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