What are the common causes and workup for elbow pain?

Common Causes and Workup for Elbow Pain

Radiographs should be the first imaging study for chronic elbow pain, followed by MRI or ultrasound if symptoms persist despite normal radiographic findings. 1

Common Causes of Elbow Pain

Tendinopathies

• Lateral epicondylitis (Tennis elbow)

  • Most common cause, affecting 1-3% of the population 1
  • Caused by tendinosis of the common extensor tendon
  • Presents with pain during wrist extension against resistance 2

• Medial epicondylitis (Golfer's elbow)

  • Less common (4:1 to 7:1 ratio compared to lateral epicondylitis) 3
  • Affects 1% of general population, but 3.8-8.2% of work-related complaints 4
  • Involves pathology of the common flexor tendon origin

Other Common Causes

• Biceps tendinopathy and ruptures 1, 3
• Triceps tendon ruptures (rare) 3
• Osteochondral injuries 1
• Collateral ligament tears (UCL injuries) 1
• Cubital tunnel syndrome and other nerve entrapments 1, 5
• Osteoarthritis 1
• Olecranon bursitis 5
• Muscle strains and ligamentous injuries 5

Diagnostic Workup

Clinical Evaluation

1. History

   • Onset (acute vs chronic)
   • Mechanism of injury (occupational vs recreational)
   • Location of pain (medial, lateral, posterior)
   • Aggravating and alleviating factors
   • Associated symptoms (swelling, numbness, tingling) 1

2. Physical Examination

   • Inspection for swelling or deformity
   • Palpation for tenderness (epicondyles, olecranon)
   • Range of motion assessment
   • Special tests:
     • Lateral epicondylitis: Pain with resisted wrist extension
     • Medial epicondylitis: Pain with resisted wrist flexion
     • Nerve compression tests

Imaging Studies

1. Radiographs (X-rays)

   • First-line imaging for chronic elbow pain 1, 6
   • Can detect:
     • Intra-articular bodies
     • Heterotopic ossification
     • Osteochondral lesions
     • Soft tissue calcification
     • Occult fractures
     • Osteoarthritis 1, 6
   • Comparison with asymptomatic side often useful 1

2. MRI

   • Indicated when radiographs are normal or nonspecific and symptoms persist 6
   • High sensitivity for tendinopathy (83.9%) and specificity (74.5%) 6
   • Evaluates:
     • Tendon pathology
     • Ligament injuries
     • Osteochondral lesions
     • Synovitis

3. Ultrasound

   • Alternative to MRI for soft tissue evaluation
   • Allows dynamic assessment
   • High sensitivity (100%) and accuracy (90%) for tendon pathology 6
   • Cost-effective and readily available

4. Electromyography (EMG) and Nerve Conduction Studies

   • Indicated when nerve entrapment is suspected
   • Helps localize site of nerve compression 1, 5

Management Approach

Conservative Treatment

1. Initial Phase (0-4 weeks) 6

   • Rest and activity modification
   • NSAIDs for pain relief (ibuprofen 1.2-2.4g daily or naproxen 500mg twice daily) 6
   • Ice application
   • Bracing (tennis-elbow band) 2
   • Protected range of motion exercises

2. Intermediate Phase (4-8 weeks) 6

   • Progressive strengthening exercises
   • Eccentric training
   • Physical therapy

3. Advanced Phase (8-12 weeks) 6

   • Occupation-specific training
   • Functional exercises

Interventional Options

• Corticosteroid injections
  • May provide short-term relief but don't change long-term outcomes
  • Limited use recommended (2-3 injections, 4-6 weeks apart) 6
  • Use aseptic technique 6

Surgical Intervention

• Consider only after failed conservative management (minimum 6 months) 7
• Involves excision of pathologic portion of tendon, repair of defect, and reattachment to epicondyle 7
• High degree of subjective relief, though objective strength deficits may persist 7

Important Considerations and Pitfalls

• Misdiagnosis: Elbow pain can be referred from cervical spine or shoulder pathology
• Overtreatment: Avoid multiple corticosteroid injections as they may weaken tendons
• Inadequate rehabilitation: Complete rehabilitation program is essential for recovery
• Delayed diagnosis: Nerve entrapment syndromes may be overlooked
• Occupational factors: Failure to address ergonomic issues may lead to recurrence

Remember that most cases of epicondylitis are caused by occupational stress rather than sports activities 2, making workplace modifications crucial for prevention of recurrence.