Elbow PainHealthshare Information for Guided Patient Management

Index

Introduction 2

Lateral epicondylitis 3

• What are the symptoms 3

• What can be done to help? 3

• Wrist flexion stretches 4

• Eccentric loading exercise programme 4

Medial epicondylitis 5

• What is medial epicondylitis? 5

• What are the symptoms? 5

• What can be done to help? 5

• Wrist extension stretches 6

• Eccentric loading exercise programme 6

Biceps tendonitis 7

• What are the symptoms 7

• What can be done to help 7

• Accentric loading exercise programme 8

Osteoarthritis (OA)/loose body problem 9

• What is elbow osteoarthritis or a loose body problem? 9

• What are the symptoms 9

• What can be done to help? 9

Olecranon bursitis 10

• What is olecranon bursitis 10

• What are the symptoms 10

• What can be done to help 10

Contact us 12

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IntroductionThe aim of this booklet is to provide you with information that may help you understand and treat your elbow problem.It has been divided up into sections that cover the various issues that can occur with elbows.

The elbow consists of the upper arm bone (humerus) and two bones in the forearm (radius and ulna). It works in twoparts. One part acts like a hinge allowing you to bend and straighten the elbow. The second part provides rotationof your forearm (e.g) palm facing up or down.

There are a few issues that can occur with the elbow joint and its surrounding soft tissues. These include:1. Lateral epicondylitis (tennis elbow)2. Medial epicondylitis (golfers elbow)3. Biceps tendonitis4. OA/loose body problem5. Olecranon bursitis

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Ulna

RadiusAnnular ligament

Joint capsule

Articularcartilage

Trochlea ofthe humerus

Jointcavity

Olecranonprocess

Olecranonbursa

Synovialmembrane

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in Lateral epicondylitis

What is lateral epicondylitis?

This is often referred to as “tennis elbow” but is rarely due to participation in the sport. Excessive overloading orprolonged wrist and hand gripping or twisting functions (e.g.) pruning the garden, painting, plastering, computerwork in poor postures and repetitive tasks like lifting and squeezing can all be common causes. This is made worseif the tendon is degenerative and aged. Local trauma (e.g.) impact to elbow going through a doorway, is a less frequentcause.

The tendons that control you wrist and gripping are attached to the lateral epicondyle (lumpy bit on the outside ofyour elbow) and they can become inflamed and painful causing weakness. Sometimes the symptoms include inabilityto fully straighten the elbow in a morning. This can be due to tendons attaching close to the elbow joint andinflammation can become thickened.

Area of pain

Lateralepicondule

Tendon Ulna(Forearm)

Humerus(Upper arm bone)

What are the symptoms?

The symptoms vary between patients but the most common include pain with gripping and twisting actions andrepetitive movements coupled with a load. These can cause severe weakness and pain. You may get discomfort whenyou move your arm (e.g.) bending and straightening your elbow. Sometimes the pain may be severe enough to disturbyour sleep. The outside of your elbow can often feel tender to the touch and there can rarely be some swelling. Youmay also have pain that travels further down your forearm. If the inflammation is very bad then the pain can wakepeople at night.

What can be done to help?

There are many options in the treatment of tennis elbow and these include:• Local icing• Medication• Exercises – stretches/strengthening.• Reduction of overloading activities• Use of a support called an Epiclasp• Injections to improve the inflammation although these may only offer short term relief• In severe cases surgery may be indicated

Icing locally over the tender outside portion of your elbow will help to reduce the pain, inflammation and any swelling.

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Medications such as analgesics (e.g.) Paracetamol, Codeine and Non-steroidal anti inflammatories (e.g.) Ibuprofen,Naproxen or Diclofenac can help by reducing the body’s pain levels and inflammation. It’s important that they aretaken on a regular basis and at the recommended dose to help you control the pain and allow you to continue withthe exercises. You must not wait until your pain is severe before taking the medication.

IMPORTANT:

You shouldn’t take ibuprofen or aspirin if you’re pregnant or have asthma, indigestion or an ulcer until you’ve

spoken to your GP or consultant.

Exercises such as tendon and muscle stretching help to restore the length of the tissue and strengthening exerciseshelp to improve the tendon loading capacity (e.g.) eccentric loading exercises.

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Wrist flexion stretches

These can be used to gently restore the length of themuscle and tendon complex prior to the eccentricloading exercise programme.1. Keep the elbow straight and flex the wrist

downwards, apply a little pressure by using theunaffected hand to gently stretch.

2. You should feel a mild stretch to the upper side ofyour forearm but this should be pain free.

3. Hold for approximately 10 seconds.4. Repeat 10-15 times, four times daily.

Eccentric loading exercise programme:

1. Seated in a chair, support the forearm over theedge of a table or over your knee and hold a weightin the hand with the palm facing down.

2. Maintain your wrist fully bent downwards. By usingyour unaffected hand lift your wrist up all the wayback.

3. Then slowly lower the weight until the wrist is fullybent (flexed).

4. Repeat this movement to 15 repetitions. It isimportant you release the hand slowly downwards

5. After 15 repetitions rest for couple of minutes thendo a further 15 reps.

6. Do 3 sets of 10-15 repetitions, twice daily.7. You may feel sore and tender during or immediately

after the exercises but don't worry this shouldgradually improve.

8. Remember you WILL NOT notice immediate resultsas it generally takes 8 to 12 weeks to improve.

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in Reducing the aggravating/overloading activities will allow the body to reduce pain and inflammation and then helpstart the repair process. This may be difficult when in work situations but lifting objects with your palms up and elbowsbent can reduce the load to the painful tendons.

An Epiclasp is useful for patients who perform lots of gripping, squeezing and lifting repetitions. Injections can oftenhelp when the pain is not settling along with medication, rest, ice and reduction of aggravating factors. They have ashort term effect of reducing the inflammation in the tendon attachment which following a period of rest can allowyou to continue the exercise rehabilitation programme.

Surgery is rarely needed with tennis elbow problems but if time and all other methods mentioned above are failingthen an orthopaedic surgeon can assess to see if necessary.

Medial epicondylitis

What is medial epicondylitis?

This is commonly referred to as “golfers elbow” but again like tennis elbow it is rarely to do with playing golf. It is alsoless common that tennis elbow. It occurs very much like tennis elbow with excessive loading to the tendons but thepain is centred on the medial epicondyle (opposite side of the elbow to the lateral epicondyle - lumpy bit on the insideof your elbow).

Inflamed tendon

Inside of elbow

Wrist flexor muscles

What are the symptoms?

The symptoms include pain and weakness with lifting and gripping actions that involve the wrist, along with squeezingand turning actions. The pain limits the body from allowing the muscle to pull on the tendon fully, hence weakness.Local pressure on the medial epicondyle will also be uncomfortable.

What can be done to help?

There are many options in the treatment of tennis elbow and these include:• Local icing• Medication• Exercises - stretches/strengthening• Reduction of overloading activities• Use of a support called an Epiclasp• Injections to improve the inflammation although these may only offer short term relief• In severe cases surgery may be indicated

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in Wrist extension stretches

These can be used to gently restore the length of themuscle and tendon complex prior to the eccentricloading exercise programme.1. Keep the elbow straight and bend the wrist

backwards (as if doing a Police stop/halt action)by using the unaffected side to apply a gentlestretch.

2. Alternatively lean with your palm flat on a tablewith a straight arm and the hand/wrist rotated toface you.

3. You should feel a mild stretch to the underside ofyour forearm but be pain free.

4. Hold for approximately 10 seconds.5. Repeat 10-15 times, four times daily.

Eccentric loading exercise programme

1. Seated in a chair, support the forearm over theedge of a table or over your knee and hold theweight in the hand with the palm facing up.

2. Maintain your wrist fully bent downwards. By usingyour unaffected hand lift your wrist up all the wayback.

3. Then slowly lower the weight until the wrist is fullyextended.

4. Repeat this movement to 15 repetitions. It isimportant you release the hand slowly downwards

5. After 15 repetitions rest for a couple of minutesthen do a further 15 reps.

6. Repeat 3 sets of 10-15 repetitions, twice daily.7. You may feel sore and tender during or immediately

after the exercises but don't worry this shouldgradually improve.

8. Remember you WILL NOT notice immediate resultsas it generally takes 8 to 12 weeks to improve.

See above “lateral epicondylitis” section for the expanded explanation of other interventions.

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Biceps tendonitis

What is biceps tendonitis?

The biceps muscle is situation at the front of your arm between the shoulder and elbow joints. The action of themuscle is to bend your elbow. As the muscle shortens it pulls on the tendons that attaches across the elbow joint andpulls the forearm up. The tendon can become painful and inflamed if there are excessive and repetitive forces applied. It will then become very painful to bend at the elbow or lift objects up.

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Proximal bicepstendon

Distal bicepstendon

What are the symptoms?

Biceps tendon pain can be setoff or aggravated with elbow bending and lifting, sometimes straightening the arm oreven carrying shopping bags. The arm can also feel weak during these activities. In severe cases the tendon canpartially tear or rupture which on contraction of the biceps looks like a “popeye muscle”. If you have this type ofsymptom please make an appointment to see your physiotherapist for further advice.

What can be done to help?

There are many options in the treatment of biceps tendinitis and these include:• Local icing• Medication• Exercises – stretches/strengthening• Reduction of overloading activities• Injections• In a small number of cases surgery may be indicated

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in Eccentric loading exercise programme

1. Seated in a chair, support the forearm over the edge of a table or over your knee and hold a small weight(e.g.) tin of beans, in the hand with the palm facing up.

2. Maintain your wrist in a neutral position. By using your unaffected hand help bend your elbow all the wayso the weight touches your shoulder.

3. Then slowly lower the weight until the elbow is fully extended.4. Repeat this movement to 15 repetitions. It is important you release the elbow slowly straight.5. After 15 repetitions rest for a couple of minutes then do a further 15 reps.6. Repeat 3 sets of 10-15 repetitions, twice daily.7. You may feel sore and tender during or immediately after the exercises but don't worry this should gradually

improve. As you get stronger increase the load on the tendon by adding more weight.8. Remember you WILL NOT notice immediate results as it generally takes 8 to 12 weeks to improve.

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What is elbow osteoarthritis or a loose body problem?

Osteoarthritis (OA) of the elbow can occur through degeneration often called “wear and tear” or following a dislocationor fracture that has healed leaving some rough surfaces of the elbow joint. This occurs as the cartilage (protectiveouter covering of the bone) starts to become thinned and worn. OA usually affects the weight-bearing joints, suchas the hip and knee. The elbow is one of the least affected joints because of its well matched joint surfaces and strongstabilising ligaments. As a result, the elbow joint can normally tolerate large forces.

The joint becomes painful and stiff as well as loss of ability to straighten or bend fully. This is commonly a slowprogressive problem over time and most patients may notice the inability to straighten their arm first.

OA can sometimes lead to a loose body which is a floating bit of bone or cartilage within the elbow joint and can causepain and intermittent locking or reduced movement. Other causes of a loose body are often trauma related throughsports (e.g.) goalkeeper impacts with ground or following a fall.

What are the symptoms?

Symptoms often include pain and reduction of normal movement. If there is a loose body in the joint then there is apossibility of intermittent locking.

What can be done to help?

There are a small number of options with elbow joint OA.• Medication• Exercises – stretches• Injections

Simple gentle bending and stretching exercises can help restore the elbow movement and reduce stiffness. If thesefail to improve your symptoms an injection could be used to help reduce the pain to allow for exercises to be completed.A loose body may need to be operated on by an Orthopaedic surgeon where they remove the offending fragmentand wash/clean the elbow joint out.

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What is olecranon bursitis?

The olecranon bursa is a fluid filled sac that sits on the tip of the elbow and its role is to allow free flowing movementof structures around the elbow joint. When it becomes irritated the bursa lining produces more fluid than usual andpain, redness and a large bulbous swelling around the olecranon is formed. This is a rare problem.

Humerus

Radius

UlnaOlecranon bursa

Bursitis normally develops as a result either of a single injury to the elbow (e.g.) a hard impact to the tip of the elbow,or more commonly due to repeated minor injuries (e.g.) repeated leaning on the point of the elbow on a hard surfaceat work. The possibility of developing the condition is more common as you get older.

Another possible cause of inflammation of the bursa is an infection. This will also be painful and red and may becaused by a cut to the region allowing bacteria to enter the elbow.

What are the symptoms?

A large soft compressive lump appears on the tip of the elbow. Pain and redness are also commonly present.

What can be done to help?

• Local icing• Medication - NSAIDS• Reduction of overloading activities• Injection/aspiration to reduce/remove the fluid• Surgery

The need to reduce the aggravating activities or trauma is essential for the stress on the bursa to be lessened and allowit to settle down.

Treatment for more severe cases may include aspirating the excess bursa fluid with a syringe (draining of the bursa).The fluid often returns if the offending actions are not changed.

In case of an infection, elbow bursitis should be treated with antibiotics. Surgery is rarely considered, only if yoursymptoms fail to improve with all conservative treatments.

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Notes

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