OBJECTIVES

• Explore differential
diagnoses of lateral
elbow pain
• Review elbow anatomy
• Review physical and
radiological tests to
confirm diagnosis
• Review effectiveness of
a range of treatment
options
The usual suspect -
tennis elbow
• 1-3% prevalence rates

• 12 weeks absenteeism for up to 30% of

sufferers

• 6-24 months duration

• Prone to recurrence

• Direct costs
 • Manual repetitive occupational upper limb activities – 30%
• Tennis players – 40%
• Smoking – current or previous
Predisposing • Elevated BMI
factors • Medication
• Statins – 10 months
• Fluroquinolones – 8/7 – 6/12
• Genetics
 • Localised epicondyle pain
Clinical signs • Onset insidious vs traumatic/direct blow
and • Aggravating activity e.g. gripping
symptoms • Tender to palpation
• Stretch can be painful
The special tests, or are
they?

• Cozens
• Maudsley’s (flipping
the bird)
• Chair test
• Grip strength test –
sens and spec 80%
What about natural resolution?
What if it doesn’t
improve

• Adequate loading
• No place for steroid
injection
• ? Surgery
• ? Correct diagnosis
 • Referred from other
structures - spinal
Differential
diagnosis • Joint mediated

• Neural
 • Fracture radial head /dislocation
• Elbow joint OA
• Intra-articular pathology – plica
• OCD
Joint mediated • Postero-lateral rotatory
instability
• Valgus Extension Overload
Radial head
fracture
 • Common injury in the adult
elbow

Incidence • 20% - 30% of all elbow trauma

radial head (McKee & Jupiter 1998)

fracture
• Fall onto outstretched hand
(FOOSH)
 Pain and swelling
lateral aspect of
the elbow

Signs and Occasional crepitus

Reduced range of
Symptoms motion

Tenderness over
radial head
Lack of elbow extension post injury – 50% chance of fracture
Full elbow extension – less than 5% risk of fracture
Caution with children and suspected olecranon fracture
Investigations
• AP and lateral view
• Fat pad sign on lateral view
• Diagnostic aspiration
• Mason 1 or 2
• Conservative Rx
• Mobilise immediately
• Mason 3 or 4 - surgery
Dislocation

• Males – assault or sport

• Female – fall from standing height
• Chronic instability in 35-40% cases
(Eygendaal et al JBJS 2000,
Mehloff et al JBJS 1988)
• Sports related – up to 50% (Kinter
et al JSES 2000)
• Three points of a triangle
 • PLRI most common form of
chronic elbow instability
• Lateral elbow pain
• Apprehension or feelings of
Elbow giving way when weight bearing
instability • Clicking
• Popping
Aetiology

• Lateral stability
• RCL
• LUCL
• Annular ligament
• Accessory LCL

• Radial head
• Coronoid
• Dynamic constraints
Postero-lateral rotatory instability

• Rotatory subluxation of the

radius from the humerus
• Both RCL and LUCL need to
be disrupted
• Fractures of bony
stabilisers may increase
instability
• Relationship of proximal
RadioUlnar joint
maintained
Aetiology

• Elbow dislocation

• Soft tissue injury without

dislocation –
hyperextension/supination injury
or varus stress injury - FOOSH

• Iatrogenic compromise –
surgery/injection

• Cubitus Varus
Table top relocation sign (Arvind & Hargreaves
JSES 2006)
Chair sign (Reagan & Lapner JSES 2006)
Active floor push up sign (Reagan & Lapner JSES
2006)

• 88-100% sensitivity
• For PLRI
Diagnosis

• Postero-lateral rotatory pivot shift test -

apprehension (O’Driscoll JBJS A 1991)

• a/a under General Anaesthetic – radial

displacement

• a/a under General Anaesthetic using

image intensifier
Positive
pivot shift
test
 • RA more common than OA
• Beware EMS, systemic symptoms
• Effusion – hold at 70-80 o to
maximise capsular volume
Osteoarthritis • Soft spot easiest to detect
effusion
• Post traumatic OA more common
than primary, especially in
undiagnosed cases of instability –
35-50%
SCREENED
‘EM - KIRWAN
PRIMARY OSTEOARTHRITIS
OF THE ELBOW

• Often related to microtrauma/sports

• Prevalence in Sheffield 2% (Lit. range 1.3% - 7%)
• Men 4x more than female
• Aetiology factors - debate between manual/ non manual work
• Radio-capitellar change usually more advanced than humero-
ulnar (Murato 1993)
PRIMARY OA OF THE ELBOW –
TREATMENT OPTIONS

Conservative-
• Physiotherapy
• Analgesia
• N.S.A.I.D.
• Intra articular steroid
injections

Surgical
• Open debridement – OK
procedure
• Arthroscopic surgery
• ?Total joint replacement
PRIMARY OSTEOARTHRITIS
OF THE ELBOW

• Total elbow arthroplasty

• Contraindicated in young patients

• Contraindicated in isolated elbow disease
• Contraindicated in heavy manual work
• Max load 2kg repetitively, 5kg rarely
• No jarring activities
• Increased loosening rate with BMI 30+
Elbow Plica
• Synovial fold
• Pain when thickened/inflamed
• Snapping/clicking over radial head
• Flexion/pronation
• 90 – 110o
• Arthroscopic removal
Valgus
Extension
Overload
• Boxers and throwers
• Medial ligament tension
• Lateral compression
• Postero-medial shear
• Posterior impingement
test
 • Rehab – medial stabilisers

• Flexor pronator mass

Valgus • Extension control - biceps

Extension
Overload • Emphasis on control including lower
limb

• Surgery
 • Bell – arthroscopic study of 52 patients
• Majority were anterior
• Pain +/- LOCKING
Loose bodies • Can co-exist with OA, VEO, OCD
• Best seen on CT scan
• Arthroscopic removal if possible
 • Cause unknown - ?genetic ?overload
• Small section cartilage separates from subchondral bone
Osteochondritis • Mitsunaga et al – capitellum
dissecans • Unilateral usually
• Lesions stable or unstable
• Unstable can separates into loose body
 • Typically in adolescent athletes, with repetitive overhead or
weight bearing activities
• 2nd decade
• Throwers

OCD • Gymnasts
• Weight lifters
• Swimmers
• Presumed OCD until proved not
• Early diagnosis key
OCD SYMPTOMS

• Subtle discomfort, swelling and

limitation of range
• Lateral or diffuse
• Popping
• Clicking
• Giving way
• Locking – loose bodies
• Grip and grind test
• Moving valgus stress test
 • Imaging – Xray only 50% sensitive
• CT/ MRI better
• Treatment stable lesions – conservative
• Avoid sport up to 6 months
OCD • Unstable – debridement and microfracture
• 50% return to elite sport
• Prognosis better with younger patients and smaller lesions
• Risk of OA unknown
Neural causes - Radial tunnel syndrome/PIN
Entrapment neuropathy of radial nerve and its branches (Roles & Maudsley)
PIN entrapment

• Lateral elbow pain

• Exacerbated by isometric
supination, in 90 flexion and
maximal pronation
• Weakness in thumb
abduction/extension
• Weakness of ED, EDM, ECU,
• EMG/NCS can be diagnostic
• ?surgical release
• No evidence
Radial tunnel Syndrome – no motor weakness
Radial Tunnel Syndrome

• Rule of nine test: proximal

forearm, divided into 9
pressure points.
• Tenderness over red circles =
radial nerve irritation
• Tenderness over yellow circles
= proximal median nerve
irritation
• Blue points = control
Take home messages

• Not all lateral elbow pain

is tennis elbow
• Remember differential
diagnosis
• In younger patients with
?OCD, or in cases of PLRI,
early recognition is vital
• May prevent degeneration
in future
• With traumatic lesions
check range and alignment
Elbow conditions PSP just launched

• James Lind Alliance Priority

Setting Partnership
• The James Lind Alliance (JLA) is
a non-profit making initiative
established in 2004. It brings
patients, carers and clinicians
together in Priority Setting
Partnerships(PSPs) to identify
and prioritise the Top 10
unanswered questions or
evidence uncertainties that they
agree are the most important.
 Thank you

valjones2305