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Posterior Impingement of the elbow

Posterior Impingement is due to overuse and repetitive forced extensions of the elbow. This may occur during sports, such as overhead racket sports, throwing, swimming and boxing. With repeated extension (straightening of the elbow), the olecranon tip is repeatedly jammed into the fossa at the back of the elbow, which results in inflammation of the joint lining (synovium), proceeding to injury to the cartilage and bone. Bone spurs may sometimes form on the tip of the olecranon leading to further injury and soft tissue impingement. 

The typical symptoms are pain and tenderness at the back of the elbow, especially when trying to throw, straighten the elbow, or during serving and overhead racket shots. This may proceed to locking and catching the elbow. There may be swelling of the elbow and an inability to serve at full speed. There may be some elbow stiffness and an inability to straighten the elbow towards the late stages fully.

This syndrome may lead to bone spurs (the extra bone that forms on the edge of an existing bone) and the inability to extend the elbow. The impinging can happen on the medial and the lateral sides of the back of the elbow. Posterior elbow impingement is a medical condition characterised by compression and injury of soft tissue structures such as cartilage at the elbow joint’s posterior aspect (back). Thus, we can categorise them into posteromedial and posterolateral Impingement. When these compressive forces become excessive, they can result in inflammation and damage of the soft tissue and/or cartilage at the back of the joint, causing Impingement of the elbow. Sometimes, bony spurs may also develop inside the joint, contributing to further worsening of the Impingement. 

Anatomy of the Elbow

The elbow is a complex hinge joint formed by articulating three bones: the humerus, radius, and ulna. The upper arm bone or humerus connects the shoulder to the elbow, including the upper portion of the hinge joint. The lower arm consists of two bones, the radius and the ulna. These connect the elbow to the wrist to form the lower portion of the hinge joint. A joint capsule surrounds the elbow joint, which contains synovial fluid for lubrication. The elbow is held in place with the support of various soft tissues such as cartilage, tendons, ligaments, muscles, nerves, blood vessels, and bursae.

What causes Posterior Impingement Syndrome?

Repetitive throwing motions force the bony tip of the elbow, called the olecranon, to repeatedly jam into the fossa (pit at the back of the elbow). This motion causes wear and tear and inflammation of the tissues at the back of the elbow joint. Baseball pitchers and tennis players are often at risk for this condition due to the repetitive extension of the elbow required in their sports. Other factors that could contribute to Impingement include congenital ligamentous laxity or ulnar collateral ligament insufficiency.

Elbow impingement is common in these sports:
• Baseball
• Softball
• Tennis and other overhead racket sports


What are the symptoms of posterior Impingement?

Some of the signs and symptoms of posterior elbow impingement include:
⦁ Pain at the back of elbow, especially when throwing or serving in racket sports.
⦁ Joint stiffness
⦁ Locking and catching of the elbow
⦁ Difficulty or inability to straighten the elbow
⦁ Abnormal popping or crackling sound
⦁ Joint effusion (abnormal fluid build-up)
⦁ Decreased range of motion
⦁ Swelling and bruising of the elbow
⦁ Inability or difficulty to extend or straighten the elbow

When to come and see us?

If you have pain in the back of your elbow associated with loss of the ability to straighten your elbow, consult with your doctor. A physical examination usually allows for a diagnosis of elbow impingement. Your doctor may also order an x-ray to help identify if bone spurs are present and an MRI to rule out other causes of your symptoms.

Causes of Posterior Impingement of the Elbow
Some of the conditions that can trigger posterior elbow impingement include:
⦁ Synovitis or inflammation of the synovium, a membrane that lines the joints
⦁ Bursitis or inflammation of the bursae, fluid-filled sacs that cushion the joints
⦁ Bone spurs or abnormal bony projections along the ends of bones
⦁ Inflammation of the joints
⦁ Rupture of cartilage or other soft tissues
⦁ Stiffening of the ligaments, muscles, and tendons

Treatment for Posterior Impingement of the Elbow
Treatment for posterior elbow impingement includes both surgical as well as non-surgical options. Your doctor will decide the best option based on the condition of your elbow.
Nonsurgical treatment options may include:
⦁ Ice: Application of ice packs on the elbow to decrease swelling and pain
⦁ Activity Modification: Avoiding activities that trigger symptoms and changing one’s habits
⦁ Physical Therapy: Regular exercise regimen to improve range of motion and strengthen elbow muscles
⦁ Anti-inflammatory Medication: Medications like naproxen and ibuprofen to relieve inflammation and pain.
⦁ Cortisone Injection: If physical therapy, medications, rest, and activity modification do not yield the desired results, a cortisone injection may be helpful. Cortisone is a very effective anti-inflammatory medicine for bursitis and a long-term pain reliever for tears and structural damage.

Surgical treatment options may include:
⦁ Arthroscopy: Your doctor will be able to repair damage to soft tissues of the elbow by using this technique. Arthroscopy is a minimally invasive surgical procedure that involves making small keyhole incisions to pass a fibre-optic tube with a tiny camera called an arthroscope and miniature instruments into the elbow joint. The camera displays pictures of the affected region on a monitor, and these images guide the doctor to carry out the necessary repair.
⦁ Open Surgery: A traditional open surgery approach would require a large surgical incision to be made to repair the affected region if the injury is large and complex. Open surgery has been utilised for joint debridement (removal of damaged cartilage or bone) or removal of posterior olecranon osteophytes (bone spurs).
⦁ Posterolateral Impingement

What is it?

Posterolateral impingement syndrome is pain caused by Impingement in the posterolateral recess of the elbow between the posterolateral facet of the olecranon and the posterolateral facet of the trochlea. It is most commonly seen in people whose sports or activities require forced elbow extension, such as boxers, canoeists, and fencers.

How is it diagnosed?

The diagnosis should be suspected in patients who present with pain in the posterolateral recess of the elbow. The pain is likely to be exacerbated by extension of the elbow, and in most cases, the patient’s activities require forced extension of the elbow. On examination, there is typically tenderness in the posterolateral recess, and boggy synovitis may be palpable. The pronation extension test will often be positive in these cases. MRI arthrogram examination is the preferred investigation. This may show a thickened posterolateral fold of the synovium called a plica. This should be thicker than 3mm to be considered pathological. Increased MRI signal suggestive of oedema within the bone may be found on both sides of the posterolateral recess. In more advanced cases, bony spurs or osteophytes may be seen.

How is it treated?

For mild symptoms, the first line of treatment is physiotherapy to strengthen the triceps and anti-inflammatory analgesia. A local steroid injection may be of benefit. If symptoms fail to settle, surgery may be indicated. Arthroscopic or open debridement may be performed with good outcomes.

⦁ Posteromedial Impingement

What is Posteromedial Impingement Syndrome?

Posteromedial impingement syndrome is a pain in the posterolateral recess of the elbow caused by the Impingement of the olecranon in the olecranon fossa on the back of the elbow. This condition is more common in sports that produce a significant valgus (outward) force on the elbow, such as baseball or javelin. Increasing laxity of the medial collateral ligament results in increased contact pressure between the olecranon’s posteromedial facet and the trochlea’s posteromedial facet.

How is it diagnosed?

The diagnosis should be suspected in people whose sports or activities involve a lot of valgus force to the elbow. A history of posteromedial pain that is made worse by forced extension of the elbow would be typical. The patient may be found to have tenderness in the posteromedial recess and a positive elbow valgus supination extension test. Plain X-ray may demonstrate a spur or osteophyte on the medial tip of the olecranon. MRI scan is the investigation of choice and may demonstrate increased signal in the posteromedial facet. Loose bodies may be seen. Synovitis in the posteromedial recess is often seen. Valgus stability of the elbow must be assessed.

What is the preferred treatment?

For mild symptoms, the first line of treatment is physiotherapy to strengthen the triceps and anti-inflammatory analgesia. A local steroid injection may be of benefit. If symptoms fail to settle, surgery may be indicated. Arthroscopic or open debridement may help, but a reconstruction of the medial collateral ligament should be performed where there is clear valgus instability.

Non-operative treatment

Generally, conservative treatment is recommended for posterior impingement syndrome, including:
• Rest: It is important to avoid activities that place stress on the elbow to give the inflamed tissues time to heal. Athletes should discontinue activities that fully extend their elbow.
• Ice: Applying ice or a cold compress to your elbow three or four times a day for 20 minutes can help reduce swelling and alleviate symptoms.
• Medication: Over-the-counter (OTC) medications, like aspirin or another nonsteroidal anti-inflammatory medication (NSAID) like ibuprofen or naproxen, can help alleviate symptoms.
• Physical Therapy: Stretching and other exercises can help ensure an optimal recovery. Your doctor can recommend specific exercises for your condition.

Surgical Treatment

Surgical treatment for posterior impingement syndrome may occasionally be needed in throwing athletes. If conservative treatment options are ineffective, particularly if you have bone spurs that require removal, your doctor may recommend arthroscopic surgery. This type of surgery is a minimally invasive procedure that allows surgeons to remove bone fragments causing damage to your elbow.

For mild cases, athletes usually can return to sports within six weeks with conservative treatment. If you undergo surgery because conservative treatment options were ineffective, a longer recovery time is required. After surgery, it usually takes three to six months before you can return to play.

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