A joint is a place where two or more bones come together and in the case of the elbow, the common term used is a hinge joint. It is made up of three different bones: the humerus of the upper arm and the radius and ulna of the lower arm. Any pain around this joint is extremely uncomfortable and can restrict movement of the arm in general. Elbow pain can broadly be categorized into two groups: an acute injury and an overuse injury. The most common area for pain is called the lateral epicondyle, which is the outside of the elbow. The area is also known as tennis elbow, although this condition is also common in manual workers.
It is also possible for pain to occur inside the elbow. This can be a result of an acute injury causing a stress problem with a ligament in the joint or overuse, which can also lead to ligament damage. Collectively, elbow pain causes and treatment can be truly uncomfortable and will affect the lifestyle of those who acquire it. The severity of an elbow injury can often be overlooked due to the fact that people will try to carry on with a regular lifestyle without the consideration that rest may be the best form of recovery. With this being said, if the specific problem is not identified at the time of injury, it can be a long duration before the pain becomes treated as the cause will be unknown. This will often lead to trial and error treatments, which can be extremely costly with no guarantee of success.
Importance of Identifying Causes
The cause of an injury is an extremely useful piece of knowledge for the patient and the therapist. With a cause, there is an explanation for the pain. Ignoring the statement “it just happened,” this can often relate a lot more to why it happened. By understanding the cause, a prognosis can be put into place altering the activity that created the injury to avoid further damage. In the cases of overuse injury, an alternative training method may be used. Knowledge of the cause of an injury can also link to the specific problem, i.e. a ligament tear may have different symptoms or pain than a repetitive stress injury. Understanding this will further the specificity of treatments.
Overview of Elbow Pain
The elbow is a complex joint designed to withstand a wide range of movement activities. It is also quite commonly injured in most sports, and is actually the most common site of injury in bodybuilders. The reason is obvious when you look at the anatomy of the elbow. It is a joint designed for throwing and lifting activities, i.e. it is meant to be a stable joint with a strong grip and quick release – due to the interlinking of the bony anatomy when compared to the shoulder and wrist. It is the compromise between these two facts that gives the elbow its flexibility in movement, but also makes it prone to injury. Due to this fact, elbow pain is quite common and often temporary, though it can be quite severe if the injury is serious. Elbow pain can arise from three main areas: the elbow joint itself, the surrounding muscles, or it may be referred pain from elsewhere.
Pain arising from the elbow joint itself can be localized to the back or front of the joint. Pain at the back of the elbow is most commonly due to degeneration and micro tears of the common extensor tendon (lateral epicondylitis). It is common in tennis players and manual workers. Pain at the front of the elbow is usually due to inflammation of the elbow joint, mainly from acute overload such as a heavy upper body weights workout, or an activity that repeatedly locks out the arms e.g. grappling sports, or due to a trauma to the elbow. An inflammatory process may restrict elbow movement and often with rest pain.
Importance of Identifying Causes
It is very important to identify the underlying causes of elbow pain in order to receive appropriate treatment. The symptoms of a number of conditions may initially appear very similar, despite very different causes. If the incorrect treatment is applied to a particular elbow condition, the possibility of a full recovery may be compromised. In the worst case scenario, it could convert an acute, simple condition into a chronic debilitating one. This is particularly relevant when we are considering elbow tendonitis. Because there are a number of activities and injuries that can cause this condition, if the activity or behavior that caused the tendonitis is continued, or the injury is repeated, it can lead to a constant state of tendon damage and repair, eventually resulting in chronic tendon pain and a very difficult treatment process. An accurate diagnosis of the factors causing the tendonitis will allow an identification of ’cause and effect’ and enable a clear plan to be developed in order to avoid repeating the injury and aid a swift recovery.
Diagnosis of elbow pain conditions can be complex and often requires the examination from a medical professional, which includes a possible referral to a specialist. Although the acronym ‘COLDER’ can be very useful for differential diagnosis of elbow pain, where the location of the pain is tested and the onset, duration, and aggravating/alleviating factors of the pain are considered. This acronym stands for Location, Onset, Duration, Exacerbating/Relieving Factor. An articular injection may be needed to confirm the site of an injury or pain provocation tests. An MRI is often the most effective way of imaging the elbow joint and can detect even very small disruptions to the common soft tissue structures. An accurate diagnosis is an investment into appropriate treatment.
Common Causes of Elbow Pain
Trauma and Injuries
There are two types of injury that cause elbow problems. One is acute injury, which occurs suddenly such as a fall that results in a fracture or dislocation of the elbow. The other is injury that occurs over time (chronic) as a result of improper or repeated stress or force to the involved part of the elbow. An example of chronic injury is an olecranon stress fracture, which affects athletes that repeatedly perform throwing motions, or heavy lifting exercises. This type of injury over time causes the bone at the tip of the elbow to become painful and tender.
Overuse and Repetitive Strain
Overuse injury is defined as a problem that occurs as a result of repeated movements of the arm and wrist. The repeated movements can cause the tendons that connect the forearm muscles to the elbow to become inflamed, which can lead to pain and stiffness. Overuse injury can be seen in people who participate in activities such as tennis, golf, or throwing sports. This problem is similar to that seen in people who develop lateral epicondylitis, more commonly known as tennis elbow. Tennis elbow is when the outer part of the elbow becomes painful and tender. It is a condition that is also caused by damaged or inflamed tendons (the ones that join the muscles of the forearm to the outer bony part of the elbow). With tennis elbow, the pain can spread to the forearm. Similarly, medial epicondylitis (golfer’s elbow) affects the inner portion of the elbow and is a type of tendinitis that causes pain on the inside of the elbow.
Elbow pain is most often the result of tendinitis, which can affect the inner or outer elbow. Treatment involves a combination of rest, ice, and splinting, anti-inflammatory medications, and physical therapy. Only in rare cases is surgery required. The following information created by the physicians of the American Society for Surgery of the Hand will help you understand:
Overuse and Repetitive Strain
This is a very common cause of elbow pain. Repeating the same motion with the arm and elbow can overwork the muscles and put too much stress on the elbow joint. Overuse can occur with any occupation or recreational activity. It is commonly seen with tennis players, golfers, or bowlers, thus earning the title ‘washerwoman’s elbow’. However, it can also affect people who perform more simple tasks such as decorating, typing or using a computer mouse. If the conditions are right, overuse could cause a tiny tear in the origin of the wrist or forearm muscle due to sudden tensing of the muscles. This is known as a strain. This is similar to the cause of medial elbow pain in throwers as is discussed in the next section. Chronic overuse can lead to what is generally referred to as ‘repetitive strain injury’ (RSI). RSI does not refer to one specific injury, but a conglomeration of various musculoskeletal conditions due to overuse of certain body parts. It has been estimated by the National Institute for Occupational Safety and Health that RSI affects 1.8 million workers each year.
Trauma and Injuries
Injuries are a common cause of elbow pain. Pain may occur immediately after an acute injury, such as an elbow fracture, or may develop over time from an injury, such as a fall on an outstretched hand. Other common acute injuries to the elbow include bruises, strains, or sprains. A dislocation occurs when the bones of the elbow are forced out of place. Dislocations can occur when a person falls on an outstretched hand, a common occurrence in sports such as gymnastics. If not obvious, dislocations are usually confirmed with an X-ray. Finally, a more severe injury includes damage to the ligaments or tendons that stabilize the elbow. This can occur over time from overuse of the elbow joint. For example, pitchers in baseball may develop a partial tear in the ulnar collateral ligament, which may eventually lead to a complete tear during a specific incident. This is known as an injury that occurs from repetitive throwing, using the same motion. Such injuries may cause the joint to become unstable and may lead to dislocations or a feeling that the elbow “gives out”.
Arthritis and Joint Conditions
Arthritis is a condition marked by inflammation of a joint, causing pain and stiffness. The most common forms of arthritis in the elbow are osteoarthritis and rheumatoid arthritis. Osteoarthritis is a degenerative joint disease and is the most common form of arthritis of the elbow. It is a result of the wear and tear of the joint. Athletes who abuse their elbows or laborers may develop this condition at an earlier age than the rest of the population. Patients usually complain of pain with gripping or lifting activities. There is rarely any swelling present. X-rays show loss of the normal joint space.
Rheumatoid arthritis is a chronic systemic disease that affects the joints throughout the body. It is an inflammation in the lining of the joint and can affect function and mobility. Rheumatoid arthritis is a relatively rare condition of the elbow. Pain, swelling, instability, and deformity are common complaints. X-rays may show a characteristic erosion of the joint, but it is best diagnosed with an MRI or ultrasound of the elbow.
Treatment Options for Elbow Pain
Medications and Pain Management – Although the majority of people with elbow pain are not prescribed medication, for some it may be necessary. Painkillers such as NSAIDs are frequently prescribed, however, a study has found that corticosteroid injections are the most effective treatment for tennis elbow, due to their rapid and sustained pain relief. Despite their efficacy, there is evidence of a high rate of recurrence and only short-term improvements in function, so corticosteroid injections are best used as a last resort for patients who have had the condition for longer than 6 months.
3.2 Physical Therapy and Rehabilitation – Specific exercises are often helpful for resolving tennis elbow and returning to normal activities. Eccentric exercise has been found to work best, or exercise in which the muscle lengthens as it gains tension from an external force. Other physical therapy and rehabilitation measures such as massage, wrist extensor mobilization, and laser therapy may be beneficial but there is little scientific evidence to support their use. Although physical therapy is generally helpful for tennis elbow, evidence suggests that no particular form of it is superior to others.
Rest and Self-Care Measures
A splint can be used as a method to immobilize the elbow and rest the muscles and tendons. A splint is usually used for more chronic overuse conditions. It is appropriate to use one if the elbow has been aggravated from a particular activity. Wear the splint for the minimum time to allow relief of the symptoms. Typically this is for a couple of weeks. Remove the splint a few times a day to do some light exercises for the elbow, so it does not become stiff. This will help prevent disuse muscle atrophy. A splint can also be useful in post-operative or post-injection treatment when the patient needs to rest the elbow.
Use ice for pain and inflammation. Ice is very effective at limiting the amount of inflammation that occurs with minor injuries. During the first 48 hours after an injury, it is important to apply ice and elevate the affected arm. To ice the elbow, you can use a bag of frozen vegetables, or a homemade ice pack. Frozen gel packs are convenient freezer items to have on hand. Apply the pack directly on the skin over the painful area for 15-20 minutes, or until the area becomes numb, and then remove it. Repeat this every 1-2 hours. Never leave ice on for longer than 20 minutes at a time. A hot pack or contrast baths can be used in later stages to help ease stiffness or achiness in the joint.
Rest is the primary treatment for new bone spurs. This one may seem obvious, but many people ignore the pain and try to ‘work through it’. It’s important to avoid the activity that initially caused the injury. Modify your work space and technique of your activities to minimize pain. For example, if your back hurts after a certain activity, get an assessment of your posture or ergonomics at work. Ice and/or heat are easily available and can help reduce pain and inflammation.
Physical Therapy and Rehabilitation
Physical therapy and rehabilitation is often used in conjunction with rest, activity modification, and medications to improve the overall function and level of discomfort experienced in the painful elbow. Therapy modalities such as ultrasound, iontophoresis, electrical stimulation, and use of heat or ice may be used to decrease pain and swelling. Range of motion exercises are initially performed in a controlled manner to avoid provoking increased pain and inflammation in the elbow. This often includes the use of a stationary bike or gentle exercises to flex and extend the elbow within a tolerable range. A dynamic splinting program may be utilized to increase elbow extension in patients who have a flexion contracture. This is important because some of the common elbow conditions may result in decreased mobility and even a slight contracture can greatly affect the overall function of the upper extremity. Strengthening exercises are initiated once pain-free range of motion is achieved. This is a key component of the rehabilitation process as increased muscle strength will provide added support to the healing structures in the elbow and will help prevent future recurrences of similar conditions. Finally, a functional progression of exercises is performed to increase upper extremity strength and endurance to allow a successful return to prior activities or sports. This may include the use of free weights, sport cords, and sport or job-specific task training.
Medications and Pain Management
This chapter will familiarize you with the different medications that are used today for the treatment of elbow pain. Medications can be used to relieve pain and/or inflammation occurring with many common elbow disorders. The simple two types of pain-relieving medication main categories of medications for articular pain are simple analgesics, such as paracetamol and NSAIDs. Paracetamol is often the first line of treatment as it has the lowest rate of side effects and is the cheapest option. Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common category of medication used to treat inflammation. They have been used in the treatment of arthritis for many years and are a mainstay of drug treatment. All of the different NSAIDs generally have very similar mode of action, or the way they produce their effects. They are effective pain relievers and they act to reduce inflammation. This is done by blocking the action of an enzyme COX, that is involved in production of chemicals that cause pain and inflammation (prostaglandins). Some NSAIDs such as ibuprofen are classified as non-selective, as they block both COX-1 and COX-2 enzymes. While newer drugs such as celecoxib are selective and only block the COX-2 enzyme. This is because long term use of NSAIDs can cause stomach pain, ulcer and heartburn as they also block COX-1 enzyme that protects the lining of the stomach. All of the NSAIDs are taken by mouth and the dose depends upon which one is being used and what it is treating. If an elderly patient has gastrointestinal and renal problems then it may be better for them to take a lower dose of NSAIDs. Alternatively it may be prescribed at a higher dose for an athlete with an acute injury and no pre-existing health problems. In comparison to these analgesics and NSAIDs, the second category of drugs corticosteroids are much more prominent in treating pain and inflammation in the elbow. This is because they do not only act as a pain reliever, they are also one of the most effective ways of reducing inflammation. Corticosteroids are hormones that are produced naturally in the body, which have many different functions including control of metabolic processes, immune system function and the body’s response to stress. In the use of medicine they can be used to imitate the effects of the steroids that are produced in the adrenal gland. A synthetic corticosteroid drug is prescribed by a doctor and administered directly into the site of inflammation in the muscle or joint. This could be done through a local injection or if inflammation is widespread then it may be given in the form of oral tablets. An injection is the most effective method of delivering the drug to the interior of a joint, where it will act more efficiently than in the surrounding tissues. Tablets are a less desirable option as they will affect the whole body, potentially causing side effects while acting only a short distance from their target. A corticosteroid is a highly effective yet controversial method of treatment, with fear of side effects and long-term suppression of natural corticosteroid production. Although this method is most effective for treatment of a severe condition, it is rarely used for simple and acute elbow injuries due to potential risk and cost of treatment.
Surgical Interventions
There are surgical options for the treatment of tennis elbow, but the evidence for their benefit is mixed. Successful surgical outcomes for tennis elbow are less predictable than those for golfer’s elbow. This is because the extensor tendon degeneration in tennis elbow can be associated with inflammatory or arthritic changes in the elbow joint. Like ligament injuries, chronic joint changes may get worse after surgery. This is particularly true in patients over 40 years old with a longstanding history of symptoms.
An innovation in the surgical management of elbow dislocations is the use of a tiny camera and instruments to repair elbow ligaments. This method, called elbow arthroscopy, is less invasive than previous open surgery and has a lower risk of complications. Unfortunately, it is often only suitable for partial tears of the lateral ligament complex. Full-thickness tears or ligament avulsions from the bone are usually best managed with open surgery.
Elbow injuries often heal with time. That’s usually not the case with recurrent elbow dislocation that has occurred over many years, especially if associated with a fracture. In these cases, the ligaments are often too damaged to heal back to the bone, and it is unlikely that the stability of the elbow will be restored without surgery. While operation carries a higher risk of long-term elbow stiffness, it can be preferable to a lifetime of intermittent elbow dislocations.
Elbow Nerve Pain Treatment in Singapore
Neurologists in Singapore are commonly seen in either government or private institutions. Patients with nerve pain are usually referred to neurologists from the polyclinics or the orthopedic surgeons. However, there are few who have a special interest in peripheral nerve problems, muscle disease, EMG, and nerve ultrasound. There are many causes of nerve pain, and these doctors would often work closely with the orthopedic surgeons to make a diagnosis and plan the right treatment. This may include referral to the neurologist in cases of nerve entrapment, i.e. carpal tunnel syndrome, cubital tunnel syndrome, and peroneal nerve entrapment.
At present, the gold standard investigation for nerve pain is nerve conduction studies and EMG. The former test assesses the function of the motor and sensory nerves in the limbs, while the latter is a needle test that assesses the function of the muscles and the nerves supplying the muscles. These tests would help the doctors confirm the site of nerve compression and the extent of damage to the nerve. High resolution (7-12 MHz) US as done by the musculoskeletal radiologists is a useful tool to aid diagnosing nerve compression, especially in the case of peroneal nerve at the fibular head or at the various common sites of radial nerve and posterior interosseous nerve.
Specialized Medical Centers and Clinics
One well-known center for pain management in Singapore is the Pain Relief Clinic at Novena Medical Center, founded by Dr. Terence Tan. He has a special interest in treating neurological pain and is trained in the method of Nerve and Spinal Cord Stimulation for pain management by world-renowned experts. Another pain specialist based in a private practice is Dr. T. Jayaraman at Gleneagles Medical Centre. These doctors would be able to diagnose the source of the pain and provide the appropriate treatment. Do note that consultations with pain specialists may not be covered by insurance, and the costs could add up. As an alternative, sufferers of nerve pain can also consult a neurologist at a public hospital (e.g., Singapore General Hospital, Tan Tock Seng Hospital). Neurologists are generally well-educated on neurological diseases and disorders and would also be able to diagnose the problem. However, the waiting time for an appointment could take several weeks to months, and often patients are not willing to wait that long to relieve their pain.
Non-Surgical Treatments for Nerve Pain
The ulnar nerve can be put under considerable stress as it travels through the cubital tunnel at the elbow. When combined with the repetitive trauma the nerve can be subjected to in tardy ulnar palsy, this can result in ulnar nerve fibrosis and partial tearing of the nerve. Ulnar nerve fibrosis refers to degenerative changes in the nerve. These changes can lead to compression and irritation of the nerve. Techniques to remove compression of the nerve at the cubital tunnel are often successful in providing pain relief and preventing disease progression. This can be done by modifying or avoiding the activity that increases the nerve compression. An example would be using a headset or speakerphone rather than cradling the phone between the ear and shoulder. For some cases of mild compression, simple bracing of the elbow at night in a position of slight flexion may be sufficient to prevent progression of the condition. This is achieved by using a towel or commercially available brace. A recent study has suggested that therapeutic ultrasound may be effective as an initial treatment for cubital tunnel syndrome.
There are a number of treatment modalities that are appropriate for elbow nerve pain treatment compression / tardy ulnar palsy that do not involve surgery. These treatments are usually based around removing the compression of the ulnar nerve and also improving its function. They are mainly for mild to moderate cases of nerve compression early in its course.
Surgical Procedures for Nerve Compression
This aspect of treatment holds much promise for both partial and complete recovery. At present, surgery is the only way to treat nerve compression effectively. This is an important consideration for an aging work force who may need partial or complete relief from their symptoms in order to continue working. The ability to arrest progressive muscle weakness and atrophy may allow some patients to regain near full function. For a high performance athlete, successful surgery may mean the difference between competing and an alternative career. Successful surgical treatment may allow return to competitive athletics in sports with a high demand on the extensor system. This may not be in the best interest of patients engaging in heavy labor or those with sedentary jobs, but the option of qualitative pain relief should be weighed against the risk of complications or need for additional surgery. An informed decision is vital to the treatment of nerve compression at the elbow.
There are various surgical techniques to decompressing a pinched ulnar nerve at the elbow (cubital tunnel syndrome). Some advocate simple in-situ decompression, whereby the constrictive tissue is divided and the overlying structures left intact. Transposition of the nerve to prevent further compression is the treatment of choice if the ulnar nerve subluxes or dislocates from its groove behind the medial epicondyle. This can occur when arresting the arm flexed for long periods, a position commonly seen in a tradesman resting on an elbow, a Sunday gardener or a patient in a recovery room. Subluxation of the nerve often causes or exacerbates symptoms and it is ill-advised to simply decompress the nerve without correcting this abnormality.
