Disorders of the Elbow: 9 

Posterior
Eugene McNally

CHAPTER OUTLINE

INTRODUCTION SYNOVITIS AND JOINT EFFUSION

OLECRANON BURSITIS OTHER CAUSES OF POSTERIOR ELBOW PAIN
TRICEPS TENDINOPATHY AND RUPTURE

may be active on Doppler or inactive and representing

INTRODUCTION
The differential diagnosis of pain in the posterior elbow
includes olecranon bursitis, joint disease, triceps disease, as
well as less common causes, including olecranon stress frac-
tures and posterior impingement syndromes.
fibrous pannus.
Occasionally aspiration and cortisone injection are carried
out for simple or inflammatory bursitis, although the latter
is controversial and may be associated with secondary infec-
tion and subcutaneous fat atrophy.

OLECRANON BURSITIS

One of the commonest causes of localized pain in the pos-

terior elbow is olecranon bursitis. This is usually a clinical
diagnosis as bursa enlargement is easily palpable in the
typical location above the olecranon. Occasionally in
patients with large limbs, subtle enlargement may be diffi-
cult to detect clinically and imaging may be helpful in these
cases (Fig. 9.1).
The cause is usually due to repetitive friction as the char-
acteristic location of the olecranon bursa makes it particu-
larly susceptible to trauma, leading to haemorrhage within a
the bursa. Conditions associated with inflammatory synovitis
also commonly affect the bursa (Fig. 9.2). Septic bursitis,
particularly related to penetrating injuries, also occurs.
The ultrasound findings are the same as bursitis elsewhere. Bursa
The bursa may be well or poorly defined depending on the
degree of inflammatory changes in the surrounding fat.

Key Point P Ulna

I S
The contents of the olecranon bursa may be clear, A
anechoic, fluid in the case of a pure adventitial bursitis, or
complex if haemorrhage or infection is present. b

Figure 9.1  Sagittal section of posterior elbow. An ill-defined pre-

dominantly low-reflective mass underlies the proximal olecranon.
The wall may be thick or thin depending on the degree of Enlargement of the olecranon bursa is one of the commonest masses
associated synovitis and, if synovial thickening is present, it around the elbow.

91
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92 PART 2 — ELBOW

Triceps

Bursa
Bursa
P
I S Ulna
s A
ep
Tric
b

Figure 9.3  Sagittal image of posterior elbow. There is abnormal

reflectivity and increased Doppler in the triceps at its attachment,
consistent with triceps enthesopathy.

Ulna

P
I S Triceps rupture may also occur in association with olecra-
A
non bursitis, infection or following local steroid injections.
b
As the separate insertion of the medial head is usually
Figure 9.2  Sagittal posterior elbow and poorly defined fluid collection spared, tears are technically most commonly partial and
underlying the olecranon. Another example of olecranon bursitis. involve the combined lateral and central heads.
The ultrasound findings include tendon enlargement,
laxity due to proximal migration and hyperechoic
haemorrhage.

TRICEPS TENDINOPATHY AND RUPTURE

Triceps tendinopathy is distinctly less common than biceps
tendinopathy (Fig. 9.3). Loss of structure, areas of delami-
nation and increased Doppler are characteristic (Fig. 9.4).
Overuse syndromes are the most common. Ultrasound is
particularly useful in detecting triceps tendinopathy due to
impingement against orthopaedic hardware, where MRI is
often unsuccessful. Tendon rupture is also rare and usually
indicates an underlying condition predisposing to tendon
degeneration, similar to those that might underlie biceps
rupture. These include diabetes, systemic arthritis, renal
failure or drug usage, particularly anabolic steroid use.
Practice Tip
In the presence of triceps rupture, joint fluid can escape
through the tear and fill the posterior soft tissues. Manual
compression of the elbow joint or gentle flexion and extension
can exaggerate this fluid movement and augment the
appearance of the tear.
In many cases of acute posttraumatic triceps rupture, a small
fragment of the bony olecranon is attached, making the
distal end of the torn tendon easier to locate.

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 CHAPTER 9 — Disorders of the Elbow: Posterior 93

Trice
ps

Fat pad

Mass
Humerus

P
I S
A
b

Figure 9.4  Abnormal reflectivity and increased Doppler of the

triceps insertion. There is also a small effusion and some surrounding P
reflected soft tissue material. Infection of the triceps insertion was ML
confirmed. Ulna A

Figure 9.5  Large synovial-based mass of posterior elbow consis-

tent with synovial cyst.

Triceps subluxation has been described. This can occur

in conjunction with subluxation of the ulnar nerve. The
medial head or occasionally an accessory slip of the medial
head is involved. Practice Tip

A simple minimally invasive manoeuvre to detect occult loose

SYNOVITIS AND JOINT EFFUSION
Synovitis of the elbow joint may present with posterior
symptoms (Fig. 9.5) and loss of movement, particularly full
extension. Joint effusion (Fig. 9.6), synovial thickening and
chondral or osteochondral loose bodies (Fig. 9.7) can be
detected by examining the posterior joint space, particularly
under dynamic flexion and extension (Fig. 9.8). Adherent
intraarticular bodies can be difficult to discern against the
underlying bony structures.
bodies is to inject the posterior compartment with saline as
the joint is being examined.
Loose bodies may displace and become more obvious as
the joint is being distended. In patients with synovitis
undergoing aspiration and injection of corticosteroids
under ultrasound guidance, screening of the joint during
or immediately after the injection is a useful adjunct,
although the normal ultrasound appearances of particulate

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94 PART 2 — ELBOW

a
a

Triceps
Triceps

Fat pad
Fat pad
*
*
Ulna
*
Loose bodies

P Humerus
ML
A Humerus
P
S I
b A
Figure 9.6  Transverse section of posterior elbow. There is a large
b
elbow effusion (*). The posterior fat pad is displaced posteriorly. The
fluid is not completely transonic. Complex effusion may be due to Figure 9.7  Sagittal posterior elbow. A low-reflective effusion is
infection or haemorrhage. present and there is displacement of the posterior fat pad. There are
multiple reflective bodies within the effusion. Multiple loose bodies
could indicate primary or secondary osteochondromatosis.

steroid should be recognized and inadvertently injected gas
bubbles should not be mistaken for loose bodies. If there is
doubt, gas bubbles move quickly to the most superficial part
of the joint.
Key Point
Septic arthritis of the elbow is not uncommon in children,
secondary only to the hip in joints presenting with
spontaneous sepsis.
Under these circumstances, aspiration is important to
secure the diagnosis.
Limitation of joint movement, particularly pronation and
supination, is a relatively common clinical presentation and
it is sometimes difficult to determine an exact cause. Plain
films should be scrutinized for bony abnormality, particu-
larly malalignment of radiocapitellar and ulnotrochlear
joints. Soft tissue calcification may also be a cause of
restricted movement and this can be detected at an earlier
stage with ultrasound, compared with plain radiography or
MRI. Ultrasound is used to detect soft tissue calcification,
ossification, impinging soft tissue structure such as ganglia

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 CHAPTER 9 — Disorders of the Elbow: Posterior 95

or bursae, although the most common cause remains simple

joint effusion or synovitis.

OTHER CAUSES OF POSTERIOR

ELBOW PAIN

There are several bony causes of posterior elbow disease that

are difficult to detect using ultrasound but can be suspected
on the basis of location of symptoms, clinical history and
exclusion of other causes during the ultrasound examina-
tion. An olecranon stress fracture has been described in
throwers, particularly where there is a torsional element to
the throwing technique, and in weightlifters and gymnasts.
Posteromedial impingement syndrome occurs in associa-
tion with medial flexor or ligament disease. The olecranon
impinges against the posteromedial aspect of the humerus,
resulting in chondromalacia and ultimately full-thickness
cartilage defects with subchondral bone oedema.
a
Key Point

The damage to the articular cartilage that occurs in

posteromedial impingement is not usually visible with
ultrasound, but the reactive bony spurs and secondary
osteophytes that form suggest the diagnosis.
Brachialis

The relationship of these osteophytes to the medially placed

ulnar nerve leading to secondary ulnar nerve impingement
can also be evaluated.

Fat pad FURTHER READING

Cain LE, Dugas JR. History and examination of the thrower’s elbow.
Loose body Clin Sports Med 2004;23:553–66.
A Loftice J, Fleisig G, Zheng N, et al. Biomechanics of the elbow in sports.
ML Clin Sports Med 2004;23(4):519–30.
P Rineer CA, Ruch DS. Elbow tendinopathy and tendon ruptures: epi-
Humerus condylitis, biceps and triceps ruptures. J Hand Surg 2009;34.3:
566–76.
Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in
b
athletes. Clin Sports Med 2010;29(4):521–53.
Figure 9.8  Axial section of anterior elbow. A single reflective focus
is present in the anterior joint space consistent with a loose body.

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