03 830 ATS Common Elbow Disorders 2021

Snehal C. Dalal, MD Atlanta Trauma Symposium

August 2021 Common Elbow Conditions Differentiating Elbow Pain

ê Lateral Elbow Pain ê Lateral epicondylitis ê Radial Tunnel Syndrome ê Posterior Lateral Rotatory Instability ê Medial Elbow Pain ê Medial Epicondylitis ê Cubital tunnel syndrome ê Medial Ulnar collateral ligament strain/tear ê Anterior Elbow Pain ê Brachioradialis strain ê Distal biceps tendonitis/tear ê Posterior Elbow Pain ê Triceps tendonitis ê Olecranon Bursitis ê Valgus Instablility/Posteromedial impingement Elbow Anatomy Elbow Anatomy Case 1

ê 31 y/o racquetball player c/o lateral elbow pain ê Pain with hitting backhand, forearm rotation ê “..hurts to take a milk jug out of the fridge.” ê Painful with grip and resisted wrist extension Exam

ê Lateral elbow pain with gripping and resisted wrist extension ê Pain to palpation just distal to the lateral epicondyle ê Pain with resisted wrist/long finger extension ê Worse with elbow extended ê Chair lift/heavy book test Ultrasound

ê Hypoechoic area on ultrasound Lateral Epicondylitis ê Differential Diagnosis ê Radiocapitellar osteochondral lesion/degenerative arthritis (DJD) ê May hurt more in flexion ê Radial tunnel syndrome/Posterior interosseus nerve syndrome ê Ache with supination, weak wrist extension ê Tender 5-6 cm distal to lateral epicondyle ê Triceps tendonitis Lateral Epicondylitis

¨ A.K.A. “Tennis Elbow” ¨ Most do not play tennis ¨ Injury ¡ Repetitive use of wrist extensors ¨ Pathology ¡ Tendinosis of ECRB (extensor carpi radialis brevis) Lateral Epicondylitis

¨ Treatment ¡ Activity Modification ¡ NSAI’s ¡ Stretching/strengthening ¡ Ice/Massage ¡ Counterforce brace ¡ Steroid Injection ¡ Surgery after at least 4-6 months of conservative treatment ú Arthroscopic ECRB release ú Open debridement and repair Lateral Epicondylitis

ê Theraband Flexbar ê Eccentric stretching is important in the rehab for tendon injury Arthroscopic Treatment

ê Arthroscopic ECRB release

ê Reproducible results: ê Early return to work ê Lower complications ê Less immobilization Arthroscopic Treatment

ê Arthroscopic visualizaton of ECRB tendon (most medial tendon)

ê Epicondylar debridement Case 2

¨ 12 y/o boy, little league pitcher c/o increasing medial elbow pain with pitching ¨ Throws occasional curve balls ¨ Practices 30-40 pitches 3x/week ¨ Goes home and throws 30-40 more after practice ¨ Felt a pop/tearing sensation ¨ Pain and swelling over the medial epicondyle Exam

ê Medial epicondyle tenderness/swelling ê Loss of full extension ê Pain with valgus stress ê No gross instability Medial Apophysitis

¨ A.K.A. Little Leaguer’s Elbow ¨ Increasing valgus load ¨ Lateral compression, medial distraction ¨ Injury: traction/avulsion at the medial epicondyle physis ¨ X-ray: widening of physis to complete avulsion of epicondyle ¨ If not sure, get contralateral films for comparison Medial Apophysitis

¨ Treatment ¡ Stop pitching ¡ Normal x-ray: stretching / strengthening ¡ Fleck/slight physeal widening: period of rest/sling, gradual rehabilitation ¡ Avulsion/very wide physeal space: ortho referral for possible fixation ¨ Limit pitching ¡ 30-40 pitches/practice/day ¡ 6-10 innings gametime ¡ 60-100 pitches gametime ¡ No sidearm throwing: sliders or curve balls Complete Avulsion

Surgical treatment if displacment over 5 mm, ulnar symptoms, joint entrapment, instability with gravity stress test Prevention Guidelines

ê 75 for 8-10 year olds ê 100 for 11-12 year olds ê 125 for 13-14 year olds ê Includes both practice and competitive play ê Play three to four innings each game Case 3

ê 32 y/o asthmatic with L anterior elbow pain ê Weight lifting Preacher Curls, felt sharp/burning pain ê Smokes 1 ppd ê Has recently taken predisone for asthma exacerbation Exam

ê Left antecubital fossa tender to palpation ê Weak elbow flexion and turning car key ê “Popeye muscle” MRI

Attenuated biceps tendon Bare Radial Tuberosity Distal Biceps Rupture ê Much less common than proximal avulsion ê Usually a complete avulsion injury ê May have h/o steroid, cigarettes, or quinolone antibiotic use ê Can occur after longstanding tendonosis/history of antecubital pain ê Diagnosed usually through H&P, although MRI helpful if incomplete rupture & surgical planning ê “Popeye deformity on exam” with weak supination Distal Biceps Rupture

ê Can be a complete or partial tear ê May have h/o steroid, cigarettes, or quinolone antibiotic use ê Can occur after longstanding tendonosis/history of antecubital pain ê Diagnosed usually through H&P, although MRI helpful if incomplete rupture Distal Biceps Rupture

ê Biceps is the most powerful supinator of the forearm ê Treatment ê Elderly ê Nonoperative ê 50% loss of supination power ê 30-40% loss of flexion power ê 35-40% complain of prolonged pain ê Rehabilitation ê Young/Active ê Surgical repair ê Long arm splint or sling initially Surgical Repair: Endobutton

ê Insertion at biceps tuberosity bare

Distal

Biceps insertion

Biceps tendon Biceps tuberosity Surgical Repair: Endobutton

ê Main substance of tendon retracted proximal to cubital fossa Surgical Repair: Endobutton Surgical Repair: Endobutton Surgical Repair

ê Start ROM after surgery, strengthening 6-8 wks postoperative Case 4

ê 36 y/o secretary c/o medial forearm achiness and paresthesias into the ring and small fingers ê Has numbness and tingling into the small finger at night ê Has to “shake it out” ê Occasional weakness in grip/clumsiness/dropping objects ê Dorsum of hand also tingling on the side of the small finger Exam

ê Positive elbow hyperflexion test ê Hold for 2 minutes

ê Tinel’s at cubital tunnel ê Tap lightly Exam

ê Weakness in small finger flexion ê Intrinsics weak/atrophy

ê Decreased Semmes- Weinstein monofilament exam/2 point discrimination Exam ê When motor function affected: ê Wartenberg’s Sign ê loss of intrinsics ê Fromment’s Sign ê loss of adductor pollicis Examination

ê Differential diagnosis ê Ulnar tunnel syndrome ê Ulnodorsal hand is unaffected ê Snapping triceps ê Snapping posteromedially with elbow flex/extension ê Ulnohumeral arthritis ê Cervical radiculopathy ê C-spine XR ê Medial epicondylitis Diagnostic Testing

ê EMG/NCS shows slowing and decreased amplitude across elbow for ulnar nerve ê Can be normal

ê Decrease 2-point discrimination ê Normal 4-5 mm

ê Decreased monofilament exam most sensitive Cubital Tunnel Syndrome

ê Ulnar nerve compressive neuropathy at the elbow ê Injury: ê Direct trauma ê Traction injury ê Compression ê Subluxation Pathoanatomy

Arcuate Ligament/Osborne’s Ligament

Tightens with elbow flexion

Overlies MUCL Cubital Tunnel Syndrome

ê Treatment ê Rest, limit flexion ê Brace at night ê Stretching/nerve glides ê Strengthen flexors/pronators ê Ulnar nerve decompression/transposition ê If any motor function affected clinically/on EMG ê At least moderate compression on EMG ê Failed treatment to mild compression Case 5

ê 40 y/o executive developed R medial elbow pain ê Golfs 2-3x a week ê Pain with lifting with palm up Ultrasound

Injury to the common flexor/pronator tendon

Normal Tendon Thickened Tendon Medial Epicondylitis

• A.K.A Golfer’s elbow • Overuse syndrome of flexor-pronator mass origin • Less common than tennis elbow • Caused by micro-trauma to insertion of flexor- pronator mass caused by repetitive activities

Symptoms: • Symptoms insidious onset pain over medial epicondyle • worse with wrist and forearm motion • worse with gripping • during late cocking/early acceleration Medial Epicondylitis

ê aka “Golfer’s Elbow” ê Pain over medial epicondyle and common flexor tendon ê Pain with resisted flexion and pronation ê Much less common the lateral tendonitis Medial Epicondylitis

Physical Exam: • Tenderness 5-10 mm distal and anterior to medial epicondyle • Soft tissue swelling and warmth if inflammation present • Pain with resisted forearm pronation and wrist flexion • Examine for associated conditions • valgus instability in overhead athlete (milking maneuver, valgus stress, moving valgus stress test) • ulnar neuritis (Tinel's along length of nerve, ulnar subluxation)

Imaging: • XR: usually WNL, sometimes will show a calcification or degenerative changes • MRI: -Standard of care for diagnosis -Will show tendinosis / tendon disruption of common flexor tendon Medial Epicondylitis

Differential Diagnosis: • MCL injury • Cubital tunnel syndrome • Fracture • Cervical radiculopathy • Triceps tendinitis • Herpes zoster (shingles) Medial Epicondylitis

ê Treatment ê Activity Modification ê NSAI’s ê Stretching/strengthening ê Ice/Massage ê Counterforce brace ê Steroid Injection ê Surgery after at least 4-6 months of conservative treatment ê Open debridement and repair ê Some patients will have concomittant ulnar nerve symptoms: perform transposition/decompression Medial Epicondylitis

Treatment: • rest, ice, activity modification (stop throwing x 6- 12wks), PT (passive stretching), counter-force bracing, NSAIDS • Cortisone injection (caution for ulnar nerve injury) • Surgery if failed conservative treatment (open medial epicondyle release) Case 6

ê 19 y/o freshman college baseball pitcher ê Increasing pain in medial elbow after pitching several innings in a game ê Progressive loss of distance and speed over the last few days ê Pain with early phase of throwing Examination

ê Point tenderness over MUCL ê Pain with late cocking/early acceleration phase of throwing ê Valgus instability with elbow flexion 20-30 degrees ê Positive Milking Maneuver ê Moving Valgus stress test ê Most sensitive and specific Ulnar Collateral Ligament Injury

MRI arthrogram to evaluate the MUCL is the study of choice Ultrasound can also be useful as a dynamic study Treatment

ê Repetitive Injury: Surgical intervention usually reserved for throwing athletes ê Intervention for either partial or complete tears ê Nonoperative treatment with brace for traumatic injuries Case 7

ê 55 y/o truck driver with R posterior elbow pain with swelling ê Progressive burning, tightness, and redness ê No trauma ê h/o of gout Olecranon Bursitis

• The olecranon bursa is located posteriorly over the olecranon process of the ulna

• It may become swollen in relation to: − Trauma − Hemorrhage − Sepsis − inflammatory arthritis − It is also a common site for the development of rheumatoid nodules or gouty tophi Olecranon Bursitis

XR: Will show soft tissue swelling at posterior elbow, occasionally there is an olecranon spur Exam: • Check for erythema, warmth, abrasion or cellulitis symptoms to r/o septic bursitis • Can distinguish between an elbow effusion if patient is able to fully extend elbow joint without accentuating pain Treatment: • 24/7 compression wrap w/ cushioning • NSAIDS • Ice • Avoid microtrauma • Olecranon bursa excision can be indicated with chronic persistent bursitis or septic bursitis Olecranon Bursitis

Aspiration: ê The two main indications to aspirate the bursa are to r/o infection or gout ê Fluid aspiration can be used to decompress the bursal sac but it is typically not recommended due to: − Risk of introducing an infection − Very common for fluid to re-accumulate rapidly into the bursa after drainage ê Do not inject glucocorticoids in patients with olecranon bursitis Examination

ê Fluid filled swelling ê Mild warmth ê Mild erythema ê No lymphadenopathy ê Pain with dependency and elbow flexion Olecranon bursitis

ê Fluid filled sac over bony prominences can become inflammed ê More common in RA and gout

OLECRANON SPUR

GOUTY CALCIFICATION Treatment

ê Compression, ice, nsai ê Antibiotic if surrounding cellulitis ê Conservative treatment for 6 weeks ê RESIST ASPIRATION, unless infected bursa is suspected ê Aspirate if persistent or recurrent ê BEWARE STEROID INJECTIONS ê Superimposed triceps tendonitis may result in triceps rupture ê May need surgical bursectomy ê May drain and place packing in clinic/ED if infected Summary

Lateral Epicondylitis ê Repetitive wrist extensor irritation ê Tendinosis of the extensor carpi radialis brevis ê Worse pain with the elbow extended rather than flexed ê Suspect radial tunnel syndrome if pain with supination and pain more distal on forearm ê Surgical consideration after MONTHS of conservative treatment Summary

Medial Apophysitis ê Peak incidence occurs during fastest growth, 10- 12 y/o girls or 12-14 y/o boys ê Comparitive radiographs are helpful ê Prevent by limiting number of pitches/adding rest days ê No sliders/curve balls/side pitching ê Treat with rest from throwing 4-6 weeks, followed by gradual rehab program ê Surgery if apophysis displaced greater than 4- 5mm Summary

Distal Biceps Rupture ê Suspect if weak forearm supination ê Fluoroquinolone, steroid, and tobacco use are associated with decreased tendon healing and higher rupture rate ê MRI indicated in partial tear/question on exam ê Majority of patients would benefit from surgical repair Summary

Cubital Tunnel Syndrome ê Medial elbow pain ê Paresthesias in entire ulnar nerve distribution ê Ulnar Tunnel spares the dorsum of the hand ê Semmes-Weinstein is the most sensitive ê Surgical consult if moderate changes on EMG or atrophy/weakness present ê Postive Wartenberg’s and Fromment’s signs Summary

Medial Epicondylitis ê Repetitive wrist flexor irritation ê Tendinosis of the common flexor tendon ê Worse pain with the elbow extended rather than flexed, and lifting with the palm up ê Evaluate for cubital tunnel syndrome when determining treatment ê Surgical consideration after MONTHS of conservative treatment ê May need decompression of ulnar nerve as well Summary

Medial Ulnar Collateral Injury ê Consider patients athletic demands ê Conservative treatment includes bracing and rehab ê Surgery usually for those athletes who wish to continue throwing and go through extensive rehab ê Cubital tunnel syndrome is still the most common complaint among throwing athletes Summary

Olecranon Bursitis ê Swelling of fluid filled sac ê Usually resolves with compression, ice, nsai ê Aspirate only if infection suspected ê Olecranon spur, RA, gout are predisposing factors ê Cortisone injections may lead to triceps tendon rupture Thank You

Snehal Dalal, MD [email protected] www.orthoatlanta.com