What is the elbow?
The elbow is the joint that joins the arm to the forearm, connecting the humerus with the proximal ends of the ulna and radius. It is formed of bone, cartilage, ligaments, and fluid. The muscles and tendons help stabilise the elbow when we move it. Trauma to any of these structures will cause problems in the elbow.
The function of the elbow
The elbow enables a series of movements for straightening and bending the arm. These include:
⦁ Extension, using the triceps brachii muscles.
⦁ Flexion, using the biceps brachii, brachialis and brachioradialis.
⦁ Supination, using the short supinator muscle and biceps brachii.
⦁ Pronation, using the round and the square pronator muscles.
Pathologies of the elbow
Many factors can cause pain in the elbow, whether injured or not. The most common of these are:
Osteoarthritis. This is a degenerative process that rarely affects the elbow. When it does occur, it is mainly caused by intense, continuous exercise or repetitive trauma.
Arthritis. An inflammatory process that affects a joint, causing pain and an increase in temperature. Its causes are varied. In the elbow, the most common causes are rheumatoid arthritis, psoriatic arthritis, infectious arthritis, gout and chondrocalcinosis.
⦁ Epicondylitis, or tennis elbow, causes pain on the outside of the elbow.
⦁ Medial epicondylitis, or golfer’s elbow, causes pain on the inside of the elbow.
⦁ Olecranon bursitis, or student’s elbow. This is a rheumatic disease that affects the soft parts (not the bone) of the joint.
⦁ Elbow luxation. Though this is less common than shoulder luxation because the surfaces of the bones fit together perfectly. The main cause is a fall onto an outstretched hand and is usually associated with a fracture.
⦁ Painful pronation (babysitter’s elbow or radial head subluxation). The head of the radius moves from its normal position without completely dislocating and is therefore referred to as a subluxation. It is common in children under five years of age due to sudden traction on the forearm (e.g. when taking a child’s hand and pulling them to help them up steps, during physical contact sports such as judo, etc.).
⦁ Fractures: Most fractures are of the lower or distal extremity of the humerus, the head of the radius and the olecranon of the ulna.
⦁ Monteggia fracture. This is a complex and rare injury where luxation of the radial head at elbow level is associated with a fracture in the proximal third of the ulna.
⦁ The terrible triad of the elbow. This is a severe injury that is usually caused by a fall onto an outstretched hand. This type of injury is usually accompanied by luxation, with a fracture of the radial dome and the coronoid process of the ulna. Treatment involves surgery.
Treatments for elbow pathologies
Treatment will depend on the cause of the problem. To diagnose any elbow injury, various tests need to be performed: direct arthrography, radiography and nuclear magnetic resonance imaging, among others. Once the diagnosis has been made, the specialist will decide how best to treat the elbow pathology in each case.
Normally, the main measure taken to treat the injured structure is to reduce inflammation, restrict mobility and alleviate pain, weakness and functional disability. This is why it is important, first of all, to administer NSAIDs (anti-inflammatory drugs), to put the arm in a sling, or similar, to limit mobility and to have physiotherapy. Physiotherapy will generally involve cryotherapy (application of cold), electrostimulation (TENS), a passive stretching programme for the pronation and supination muscles (those involved in twisting the forearm), wrist extensions and flexions, together with postural recommendations. Once the pain has subsided, exercises can be carried out to strengthen the muscles of the affected arm.
If the injury is more severe, the specialist may recommend other procedures. These may include elbow arthroplasty, surgery for tennis elbow or if surgery is not recommended, injections into the joints and soft tissues.
Elbow pain
What can cause elbow pain?
The elbow is a complex joint formed by bones, cartilage, ligaments and fluids. The muscles and tendons help to move the joint and if any of these parts suffers any damage, the pains and problems appear.
Elbow pain can occur as a result of:
Muscle strain or sprain – the muscles or ligaments in your elbow can be strained from overexertion. However, with rest and proper support, they should heal over time sand your symptoms should improve.
Bone fracture – this usually occurs as a result of playing sport or a fall, and is a sudden injury. You may still be able to move the elbow but it will be painful to do so. It’s important to seek medical help if you suspect you’ve had a fracture, as leaving the elbow untreated can lead to the bones not healing properly
Dislocation – this occurs when one of the bones in the elbow moves out of place, causing significant pain. You should get medical help for a dislocated elbow immediately.
Tendinitis – certain movement, such as arm movements involved in playing golf (golfer’s elbow or medial epicondylitis) or tennis (tennis elbow or lateral epicondylitis), can result in the tendons in your elbow becoming inflamed from overuse. These injuries are not limited to sports players – they can happen to anyone who frequently carries out a similar arm movement, such as at work.
Bursitis – another injury from repetitive arm movement, where sacs containing fluid become swollen and cause pain in the elbow.
Arthritis – both ⦁ osteoarthritis (wear and tear of the cartilage in your elbow) and rheumatoid arthritis (a condition causing inflammation in your joints) can result in joint pain in the elbow. In this situation a rheumatologist will recommend the best treatment.
Trapped nerve – everyone has a number of nerves travelling down the arm, through the elbow and the hand. Sometimes a nerve can get trapped in the elbow, causing constant pain and some tingling. This can also cause similar symptoms in the hand and fingers.
Who should I see about elbow pain?
You should see your GP in the first instance, who is likely to refer you to a specialist rheumatologist for pain management, or possibly an orthopaedic surgeon if surgery is required. As part of your diagnosis, imaging tests (such as an X-ray or MRI) may be required.
The relevant specialist will coordinate your care, which may involve:
⦁ medication
⦁ physical therapies, including rest, ice, ultrasound and massage
⦁ accupuncture laser therapy (this aims to stimulate the release of serotonin and endorphins, resulting in pain relief and improved mood, sometimes negating the need for taking NSAIDs)
⦁ splints and other support for the elbow
If no improvement is seen in the patient’s elbow pain, then the following treatments may be required:
⦁ anti-inflammatory injections
⦁ in severe cases,
⦁ elbow surgery
Elbow Examination
Look for evidence of swelling, previous scars, nodules. An effusion of the elbow is most easily seen in the posterolateral recess behind the radial head. Nodules on the extensor surface of the olecranon may indicate rheumatoid arthritis or gout. Swelling over the point of the elbow may indicate an olecranon bursitis. After injury look at the medial aspect of the elbow, bruising around the medial epicondyle may indicate an injury to the medial ligament or common flexor origin. Bruising more distally in the medial forearm is often seen after a distal biceps rupture. Look to see if the ulnar nerve subluxates during elbow flexion.
Feel the elbow with one finger starting on the lateral side of the elbow with the elbow bent at 90degrees, move your finger down the lateral ridge to the most prominent part of the lateral epicondyle. Move your finger 0.5cm distally to feel for tenderness at the origin of ECRB that may indicate tennis elbow. Move your finger another 0.5cm distally to feel for tenderness along the radiocapitellar joint line that may indicate osteoarthritis or a plica. Then move your finger posteriorly to and around the lateral side of the olecranon to examine for tenderness in the posterolateral recess or posteromedial recess indicative of posterior impingement.
Then feel the ulnar nerve behind the medial epicondyle for instability or tenderness. Gently tap over the nerve, if this produces tingling in to the little finger this is suggestive of cubital tunnel syndrome. Then feel over the medial epicondyle for tenderness associated with golfer’s elbow. 1cm anterior and lateral to the medial epicondyle lies the medial ligament that can be palpated for tenderness.
It is more difficult to obtain any specific diagnosis from feeling over the front of the elbow but tenderness here may be associated with a bicipital bursitis, distal biceps tendinopathy, or joint pathology.
Ask the patient to move the elbow with the arm held out the side. Start with the arms as straight as possible with the palms facing upwards. By convention of the arm and forearm are in a straight line this is zero degrees. Some patients, mainly females, will be able to extend their elbows beyond zero degrees, up to 15 degrees. This is reported as a negative value by convention. Then ask the patient to bend the elbows as far as possible and measure the angle that the arm and forearm make. There is a large range of ‘normal’ elbow flexion, often determined by the size of the biceps, but most patients can flex to 140 degrees. You are looking for asymmetry. The angles should be measured with a goniometer to ensure accuracy. A sudden loss of range in both directions is indicative of fluid in the elbow. Sudden loss of extension only may be caused by a loose body. Gradual loss of range of movement occurs in arthritis.
Next ask the patient to fully straighten the elbows by their sides with the palms facing forwards. Measure the angle between the arm and forearm, known as the carrying angle. This is normally measures around 11 degrees. Be aware that in the presence of a flexion contracture of the elbow the carrying angle cannot be measured reliably. An increased or decreases carrying angle may indicate a previous elbow injury such as a supracondylar fracture of the humerus. If the patient has a marked valgus deformity this may predispose to the development of an ulnar nerve lesion.
As the patient to hold the elbow flexed at 90 degrees and with the elbows tucked in by their sides to rotate the forearm from palm up to palm down. Loss of range of movement compared to the opposite side indicates a problem within the forearm from joint between the radial head and lesser sigmoid notch of the ulna to the distal radio-ulnar joint.
Special tests
Tennis elbow
Mill’s sign – performed by passively flexing the wrist with the elbow bent. The examiner slowly brings the elbow into extension which will elicit pain in a positive test.
Maudsley’s sign – ask the patient to keep the elbow, wrist and fingers straight with the palm facing down while pressure is applied by the examiner over the distal end of the middle finger metacarpal. This will produce pain in a positive test.
Golfer’s elbow
Pronator Teres Provocation – the patient holds the elbow bent by their side with the palm facing down. The examiner tries to turn the palm to face upwards while the patient resists. This will produce pain in a positive test.
Distal Biceps Tendinopathy
O’Driscoll’s Hook Test – With the shoulder abducted to 90 degrees the patient is asked to look at their palm in front of their face. The examiner then brings a finger from lateral to medial to ‘hook’ the distal biceps tendon. The tendon can then be stretched in isolation. This will produce pain in a positive test. If the distal biceps cannot be ‘hooked’ then the patient may have a distal biceps tendon rupture.
Triceps Tendinopathy
Triceps provocation – Ask the seated patient to bring their arm above their head with the elbow bent at 90degrees. While the examiner tries to push the arm down the patient resists. This will produce pain in a positive test. Isolated tenderness at the triceps insertion may indicate an enthesophyte fracture.
Biceps Tendon rupture
O’Driscolls Hook Test – see above
Biceps squeeze test – ask the seated patient to sit with the forearm relaxed across their lap. The examiner squeezes the biceps and examines for passive forearm supination. If there is no movement the patient may have a biceps tendon rupture.
Pop-eye sign – proximal retraction of the biceps muscle belly
Passive rotation – with passive rotation of the forearm with the elbow flexed to 90degrees the biceps muscle belly should be seen to move.
Resisted elbow flexion – strength may well be preserved even with a complete rupture, but the patient will fatigue more rapidly.
Resisted supination – the patient is asked to hold the hand palm upwards with the elbow bent by their side at 90degrees while the examiner tries to turn to palm down. This will be weaker with a biceps rupture.
Instability
Lateral ligament incompetence
Varus instability – with the humerus in full internal rotation and the elbow flexed to 30degrees a varus force is applied to the elbow while inspecting the lateral joint line.
Bench press test – the patient is asked to attempt a press-up on the edge of a desk with the arm in pronation, if they can do this but are then unable to perform the same test with the forearm in supination this is indicative of postero-lateral rotatory instability. The examiner can then place a thumb on the back of the radial head maintaining the reduced position of the radial head and the test is repeated.
Push up test – as above but performed with the patient seated. The patient is asked to push themselves up with their hands on the arm rests of the chair. Firstly with forearm pronation then supination.
Pivot shift test – this test should be reserved for the anaesthetised patient. The forearm is placed in supination and flexion and a valgus and axial load is applied as the elbow is straightened. The radial head will be seen to dislocate.
Medial ligament injury
Valgus instability – with the humerus in full external rotation and the elbow flexed to 30degrees a valgus force is applied to the elbow while palpating the medial joint line.
Passive Milking manoeuvre – with the shoulder abducted to 90 degrees and elbow flexed to 90degrees the examiner grasps the patients thumb and applies a valgus force.
Moving valgus stress test – A valgus force is applied as the elbow is moved from full flexion to full extension passively by the examiner. Pain at around 90 to 70degrees indicates pathology of the medial ligament.
Ulnar nerve examination
Froment’s sign – ask the patient to grip a piece of paper between both thumbs and index finger, in the “key-pinch” position. The examiner then tries to pull the piece of paper away. In a positive test the patient will have to flex the interphalangeal joint of the thumb, recruiting the median nerve innervated flexor pollicis longus, because of the weak ulnar nerve innervated muscles.
Apley’s sign – The patient is asked to spread their fingers wide and to push their little fingers hard against each other. In a positive test the anduction of the little finger of the hand with an ulnar nerve lesion will be overcome by the uninjured hand. Note that the dominant hand may be stronger than the non-dominant hand.
Reverse Apley’s sign – as above but using the index finger
Wartenberg’s sign – the little finger is held in abduction due to the eccentric pull of extensor digiti minimi.
Tinel’s sign – gentle percussion over the ulnar nerve at the elbow sends a shooting pain or tingling into the ulnar innervated fingers in the hand.
Flexion test – the patient extends the wrist and flexes the elbow. A positive test reproduces the symptoms in the hand.
Pressure test – direct pressure is applied over the ulnar nerve in the cubital tunnel to reproduce symptoms.
Flexion-pressure test – a combination of the two tests above. It is said that this increases the sensitivity of the test.
Other special tests
Spinner’s sign for snapping triceps – the patient is asked to push against the examiners hand as the examiner passively flexes the elbow while looking at the medial side of the elbow. This will reproduce the patients symptoms of painful snapping of the tendon in the medial border of triceps. At the same time first the nerve and then the tendon will be seen to subluxate over the medial epicondyle.
The Elbow Joint
