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Mustafa Javed, Saadia Mustafa, Simon Boyle and Fiona Scott

Elbow : a guide to assessment and management in primary care

Introduction restriction of extension and end range pain is a common presenting of movements (ROM), along with painful symptom in primary care. can clicking, catching, or locking of elbow, arise from any component of the joint point towards . including tendons, bursae, bones, or nerves. • Bilateral elbow pain with stiffness It is a commonly dislocated joint, especially and joint swelling, loss of full ROM, in children (‘pulled elbow’). involvement of other joints, and systemic (lateral and medial epicondylitis) can symptoms point towards inflammatory result from a number of popular sports ; 20–50% of patients with and activities of daily living. Rheumatoid rheumatoid arthritis have involvement of (inflammatory), post-traumatic, and .1 primary osteoarthritis are three primary patterns of arthritis affecting the elbow. Associated symptoms History • Elbow stiffness is associated with arthritis or trauma. Stiffness restricting Elbow pain can present in any age group flexion is more disabling then restriction with varying symptom complex (Figure 1). of extension. Red flags • Neurological symptoms like numbness Exclude red flags such as swelling and and tingling should be assessed. Ulnar dislocation following trauma, a tender, nerve is common in medial swollen joint, or rapidly increasing mass. epicondylitis, osteoarthritis (50% of These require urgent referral to secondary patients), and inflammatory arthritis.2 care (Figure 1). • Referred pain from neck or can present as elbow pain. Assessment of Assessment of pain cervical spine is particularly important in A systematic approach towards assessment suspected rheumatoid arthritis. of nature, onset, and duration of pain and associated symptoms is key to diagnosis. Examination Also ask about exacerbating activities and Before examining the elbow, evaluate the mechanism of injury. Mustafa Javed, MRCS, specialty registrar, neck and shoulder to rule out radiculopathy, trauma and orthopaedics; Simon Boyle, MSc, shoulder weakness, or referred pain. Use FRCS, consultant orthopaedics surgeon, York • A traumatic onset of elbow pain Saadia Mustafa the Spurling Test (pain when extending and District Hospital, York. , MRCOG, in dominant arm, localised to lateral DFSRH, GP registrar, Hull VTS Scheme, rotating the head to the affected side while epicondyle with occasional radiation Brough and South Cave Medical Practice, pressing down on the head) to exclude Brough, East Riding of Yorkshire, Yorkshire. to , is characteristic of lateral cervical nerve root compression. Perform Fiona Scott, DRCOG, DCH, DFSRH, senior epicondylitis (tennis elbow). It is found in partner, Haxby Group, City of Kingston-upon- a systematic examination of the elbow 20–50% of tennis players,1 but is equally Hull, Hull. joint with the usual ‘look, feel, and move’ common in manual labourers and people Address for correspondence approach. caring for young children. Mustafa Javed, York District Hospital, The patient should be suitably undressed Wigginton Road, York, YO23 8HE, UK. • Pain worsening with gripping activities to allow for a full examination of trunk and E-mail: [email protected] localised to medial aspect of elbow Submitted: 25 May 2015; Editor’s response: 11 neck down to both hands. Always compare June 2015; final acceptance: 26 June 2015. (dominant arm in 75% of cases) is due both sides. Look for any redness, swelling, ©British Journal of General Practice 2015; to medial epicondylitis, also known as atrophy, asymmetry, or gross deformity. 65: 610–612. ‘golfer’s elbow’. History of repeated Note full body posture to assess referral of 2 DOI: 10.3399/bjgp15X687625 stress and trauma should be explored. symptoms, especially in . • Chronic progressive elbow pain with When feeling for the joint, try to elicit

610 British Journal of General Practice, November 2015 Elbow pain history/examination Exclude referred pain shoulder/neck

Red flags Point tenderness Swelling & stiffness

History of Swollen red & Rapidly Localised at lateral Localised at medial Bilateral, females Middle-aged males, loss trauma, swelling/ tender joint, increasing epicondyle, age epicondyle, age > males, loss of of end ROM, clicking/ dislocation systemic mass/swelling 35−50 years, dominant 40−60 years, males = full ROM catching/locking symptoms arm, males = females, females, trauma/ sports/work related stress/sports related

Fractures, Septic arthritis Malignancy Lateral epicondylitis Medial epicondylitis Inflammatory Osteoarthritis dislocation arthritis (pulled elbow) Activity, modification, counterforce Blood including autoantibodies (inflammatory bracing, physiotherapy/exercise, arthritis), X-ray, activity modification, / injection NSAIDs, physiotherapy/exercise, splinting, ice/heat, (oral versus intra-articular)

Urgent referral to secondary care Refer to secondary care if no response to Refer if no response to conservative management, Follow local pathway 6−12 months of Rx for consideration of limitation of daily activity, painful locking/catching USS/MRI, PRP injection, For consideration of DMARDs open/arthroscopic (inflammatory arthritis), surgery

Figure 1. Elbow pain management algorithm. the point of tenderness, feel for any inflammatory arthritis is suspected. DMARDs = disease-modifying anti-rheumatic drugs. suspicious mass and note any changes Plain radiographs are usually normal in MRI = magnetic resonance imaging. NSAIDs = non- in temperature or texture. Tenderness tendinopathies and are not indicated.3 steroidal anti-inflammatory drugs. PRP = platelet- anteriorly in ante-cubital fossa can be Standard anteroposterior and lateral rich plasma. ROM = range of movement. due to tendonitis. Tenderness to radiographs should always be obtained Rx = medication prescribed. USS = ultrasound scanning. palpation just anterior to medial epicondyle if pain is accompanied with stiffness, signifies medial epicondylitis. Ulnar nerve suggestive of arthritis or trauma. tenderness (Tinel’s sign) can be elicited just Ultrasound scanning (USS) requires an posterior to medial epicondyle, indicating experienced operator and has variable ulnar neuropathy. Point tenderness anterior sensitivity and specificity.1 Magnetic to lateral epicondyle is diagnostic of lateral resonance imaging (MRI) is best used to epicondylitis. Tenderness localised to area diagnose injuries; USS and MRI distal to radial head is diagnostic of posterior are useful in secondary care settings.2 interosseous nerve (PIN) compression, a Electromyography/nerve conduction of lateral elbow pain velocity studies are useful if nerve (coexistent with lateral epicondylitis in 5% dysfunction is suspected. of cases).1 Posteriorly, pathology in muscle, olecranon process, and its bursa Treatment can give rise to tenderness. Also feel for any Treatment should be aimed at alleviating click or crepitus in these areas to exclude pain, restoring normal physical functioning, radial head fracture, arthritis, or loose body. and maintaining the patient’s ability to work. Check for active and passive ROM, Therapeutic modalities like rest, remembering to do active movements analgesia, and steroid injections provide first. Hyperextension is common in temporary pain relief but must only be used females and normal if bilateral, and in as part of a larger treatment plan. the absence of trauma. Restriction of full Primary care management of extension is diagnostic of osteoarthritis. tendinopathies aims at decreasing stress Flexion, supination, and pronation should and increasing the strength of the injured all be tested. movements should tendon. Rest should be relative and the also be assessed because of the shared patient should avoid activities that aggravate musculature between wrist and elbow. symptoms. Counterforce bracing (band Complete the assessment by performing over muscle body) reduces stress,3 while a neurovascular examination. Include rehabilitative exercises and physiotherapy assessment of other joints and systemic improve muscle strength. Physiotherapy examination, if indicated. has shown to be 91% effective in 52weeks. 4 Corticosteroid injections can provide short- Investigations term symptom relief but may be associated Blood tests (full blood count, erythrocyte with worse long-term outcomes.5 Use of sedimentation rate, rheumatoid factor, and platelet-rich plasma to and autoantibodies) should be done if treat tendinopathies has recently increased

British Journal of General Practice, November 2015 611 in the past 5 years but there is no clinical Competing interests evidence of its superiority over placebo.3 The authors have declared no competing Referral to secondary care is indicated interests. following persistent symptoms despite Discuss this article 6–12 months of conservative management. However, results are variable after surgery Contribute and read comments about as 25% patients still have pain at 1 year.3 this article: bjgp.org/letters Arthritis can be managed non-operatively with activity modification, NSAIDs, disease- modifying agents in inflammatory arthritis, steroids (oral versus intra-articular), REFERENCES splinting, and use of ice or heat. Indication 1. Trumble T, Cornwall R, Budoff J.Core for referral to secondary care is: failure knowledge in orthopedics: hand, elbow, and to respond to non-surgical interventions, shoulder. Philadelphia, PA: Mosby Elsevier, 2005. interference with daily living, and painful 6 2. Boyer M, ed. American Academy of locking of the elbow. Orthopaedics Surgeons (AAOS) comprehensive Primary care management of painful orthopaedic review. 2nd edn. Rosemont, IL: elbow conditions may require many AAOS, 2014. months of conservative management, 3. Ahmad ZA, Siddiqui N, Malik SS,et al. Lateral perseverance with rehabilitative exercises,7 epicondylitis: a review of pathology and management. Bone Joint J 2013; 95-B(9): and physiotherapy. Work-related problems 1158–1164. causing elbow pain are more resistant 4. Murtaugh B, Ihm JM. Eccentric training for the to non-operative management. In this treatment of tendinopathies. Curr Sports Med situation consider advising patients to take Rep 2013; 12(3): 175–182. a short period of time off work to help 5. Coombes BK, Bisset L, Vicenzino B. Efficacy restore function by promoting rest. Follow- and safety of corticosteroid injections and other injections for management of : a up should be tailored to the individual systematic review of randomised controlled patient, and review after 2–4 weeks trials. Lancet 2010: 376(9754): 1751–1767. depending on severity of symptoms is a 6. Papatheodorou LK, Baratz ME, Sotereanos DG. reasonable option. Elbow arthritis: current concepts. J Hand Surg Am 2013; 38(3): 605–613. 7. Arthritis Research UK, Chartered Society of Physiotherapy. Exercise advice: tennis elbow. http://www.csp.org.uk/your-health/exercise- Provenance advice/tennis-elbow (accessed 21 Sep 2015). Freely submitted; externally peer reviewed.

612 British Journal of General Practice, November 2015