A 58-year-old, right-hand dominant male is referred to the Physical Medicine and Rehabilitation (PM&R) clinic from his primary care provider for right elbow pain. His pain is located on the medial aspect of his elbow. The pain started 4 months ago and was a dull and achy sensation initially but has worsened to a sharp pain radiating to his inner forearm for 1 month. He notes pain is 6 on a 10-point visual analogue scale. He has occasional numbness and tingling in the medial aspect of his palm and pinky finger for the past 3 weeks which was not present in preceding months. Pain at times wakes him up from his sleep. He does not recall any inciting event, trauma, or accidents. He denies any neck pain, arm, or hand weakness. He has taken ibuprofen which helped initially but now provides minimal pain relief.
Review of Systems
Past medical history: He has a history of diabetes for which he is on metformin 500 mg daily for the past 15 years and knee osteoarthritis
Social history: He works as a mechanic. He is widowed and lives in a private house with his 22-year-old son. He smokes 3 to 4 cigarettes per day.
Past surgical history: Tonsillectomy at 13 years of age
Allergies: Shellfish, pollen
Medications: Metformin 500 mg bid, occasional Tylenol and ibuprofen
Vitals: BP: 128/78 mmHg, HR: 72 beats per min, RR: 14/min, Temp: 98.2° F, Ht: 5’10”, Wt: 235 lbs, BMI 32.2 kg/m 2
Examination
General: Obese middle aged man, appears in mild distress, alert
Head, eyes, ear, nose, and throat (HEENT)-PERRLA-extraocular movements (EOM) intact, no ptosis, anicteric sclera
Extremities: No edema, no skin rashes, no surgical scars, no fasciculations seen on C spine
Full range of motion (ROM) of C-spine in all directions
Manual muscle testing: 5/5 shoulder abduction, elbow flexion and extension, wrist extension, finger abduction, finger flexion but giveway because of pain with resisted wrist flexion and pronation on the right fist grip intact bilaterally
Deep tendon reflexes 1+ Biceps, BR, triceps bilaterally, negative Hoffman
Tone normal
2+ radial pulses
Sensation: Intact to light touch in arm and forearm in all dermatomes, diminished light touch over dorsal and palmar ulnar aspect of the little and ring finger
Musculoskeletal pain with palpation at the medial epicondyle
No muscle atrophy, no deformities
Full ROM of elbow but pain at end of range of elbow flexion, shoulder, and wrist
Gait normal, nonantalgic
Laboratories: White blood cell (WBC) 6.5 H/H 34/13, blood urea nitrogen (BUN)/creatinine (Cr) 21/0.9, hemoglobin (Hgb)A1c 6.4%
General Discussion
There are several causes of medial elbow pain. A differential diagnosis should be generated as an initial approach to identify the most likely condition(s). One should be aware of the potential for more than one condition present at the same time. Medical history should include questions about recent trauma, surgery, illness, and intravenous (IV) drug use. Physical examination should include examination of cervical spine, shoulder, elbow, wrist, and hand with comparison to the unaffected side. Report of numbness and/or tingling of the hands and an abnormal sensory examination should prompt further investigation for possible nerve compression.
Differential Diagnosis
Medial epicondylitis (ME)— also known as golfer’s elbow. Patient complains of pain over the medial epicondyle. Caused by repetitive valgus stress, flexion leading to inflammation of the common flexor tendon, and hypertrophy of medial epicondyle. Pain is reproduced with flexion and pronation. May involve an associated ulnar nerve neuropathy ( Fig. 7.1 ).
Fig. 7.1
Medial elbow anatomic structures.
S.D. Waldman, Atlas of Pain Management Injection Techniques, 3e, Elsevier, Philadelphia, 2012, Fig. 49-3.
Ulnar collateral ligament (UCL) sprain —typically seen with overhead athletes, such as baseball pitchers, tennis players, football quarterbacks, and volleyball players. It is also important not to overlook an associated UCL tear.
Cubital tunnel syndrome— common medial elbow pain found in athletes and manual laborers or workers exposed to repetitive motion. The incidence is quite high and is reported at a rate of 0.8% per person-year in laborers. Cubital tunnel is formed by the medial epicondyle medially, olecranon process posteriorly, and bordered by the Osborne ligament and the ulnar collateral ligaments. The ulnar nerve passes through this tunnel and is vulnerable for compression.
Osteochondritis dissecans (OCD)— is defined as an inflammatory condition of bone and cartilage. This can result in localized necrosis and fragmentation of bone and cartilage. OCD of the elbow is most commonly seen in the adolescent population (ages 12-14) in particular throwing sports or upper limb dominant sports such as baseball or hockey; hence the common term little leaguer elbow.
In the elbow, the most common area affected is the capitellum, although it has been reported to affect the olecranon and the trochlea. One or more flakes of articular cartilage have become separated. These form loose bodies within the joint. The separated flakes can then ossify due to nourishment by the synovial fluid. The cartilage is damaged and can form a loose body. Conservative management, analgesia, NSAIDs, and bracing to offload the joint are indicated. Treatment includes a hinged brace set to a pain-free range of movement (ROM), ceasing sports or activities that aggravate symptoms for 6-12 weeks, activity modification, and occupational therapy (OT). 17
Surgical management: Arthroscopic surgery will aim to assess the anterior elbow, remove loose bodies and fragments, debride any necrotic bone to stimulate increased blood flow. A large fragment may need to be reattached to the capitellum via K wire or screw fixation. In severe cases, osteochondral grafting may be required. 18,19
Ulnohumeral osteoarthritis —presents as pain in the elbow. Affects women >men in early osteoarthritis, patients complain of elbow pain at the extremes of flexion and extension. At maximum extension, degenerative osteophytes on the olecranon impinge with osteophytes present on the olecranon fossa. At maximum flexion, osteophytes of the trochlea and coronoid cause impingement. Coupled with pain, elbow stiffness and ROM are due to these impinging osteophytes and the capsular contracture that commonly develops during the disease process. Mechanical symptoms such as catching and locking may be present due to the presence of intraarticular loose bodies. In addition to pain with ROM, patients with elbow arthritis often report an inability to carry heavy objects.
Treatment is pain relief with NSAIDs, physical/occupational therapy for modalities, ROM exercises, bracing and position modifying techniques, elbow bracing for unloading. If conservative management fails, surgical ulnohumeral arthroplasty, open osteocapsular debridement, and/or arthroscopic debridement are recommended for patients with impingement symptoms and pain at the extremes of motion and those with mild to moderate degenerative changes associated with restricted ROM short of the functional range. For patients older than 60-65 years, total elbow arthroplasty is considered the treatment of choice, and for those who complain of a painful elbow with a restricted ROM in the setting of significant degenerative changes
Occult fracture — can occur because of a fall or other type of sudden (acute) injury. Such fractures can also occur because of repetitive injuries or normal stresses on weak bones such as osteoporotic bones, Fractures caused by repetitive injuries are fatigue fractures. Those that result from normal stresses on weak bones are insufficiency fractures. Another name for these fractures is stress fractures. These features can be induced by long-term steroid use. MRI is one of the best tools for diagnosing occult fractures. Treatment depends on the cause. Bracing is helpful. If conservative management fails patient may need surgical fixation.
Case Discussion
The patient reports no preceding trauma or illness. Cervical spine should be evaluated to rule out other causes of neuropathy. The intrinsic muscles of the hand should be examined for muscle atrophy as may be seen with ulnar nerve pathology. The active and passive ROM of the elbow may be used as a dynamic evaluation of any abnormalities that may contribute to nerve compression. Two-point discrimination involves the use of monofilaments to accurately test the loss of a patient’s sensation. Motor strength in all upper extremity muscle groups is tested, with particular focus on grip strength and the ability to abduct fingers against resistance. Provocative tests include the Tinel sign, which is positive if the patient experiences a tingling sensation in the ulnar nerve distribution when the ulnar nerve is percussed proximally at the elbow. Elbow flexion-compression test is another provocative test, which is positive if the patient experiences numbness in the ulnar nerve distribution while the elbow is flexed. Other tests include the compression test and ulnar nerve subluxation.
ME is typically seen in 40- to 60-year-olds. Besides athletes, it is a common occupational disorder with a prevalence as high as 5%. There is a common association between ME and ulnar neuropathy at the elbow with a range in prevalence from 23% to 61%. Classification of ME is related to the presence and severity of concomitant ulnar neuropathy. Type 1 includes epitrochleitis without neuropathy, type IIA includes symptomatic patients without deficit, and type IIB include patients with clinical deficit and electromyographic changes.
Cubital tunnel syndrome is common medial elbow pain found in athletes and manual laborers or workers exposed to repetitive motion. The incidence of cubital tunnel syndrome is quite high and is reported at a rate of 0.8% per person year in laborers ( Fig. 7.2 ). Paresthesia of the ulnar hand can also result from C8/T1 radicular compression, lower trunk or medial cord brachial plexopathy, thoracic outlet syndrome, or ulnar nerve compression within the Guyon canal at the wrist or at the cubital tunnel at the elbow. Patients who have cervical radiculopathy generally report neck pain radiating into the arm, sensory changes, and weakness in ulnar and median innervated muscles, such as the thumb abductors (median innervated) and finger extensors (radial innervated), with sensory changes that extend into the medial forearm.
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