Robert P. Nirschl, MD, MS; Barry S. Kraushaar, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 5 - MAY 96
In Brief: Acute elbow injuries are often collision related; chronic elbow injuries typically stem from overuse and valgus stress. What seems a purely traumatic injury, though, may actually represent an acute-on-chronic process, so a detailed history and physical exam are essential in pinpointing the injury process and making a specific diagnosis. Important details in the history are the quality, intensity, and onset of pain and the location of symptoms and their effect on function. The exam should include visual inspection, palpation, range of motion, and key tests such as applying valgus stress. Treatment can often be conservative, with emphasis on strength-building rehabilitation.
Elbow injuries can be divided into three categories: single-event macrotrauma (acute injuries), single-event trauma to tissue made vulnerable by overuse (acute on chronic), and multiple-repetition overuse (chronic). Chronic injuries, such as tennis elbow and chondromalacia, are the most common type of elbow injury seen in the outpatient office setting.
To the sideline observer, however, single-event trauma is the most visible cause of injury. Because the elbow is quite stable, direct trauma to the elbow is usually necessary to cause fracture or dislocation. Perceived single-event disruption of soft tissue, though, may represent an acute-on-chronic injury. For example, rupture of the ulnar collateral ligament (UCL) may occur with throwing but commonly involves a ligament weakened by overuse.
Anatomy and Biomechanics
The elbow is made of three bones with three articulations (figure 1: not shown). The trochlea of the humerus, which articulates with the olecranon of the ulna, defines the plane of flexion and extension. The depth of the humeroulnar joint and the congruence of the medial joint surface limit function to that of a true hinge joint--stable to all motions except varus and valgus stresses.
The radiocapitellar joint provides some stability against valgus stresses (figure 2: not shown) by acting as a pivot for axial load. However, without a strong UCL on the medial side of the joint, the forearm would dislocate laterally during valgus stress. The UCL is the primary stabilizing ligament of the elbow and is better developed than the lateral ligaments. This stability aids in activities such as lifting large objects during which the elbow is more commonly subjected to valgus than varus stresses.
The wrist extensor tendons, originating on the lateral intermuscular septum of the arm and the lateral epicondyle, help stabilize the elbow against varus stress. In the process of stabilization, this musculotendinous complex is subject to eccentric loading and potential overuse. The elbow facilitates forearm pronation and supination. The radial head and neck are contained by a capsuloligamentous complex that includes the annular ligament. Although rarely exposed to acute traumatic pronation and supination, the elbow commonly sees overuse in these planes of motion, resulting in soft-tissue injury such as tendinosis (old term: epicondylitis). Radial nerve entrapment also can occur but is rare.
Mechanism of Injury
Acute injuries are most often the result of collision of an outstretched hand with the ground. If the elbow is somewhat flexed, posterolateral dislocation may occur. If the elbow is fully extended, force transmitted up the radius may cause a fracture of the radial head or capitellum. Varus or valgus shear forces at the time of impact may cause a fracture of condylar and supracondylar structures, but this injury is more common in children. Direct impact to the elbow, another mechanism of injury, may result in fracture, most likely of the olecranon. Entrapment of the elbow between players (as in football tackling) can also result in fracture or, more likely, dislocation.
The most common causes of overuse include eccentric overuse of the forearm extensors (eg, a tennis backhand that results in lateral tennis elbow), and valgus stress in throwing (eg, UCL attrition and rupture, common flexor tendon overuse, or olecranon compartment chondromalacia and loose bodies secondary to valgus instability) (figure 2: not shown).
Components of the patient history that help differentiate the three categories of injury are found in the patient's description of the quality, intensity, and onset of pain. The exact location of symptoms and their effect on function are important. Neurovascular symptoms in the history and episodes of swelling indicate extra- and intra-articular pathology, respectively.
Intense, sudden pain after a known stress (such as a collision) suggests an acute process. If the injured region has had any associated symptoms in the past, one must consider an underlying chronic component. If pain has recurred with a similar intensity and location, overuse is suspected.
Acute injuries may disrupt many tissues, so the pain may be diffuse. An isolated fracture of the radial head may be more localized, mimicking lateral epicondyle pain, but this fracture is caused by an axial load on an extended elbow or by valgus stress. The location of pain from chronic injuries tends to reflect the anatomic course of the damaged tissues. Acute-on-chronic injuries may cause both localized and generalized pain.
In the acute setting, functional loss may stem from gross structural disruption or solely from pain. To differentiate mechanical blockade from protective splinting, a careful physical examination is required (see below). With overuse injuries, loss of function is usually less dramatic, but long-standing limitation of motion may result in fibrous ankylosis of the elbow or even osteophyte buildup in the joint, so a patient may lose motion.
Reported neurologic and vascular symptoms such as paresthesias, coolness, numbness, or clumsiness are vital because the brachial artery and the ulnar, median, and radial nerves traverse the elbow. Peripheral nerve dysfunction may reflect neuropathy, radiculopathy, or local nerve compression. If trauma is associated with neurologic complaints, then nerve entrapment or neurapraxia is considered. Cubital tunnel syndrome (ulnar nerve) most often produces neurologic complaints, but pronator syndrome (median nerve) occasionally is noted. Posterior interosseous nerve syndrome generally does not cause sensory disturbance because it affects a primarily motor nerve, with resultant weakness rather than pain. Vascular symptoms, which are usually limited to acute injuries such as fractures or dislocations, should be aggressively investigated.
When a patient reports swelling and sensations of clicking or grinding, intra-articular pathology of the synovium, cartilage, or bone is suspected. Acute onset of these symptoms after trauma in a previously normal elbow suggests that a hemarthrosis caused by fracture or dislocation has occurred. Recurrence and remission of these symptoms with no known origin indicate overuse. Lateral tendinitis may cause swelling over the origin of the wrist extensor tendons. Whenever painful swelling occurs near a joint, inflammatory conditions and septic arthritis are part of the differential diagnosis.
Injury Assessment and Differential
Visual inspection for anatomic distortion is the first step in assessment. Alteration of skeletal alignment accompanied by pain and tenderness indicates an acute fracture or dislocation. Distortion without acute signs may indicate prior skeletal injury with malunion or malformation. The soft tissues may be distorted from localized hematoma, edema, effusion, or muscle or tendon rupture.
The next assessment steps include palpation for tenderness, crepitus, and swelling, followed by evaluation of motion. Pain-related restriction of motion is much different from restriction because of tendon scar, adhesive capsulitis, or bony blockade (eg, loose bodies, bony exostosis, fracture, or dislocation). Painful immobility tends to have a soft endpoint and associated guarding, whereas purely mechanical limitation has a firm endpoint, less guarding, and possibly some associated crepitus. It is important to assess not only flexion and extension but also pronation and supination.
Acute injuries. When a patient has had a collision, the major diagnostic issue is to rule out fracture and dislocation. The most common sports-related fractures about the elbow involve the radial head, olecranon, and capitellum, but other fractures can, of course, occur. In adolescents, throwing or a collision can produce avulsion of the medial epicondylar apophysis (Little League elbow). A common companion to Little League elbow is osteochondritis dissecans of the capitellum.
Dislocation is most commonly posterolateral and may be accompanied by a fracture of the coronoid process at the insertion of the brachialis muscle. This type of dislocation always involves major disruption of the UCL and often ruptures the radial collateral ligament as well. With collision injuries, neurovascular injury is always a possibility, especially of the brachial artery, so neurovascular assessment is advised.
Collision and throwing injuries warrant a check for stability. Valgus instability is checked by applying a valgus stress with the elbow flexed 20° to release the olecranon (figure 3). Laxity greater than in the uninjured elbow indicates UCL rupture. Medial joint opening of greater than 1 cm with a soft endpoint suggests a complete UCL rupture. Chondromalacia in the olecranon fossa is common in this circumstance. Tenderness distal to and just under the medial epicondyle confirms UCL injury. For posterolateral instability, forced elbow extension, axial loading, and forearm supination (elbow pivot shift test) will cause posterolateral subluxation associated with a rupture of the collateral ligament.
Chronic injuries. Chronic elbow injuries include tendinosis, ulnar nerve neurapraxia, UCL ligament attrition and rupture, loose bodies, and chondromalacia of the olecranon fossa, capitellum, and posterolateral compartment. Lateral and medial tennis elbow (lateral and medial tendinosis), however, are the most common. (The word "tendinosis" is substituted for "tendinitis" or "epicondylitis" because degeneration, rather than inflammatory conditions, exists.) Palpable tenderness over the origin of the extensor carpi radialis brevis approximately 1 cm medial and distal to the lateral epicondyle) indicates lateral tennis elbow. Tenderness over the tip of the medial epicondyle extending distally 1 to 2 cm along the track of the flexor carpi radialis and pronator teres typifies medial tennis elbow.
Manual resistance testing confirms the diagnosis. Useful tests for lateral tennis elbow are resisted wrist extension and resisted grasping with the elbow extended. For medial tennis elbow, resisted wrist flexion and pronation serve as provocative tests. A common companion to medial tennis elbow is neurapraxia of the ulnar nerve owing to compression in the medial epicondylar groove distal to the medial epicondyle. Tenderness and Tinel's sign (tingling with percussion) over the nerve distal to the medial epicondyle signal ulnar nerve problems.
We have rarely noted radial nerve dysfunction, but it is often cited as the cause of lateral tennis elbow. A positive Tinel's sign over the radial nerve, suggesting nerve compression, would occur more distally and radially--along the lateral border of the brachioradialis--than the site of lateral tendinosis pain.
Lateral and medial tennis elbow are often associated with tendinosis elsewhere in the upper extremity. Problems related to tennis elbow have been termed "mesenchymal syndrome," (1-3) and include shoulder tendinosis, upper-back and scapular weakness, and carpal tunnel syndrome. These related problems should be anticipated and sought out by examining for tenderness and weakness in the rotator cuff, scapular stabilizers, and wrist, respectively. Mesenchymal syndrome is often bilateral and shows that the workup must include conditions beyond the elbow. In patients older than 40, cervical osteoarthritis may be present but not etiologically related to the elbow condition.
Acute injuries require careful review of neurovascular compromise. Anti-inflammatory measures, such as ice if vascular alteration is absent, are indicated, as is protective splinting. Open injuries require immediate wound cleaning and coverage. With dislocation, gentle elbow flexion with forearm rotation to a neutral position may result in spontaneous reduction. If neurovascular injury occurs as a direct result of a fracture or dislocation and prior to a reduction attempt-and no medical facility is nearby-immediate reduction can be considered, depending partly on the experience of the treating physician. But if a medical facility is nearby and no nerve or vessel is damaged, it is best to splint the arm without moving it, transport the patient, and obtain radiographs first, before reducing the dislocation in a controlled environment such as an emergency room. Acute injuries in general warrant prompt imaging and treatment, whereas overuse injuries may benefit from a more leisurely and definitive approach to diagnosis and treatment.
On-field treatment of overuse injuries does not warrant the urgency of acute injuries. Comfort and anti-inflammatory measures (such as cryotherapy) are the key, along with advice about continuing or withdrawing from competition. As a general rule regarding overuse injuries, withdrawal from participation is indicated when pain causes the athlete to change his or her technique.
What Tests to Order
Regular anteroposterior, lateral (figure 4), and olecranon x-rays may suffice for fractures and dislocations, but on occasion oblique views, tomograms, or stress views are needed. Computed tomography may be needed to enhance bony detail, and magnetic resonance imaging (MRI) is useful for soft-tissue detail but is rarely necessary for acute injury. Vascular compromise is of course an emergency and requires immediate consultation and testing as indicated.
Patients with chronic injuries should have routine x-rays, which are helpful to rule out other maladies (chronic pain may be caused by systemic disease like rheumatoid arthritis). Loose bodies may require arthrography or tomography. Suspected UCL damage may require MRI for confirmation. In exotic and unresponsive pain situations (ie, the above tests reveal no pathology), a bone scan may help delineate a stress fracture or detect an elusive systemic disease. Diagnosis of peripheral nerve dysfunction may be aided by electromyography and nerve conduction studies. In unusual clinical presentations, serologic studies may reveal any underlying inflammatory arthopathy. Joint aspiration may be valuable to diagnose joint sepsis or gout.
Fractures and dislocations require open or closed reduction followed by surgical or nonsurgical stabilization. Splinting that includes the wrist, elbow, and upper arm may be needed. Bandages should not be wrapped tightly because a tourniquet effect can occur.
Even after reduction, elbow dislocation may require operative intervention to repair ligamentous disruption, particularly if a bone fragment (such as the medial epicondyle attached to the UCL) becomes entrapped. The distinction between dislocation and subluxation becomes unclear when a dislocation spontaneously reduces, but the more important issue is whether the patient has lasting instability that requires surgery. Dislocations do not, however, generally require surgical intervention because closed reduction usually places the ligaments in a position adequate for quality healing.
On the other hand, the magnitude of soft-tissue damage associated with dislocation and the usually abundant reparative process often results in scar adhesions and contractures. Early mobilization (usually within a few days after a stable reduction) is often the best treatment. A removable pouch sling will suffice in most cases. If the patient has varus-valgus instability after trauma, a hinge brace allowing flexion and extension may be used. A posterior splint is reserved for the most unstable injuries or the immediate postoperative period. We use an elbow immobilizer with Velcro closures (figure 5). If adhesive capsulitis does eventually occur, it can be resolved by operative release using the surgical approach recently described by Cox et al (4).
Initial treatment of complete UCL rupture involves splinting and early rehabilitation while the elbow is protected from valgus forces. (A hinge brace may help here.) If conservative therapy fails, appropriate care will likely involve surgical intervention. Ulnar nerve neurapraxia and UCL attrition may be aided by rehabilitative exercise but often require surgical intervention.
For tennis elbow, curative goals include neovascularization of the injured tissue, collagen production and maturation, and restoration of strength, endurance, and flexibility. The strength deficiencies associated with tennis elbow extend far beyond the elbow to include the arm, shoulder, scapular, thoracic, and cervical muscles. Though they offer comfort, rest and anti-inflammatory medicines (including cortisone injections) have no curative potential and in fact may be detrimental to tendon healing (5). They are used only as an adjunct to allow effective rehabilitative exercise. Similarly, counterforce braces designed for medial or lateral tendinosis (figure 6) provide comfort by reducing stresses to underlying damaged tissues, but these braces are not a substitute for rehabilitative exercises. Failed rehabilitation may signal a need for surgical intervention, particularly if the patient's activities of daily living are disrupted or sports potential is compromised.
Chondromalacia and synovitis of the posterior olecranon fossa and lateral compartments may show some response to rehabilitation exercises and comfort modalities within weeks. Loose bodies and intra-articular osteophytes will generally be unresponsive to nonsurgical treatment. However, failed comfort treatment without appropriate rehabilitative exercise is not an indication for surgery.
When to Refer
Decisions about referral are subject to many variables, but the two primary factors are the expertise of the physician and the complexity of the problem. In general, the care of elbow injury is quite complex because a wide variety of pathoanatomic presentations exists. Precise pathoanatomic diagnosis is, therefore, critical, and any confusion concerning the diagnosis is a sufficient reason to refer.
With acute injuries, stabilization, protection, and pain control are best followed by referral. Because overuse injuries are not typically emergencies, however, primary care physicians can provide at least initial treatment. Because rehabilitation is the key to definitive treatment of chronic injuries, lack of expertise or adequate rehab facilities is an indication for referral.
Principles of Rehabilitation
The principles of musculoskeletal rehabilitation of the elbow as practiced in our clinic are relief of pain and inflammation, maintenance of general fitness, targeted rehabilitation exercises, and control of overuse.
In pain and inflammation relief, the mnemonic PRICEMM (protection, rest, ice, compression, elevation, medications, and modalities) works well. The most effective modalities are heat, cold, and high-voltage electrical stimulation. Analgesics, anti-inflammatory drugs, and cortisone injections are used selectively and sparingly for comfort to aid in the progression of rehabilitative and fitness exercises. To maintain general fitness, the patient starts fitness programs for all uninjured areas immediately. Exercises to restore normal strength include progressive resistance and postural exercises and should involve the biceps and triceps as well as the entire shoulder girdle, upper back, and neck. (For specifics about tennis elbow rehabilitation, see "Keeping Tennis Elbow at Arm's Length: Simple, Effective Strengthening Exercises") Transitional exercises, including eccentric and concentric loading, plyometrics, and sport-specific drills, are critical to the successful return process, as are development of proper technique, bracing, and transitional performance exercise like agility training. It must be appreciated that the power, speed, and angles at which sports are played far exceed the criteria for successful completion of rehabilitation exercise.
Finally, to prevent overuse in sports--and in fitness and rehabilitative exercises--the patient focuses on proper technique, intensity, duration, and equipment. He or she wears protective counterforce bracing as needed to prevent reinjury.
Appropriate Time Course for Resolution
The diversity of elbow injuries makes for a wide range of resolution times. Dislocations, because of soft-tissue damage, often take months to fully heal. Similar situations may occur with fractures, although a patient who has a nondisplaced fracture of the radial head and is treated with aggressive rehabilitation should perform well at 6 to 8 weeks, except in elbow-loading sports such as gymnastics.
Conservative treatment of tennis elbow usually brings results within weeks, but full return to sports often takes 3 to 4 months. Similar time frames are noted with UCL attrition. Complete UCL rupture, however, may not allow a return to throwing sports even after 6 to 9 months of conservative treatment or of postoperative convalescence.
The criteria for return to play after an elbow injury are similar to those for other musculoskeletal injuries. The ideal criteria include restoration of normal strength, endurance, and flexibility. Two principal factors must be considered: the risk of reinjury, and the ability to perform at a satisfactory level. These factors are often intertwined. When there is a risk of reinjury, the potential for expanded or permanent damage must also be considered.
Because elbow injuries typically are not life threatening and do not pose major obstacles to daily activities, a certain latitude may be assumed regarding return criteria. Thus, some patients may gradually return to sport with less-than-normal physical capacity. Examples include a pitcher with up to 10° loss of extension or painless ulnar nerve motor dysfunction, and a tennis player with tennis elbow who gradually returns to sports after achieving 90% of grip strength compared with the nondominant uninjured arm. (For full competitive play, grip strength in the dominant arm should exceed that in the nondominant by at least 10%.)
It is important to identify the specific activity that caused the initial injury so that the patient can avoid that activity. Avoidance steps may include changing sports technique, training habits, and equipment, and using an elbow counterforce brace.
Expanding Clinical Knowledge
That elbow injuries are typically not life threatening does not diminish their importance to the injured athlete. Patients can lose strength and range of motion if their injuries are not expediently diagnosed or appropriately treated with early rehabilitation. This reality, combined with the fairly high incidence of elbow injuries, underscores the importance of knowing how to treat patients who sustain injuries to this joint.
- Regan WD, Morrey BF: Physical examination of the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, WB Saunders Co, 1993
- Frelic DC, Morrey BF: Evaluation of the painful elbow: the problem elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, WB Saunders Co, 1993
- Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, WB Saunders Co, 1993
- Cox W, Nirschl RP, Kraushaar BS: New anterolateral approach in the treatment of elbow contractures. Read before the American Academy of Orthopaedic Surgeons annual meeting, Atlanta, February 1996
- Buckwalter JA: Pharmacological treatment of soft-tissue injuries. J Bone Joint Surg (Am) 1995;77(12):1902-1914
- Nirschl RP: Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11(4):851-870
- Nirschl RP: Muscle and tendon trauma, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, WB Saunders Co, 1993, pp 537-552
- Nirschl RP: Patterns of failed healing in tendon injury, in Leadbetter W, Buckwalter J, Gordon SL (eds): Sports-Induced Inflammation: Clinical and Basic Science Concepts. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 577-585 O'Connor FG, Sobel JR, Nirschl RP: Five-step treatment for overuse injuries. Phys Sportsmed 1992;20(10):128-142