1. Elbow Pain
Professor Hamdy Koryem;MD
2012

2. PAINFULE ELBOW :Anatomy

3. Muscles around elbow: Posterior

4. Muscles around elbow: Anterior

5. Elbow pain may be due to
Generalized causes
OR
Localized causes

6. EP As a part of generalized causes:
 Arthritis
 RA.
 Septic.
 Hemophilic
 OA.
 Crystal induced.(gout or pseudo gout)
 Enteropathic arthropathy.
 Traumatic.
 Neoplasm.
 Bones.
 Muscles.
 Synovial membrane.etc

7. OR
Localized causes for EP

8. MEDIAL EPICONDYLITIS
Synonyms
• Golfer’s elbow • Little leaguer’s elbow (children)
Medial epicondylitis:
Inflammation of the common flexor tendon.
Little leaguer’s elbow: (children)
Hypertrophy of the medial epicondyle with
micro tearing and fragmentation of the medial
epicondylar apophysis.

9. MEDIAL EPICONDYLITIS
Mechanism
A repetitive valgus stress commonly seen in
the throwing motion.
• The back and downward motion of a golf
swing just prior to the impact of the ball.
Clinical presentation:
Tenderness over the medial epicondyle.
• Pain may be reproduced with wrist flexion
and pronation.

10. Treatment:
• Conservative:
 Rest, ice, NSAIDs, immobilization.
• Surgical pinning:
 Reserved for an unstable elbow joint.

11. •LATERAL EPICONDYLITIS
Synonyms :Tennis elbow
 Mechanism :
Overuse and overload of the extensor and
supinator tendons seen in Sports or Work
that require repetitive extension elbow
movements.
Pathology:
Micro-tearing of the extensor carpi radialis brevis
muscle.

12. LATERAL EPICONDYLITIS
CLINICAL:
1. Tenderness just distal to the lateral epicondyle
at the common extensor origin.
2. Pain and weakness in hand grip strength.
3. Pain can be produced by Cozens test.

13. Cozens test
Passive extension of the elbow
with forced flexion of the wrist
may precipitate pain at the
lateral epicondyle

14. Cozens testThe examiner stabilizes
the elbow with a thumb
over the lateral
epicondyle.
Pain in the lateral
epicondyle is seen with
patient making a
fist, pronating the
forearm, radially
deviating and
extending the wrist
against resistance
by the examiner.

15. Cozens test
The test may be more sensitive
when done in full extension at the
elbow.

16. LATERAL EPICONDYLITIS
Treatment
Conservative:
 Relative rest, ice, NSAIDs for 10–14 days
 Physical therapy (modalities)
 Splinting, bands
 Local Corticosteroid injection
 Correct improper technique
Operative:
 ECRB debridement

17. OLECRANON BURSITIS
Synonyms:
Student’s elbow
Miner’s elbow
Draftsman’s elbow

18. OLECRANON BURSITIS
Mechanism
 Repetitive trauma,
 Inflammatory disorder (gout, pseudogout,
RA)
Pathology
 Inflammation of the bursa located between the
olecranon and skin
Clinical
 Swelling, pain, and a decreased range of motion in the
posterior aspect of the elbow
 A hot, erythematous elbow may indicate infection

19. Treatment
• Conservative: Rest, NSAIDs,
elbow padding.
• Aspiration of fluid and send it
for culture if indicated

20. DISLOCATION OF THE ELBOW
General
 The most common type of dislocation
in children and the second most
common type in adults following
shoulder dislocation.
 Sports activities account for almost
50% of these injuries

21. DISLOCATION OF THE
ELBOW
Mechanism:
Fall on the Outstretched hand.

22. DISLOCATION OF THE ELBOW
Clinical
 Dislocation can be anterior or posterior with
posterior being the most common, occurring
98% of the time .
 Associated injuries include fracture of the radial
head, injury to the brachial artery and median
nerve.

23. DISLOCATION OF THE ELBOW
Symptoms
 Inability to bend the elbow.
 Pain in the shoulder and wrist
On physical exam:
The most important part of the exam is the
neurovascular evaluation of the radial artery, and
median, ulnar and radial nerves
 Plain AP and lateral radiographs

24. DISTAL BICEPS TENDONITIS
Mechanism
Overloading of the biceps tendon commonly due to
repetitive elbow flexion and supination or resisted
elbow extension.
Pathology
Micro tearing of the biceps tendon distally.

25. DISTAL BICEPS TENDONITIS
Complication
 Biceps tendon avulsion
Clinical
 Insidious onset of pain in the ante-cubital
fossa usually after an eccentric overload
 Audible snap with an obvious deformity,
swelling, and ecchymosis if an avulsion is
suspected

26. DISTAL BICEPS TENDONITIS
Treatment
Conservative
 Relative rest, ice, NSAIDs.
 Physical therapy: Modalities.
 Correct improper technique.
Surgical:
 Reattachment.

27. TRICEPS TENDON AVULSION
Mechanism
Tendonitis:
Overuse syndrome secondary to repetitive triceps
extension
Avulsion:
A decelerating counterforce during active elbow
extension

28. TRICEPS TENDONITIS/AVULSION
Clinical
 Posterior elbow pain with tenderness at the
insertion of the triceps tendon
 Pain with resistive elbow extension or
sudden loss of extension with a palpable
defect in the triceps tendon (avulsion)
Imaging
 Plain films to rule out other causes, if
indicated

29. TRICEPS TENDONITIS/AVULSION
Treatment
 Conservative
 Surgical:
Reattachment.

30. VALGUS EXTENSION OVERLOAD
SYNDROME OF THE ELBOW
Synonyms
Boxer’s elbow

31. Boxer’s elbow
Mechanism
An overuse disorder caused by repetitive and
uncontrolled valgus forces demonstrated
during the throwing motion, especially in late
acceleration and deceleration.
Also may be seen in boxers.
Pathology
Osteophyte and loose body formation occurs
secondary to a repetitive friction of the
olecranon against the fossa.

32. Boxer’s elbow
Clinical
 Posterior elbow pain with lack of full extension
 Catching or locking during elbow extension
Imaging
 Plain films: AP/lateral may show a loose body or
osteophyte formation at the olecranon
Treatment
 Conservative
 Surgical: Removal of the loose body

33. ULNAR COLLATERAL LIGAMENT
SPRAIN
Mechanism
 A repetitive valgus stress occurring across
the elbow during the acceleration phase of
throwing.
Pathology
 Inflammation to the anterior band of the
ulnar collateral ligament.

34. ULNAR COLLATERAL LIGAMENT SPRAIN
Clinical
 Significant medial elbow pain occurring after the
throwing motion
 A pop or click may be heard precipitating the pain
 Medial pain or instability on valgus stress with the
elbow, flexed 20–30 if the UCL is torn.
Provocative Test
 Valgus stress test:
Tenderness over the medial aspect of the elbow which
may be increased with a valgus stress.

35. Imaging
 Plain films may reveal calcification and spurring along
the UCL
 Valgus stress radiographs demonstrating a 2 mm
joint space suggestive of UCL injury
Treatment
Conservative
1. Rest, ice,
2. NSAIDs
3. Rehabilitation program for strengthening and stretching
Surgical reconstruction if needed

36. RADIAL COLLATERAL LIGAMENT (RCL)
SPRAIN
Mechanism
 Elbow dislocation from a traumatic event
Clinical
 Recurrent locking or clicking of the elbow with
extension and supination
 Lateral pain or instability on varus stress with the elbow
flexed 20–30 if the RCL is torn
Provocative test
 Varus stress test
Tenderness over the lateral aspect of the elbow, which
may be increased with a varus stress.

37. Imaging
 Varus stress radiographs demonstrating a 2 mm joint
space suggestive of RCL injury
Treatment
Conservative:
 Rest, ice, NSAIDs
 Rehabilitation program for strengthening and stretching
 Establishing return to play criteria
Surgical reconstruction if needed.

38. PRONATOR SYNDROME
Clinical
1. Dull aching pain in the proximal forearm just distal to the
elbow
2. Numbness in the median nerve distribution of the hand
3. Symptoms exacerbated by pronation

39. PRONATOR SYNDROME
Mechanism
Median nerve compression at the elbow by the
following structures:
1. Ligament .
2. Supracondylar spur.
3. Fibrosis.
4. Pronator teres muscle.
5. Between the two heads of the flexor
digitorum superficialis (FDS).

40. PRONATOR SYNDROME
Imaging
Plain films: Rule out spur
EMG/NCS
Treatment
Conservative
 Modification of activities
 Avoid aggravating factors
 Stretching and strengthening program
Surgical:
Release of the median nerve at the location of the
compression

41. ENTRAPMENT OF THE ULNAR
NERVE
Synonyms
Cubital tunnel syndrome

42. Cubital tunnel syndrome
Clinical
 An aching pain with paraesthesias, which may radiate distally to
the fourth and fifth digits
 Positive Tinel’s sign at the elbow
 Weakness in the ulnar musculature of the hand, demonstrated
by a weak grip strength and atrophy and poor hand coordination.
Mechanism
 A hyper mobility of the ulnar nerve, excessive valgus force or
loose body/osteophyte formation, which aggravates the integrity
of the ulnar nerve at the elbow.
Pathology
 Hyperirritability of the ulnar nerve

43. Cubital tunnel syndrome
EMG/NCS
Above and below the elbow
Treatment
Conservative
Relative rest, NSAIDs, elbow protection
(splinting) and technique modification

44. OSTEOCHONDROSIS DISSECANS
OF THE ELBOW
Synonyms
Panner’s disease.
(involving epiphysial aseptic necrosis of the
capitellum)

45. OSTEOCHONDROSIS
DISSECANS OF THE ELBOW

46. FRACTURES
 FRACTURE OF THE HUMERAL SHAFT
 FRACTURE OF THE DISTAL
HUMERUS
 RADIAL HEAD FRACTURE
 FRACTURE OF THE OLECRANON