Elbow pain
Questionnaire/history:
Red flags?
- History of trauma?
- Pulled elbow?
- Dislocation?
- Fracture?
- Septic arthritis (unilateral swelling, red, tender joint +/- systemic symptoms)?
- Malignancy (rapidly increasing mass/swelling)?
Lateral elbow tendinosis (LET)?
Insidious onset pain localised to the lateral epicondyle of the elbow with radiation down the extensor aspect of the forearm?
(Note: Evidence now shows tennis elbow to be a tendinosis, rather than an inflammatory condition and is increasingly being termed ‘lateral elbow tendinosis’ (LET) rather than ‘lateral epicondylitis’)
Osteoarthritis?
Chronic progressive elbow pain with restriction of extension and end range of movements, painful clicking, catching or locking of elbow?
Inflammatory arthritis?
Bilateral elbow pain with stiffness and joint swelling, loss of full ROM, involvement of other joints, and systemic symptoms?
(Note: 20–50% of patients with rheumatoid arthritis have involvement of elbows)
Ulnar nerve radiculopathy?
Neurological symptoms?
(Note: Common in golfer's elbow, osteoarthritis (50% of patients) and inflammatory arthritis)
Referred pain from neck or shoulder?
Examination:
Neck and shoulder (?radiculopathy or referred pain)?
Swelling?
Mass?
Red?
Heat?
Point tenderness?
- Anterior to lateral epicondyle (diagnostic of lateral elbow tendinosis (LET/tennis elbow)?
- If LET suspected: Cozen’s test (resisted wrist extension with the elbow extended and forearm pronated, test positive if pain reproduced)?
- Just anterior to medial epicondyle (suggesting golfers elbow)?
- Ulnar nerve tenderness (Tinel’s sign) can be elicited just posterior to the medial epicondyle (suggesting ulnar neuropathy)?
- Localised to the area distal to radial head (diagnostic of posterior interosseous nerve compression/radial tunnel syndrome)?
Active and passive range of movement?
- Loss of full extension (suggestive of elbow osteoarthritis)?
- Reduced pronation/supination together with tenderness over the radiocapitellar joint (suggesting osteoarthritis a the radiocapitellar joint)?
(Note: Range of movement is not affected by LET)?
Investigations:
Rarely required and most diagnoses can be made clinically
X-rays if bony pathology, arthritis or trauma present/suspected?
Blood tests (and X-ryas) if rheumatoid arthritis suspected (should not delay urgent rheumatology referral)?
Management:
Will depend on the cause but for LET/tennis elbow:
Advised:
Self-management including exercises
Activity modification and relative offloading including use of tennis elbow splints (clasps)
Analgesia and ice/heat packs
Corticosteroid injections should generally be avoided - evidence they can slow/delay recovery
Resource(s):
Information for patient/carer(s):
Versus Arthritis: What is elbow pain?