Elbow Differential Dx

The elbow tends to see less variability in which injuries occur.  In fact, even though there could be a number of different diagnosis dealing with the elbow and forearm we typically really only see a handful regularly.  Is this due to misdiagnosis or the lack of prevalence of those ‘other’ injuries?  IDK.  Either way, here are the ones we tend to see frequently.

Dislocations

Common Elbow Injuries. Elbow dislocation.

X-ray of Posterior Elbow Dislocation. © Ultra67 | Dreamstime.com

Posterior elbow dislocation: Often occurs due to a Fall On an Outstretched Hand (or FOOSH) or hyperextension of the elbow.  It tends to be the most common amongst adolescents and young adults. With dislocation, the pointy part of the elbow moves out and back. The person will present with pain, difficulty bending the elbow and deformity at the elbow. It is usually confirmed by an X-ray and the person may be sent to physical therapy for rehab.

Radial head dislocation aka Nursemaid’s elbow: Common in children between 1-4 years old.  Typical occurs when a child is being picked up or swung by the hand or forearm while creating a distraction force. The most common example is when we pick up our kids by their arms or their arm and leg and swing them around like an airplane while we spin in a circle.  When it happens, the child will usually autosplint their arm,  which is fancy for they bring their arm in across their belly elbow at 90 degrees and supported by the other arm. Pain will be present by the wrist and the child will not be able to turn the palm up due to pain. Swelling may occur. If left neglected, nursemaid elbow may cause functional disability of the elbow. An important part of the management is educating parents about the risk of recurrence.

Ligament Sprains

UCL sprain: Ulnar Collateral Ligament or UCL, is located on the medial side of the elbow, which is the side closer to the body. UCL sprains often occur due to repetitive movements or direct blow to the elbow causing valgus, or lateral stress, onto the elbow. In acute, direct blow injuries, athlete will experience a “pop”.  This type of injury is very common in overhead athletes such as pitchers, javelin throwers, quarterbacks, tennis, volleyball, and water polo players.  A lot of times, the athlete will present with pain on the inside and back of the elbow which will differentiate it from other medial elbow injuries. They will feel pain, tenderness and instability on the inside of the elbow. If the injury cannot be fixed with therapy, another very successful way of fixing it is Tommy John surgery followed by physical therapy.  Tommy John Surgery is reconstruction of the UCL and is named after the first successful surgery on an MLB pitcher, Tommy John.

Overuse Injuries

Common Elbow injuries

Tennis Elbow, Also known as lateral epicondylitis. © Medical Stocks | Dreamstime.com

Lateral Epicondylitis aka Tennis elbow:  The Most common elbow injury. Inflammation of the lateral (outside) musculature of the elbow due to overuse or microtrauma.  The two main culprits are the tendons of the Extensor Carpi Radialis Longus (ECRL) and the Extensor Carpi Radialis Brevis (ECRB), both of which are responsible for wrist stabilization when the elbow is straight. This kind of motion or position occurs while holding a tennis racket.  Person may present with localized swelling, pain, weakness of wrist extension and grip, pain/stiffness in the AM or after periods of prolonged rest. The injury has a self-limiting course of between 12 and 18 months.  It is most commonly treated with physical therapy and in most severe cases, surgery my be required.  By the time most patients come in for therapy the swelling has abolished but the pain remains.  At this point it is treated more like a tendinopathy.

So what is tendinopathy?  Tendinopathy (or tendinosis) is a condition where the collagen fibers (that make up our tendons) begin to breakdown.  This causes pain, reduced flexibility, and decreased range of motion.  However, there typically is no swelling associated with tendinopathy.  Which is why many experts believe it is more common than tendinitis since the majority of these cases have little to no swelling.

Common Elbow Injuries

Golfers Elbow, also known as Medial Epicondylitis. © Aksana Kulchytskaya | Dreamstime.com

Medial Epicondylitis aka Golfer’s elbow: A medial elbow injury which is not as common as an UCL sprain and definitely less common than lateral epicondilytis or tennis elbow. It is an inflammation of the tendons that attach the forearm muscles to the inside of the elbow. It occurs due to repetitive movements that cause stress to the medial elbow while gripping onto something such as golf club or a baseball bat.  A Person will present with pain with resisted wrist flexion and ulnar deviation (moving the wrist towards the pinky). Tenderness is usually present with palpation of the wrist flexors muscles. Weakness in hand and fingers with numbness and tingling may also be present. This condition is usually treated conservatively at first including a combination of activity modification: ice, oral analgesics, anti-inflammatories and physical therapy. In most severe cases, surgery may be required.  Again, it more frequently presents as tendinopathy instead of tendinitis as most patients do not have a lot of swelling in the area.

Olecranon Bursitis aka student’s elbow: Bursae sacs are a thin sacs of fluid that lie between a bone and tendons, ligaments, or skin.  They are located anywhere our body has a number of soft tissue structures that run over any bony prominence.  In essence they are like our bodies ball bearings lubricating areas where a lot of repeated movement would occur over bones.  The Olecranon is the pointy part of the tip of the elbow. Olecranon bursitis is an inflammation of that bursa that lines the tip of the elbow. It may present as painful swelling and redness with a possible mass development and difficulty straightening out the arm. This condition may occur from direct trauma to the elbow or repetitive aggravation such as continuous leaning on the elbow. It is most commonly treated with rest and anti-inflammatories. Most severe cases will require surgical repair.

If you are having any symptoms described in this article or have a new pain, numbness, stiffness or tingling in any part of your body, arms or legs, contact us today!  With Direct Access in NJ we can get you in for an evaluation without you having to see your Doctor, probably quicker than you could get that appointment, while also saving you both time and money!  

Please, call us to schedule your evaluation at one of BeneFIT’s locations, Bridgewater (908.203.5200) or Chester (908.879.5700)  with one of our highly trained Doctors of Physical Therapy!

 

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