Elbow Pain

Elbow Pain, What is it?

Experiencing elbow pain can be frustrating and limiting.  While elbow pain typically isn’t serious, if not addressed, it can turn into a chronic condition. The causes of elbow pain can range from a sudden onset like simply hitting the elbow on a surface, causing a quick occurrence of pain or tingling, to repetitive wear and tear over months or years, inflammation, or pain from a major traumatic injury.

The elbow has three bones including the humerus (upper arm), ulna (forearm bone), and radius (forearm bone).  The humerus is the largest of the three bones.

The ulna is the second largest bone which makes up the elbow joint. The ulna forms the “point” of the elbow, called the olecranon. The cup shape of the ulna aligns perfectly with the humerus on the inside of the elbow. The radius is the smallest of the elbow bones. It is also cup-shaped and fits with the humerus on the outside of the joint when the palm is facing forward.

The three bones make up three joints within the elbow that allow for flexion, or bending the elbow; extension, or straightening the elbow; and pronation and supination, motions in which the forearm turns palm-down and palm-up.

An injury can occur to any of, or all, the bones of the elbow. Injuries can also occur to soft tissue like muscles, tendons, ligament, cartilage, and the bursa. There are six major muscles around the elbow that assist with movements, they are:

  • Biceps Brachii- begins at the front of the shoulder blade and humerus with two heads – or starting points, and runs down the front of the arm and attaches to the radius bone; main function is flexion and supination of forearm
  • Triceps Brachii- also begins at the shoulder blade, has three heads, and runs down the back of the arm and attaches to the olecranon; the main function is extension of the elbow
  • Brachialis- starts at the lower half of the humerus bone and attaches to the ulna; the main function is flexion and pronation
  • Brachioradialis- starts at the lower third of the humerus on the outer side and attaches at the radius; the main function is flexion, supination, and pronation
  • Pronator Teres- starts on the humerus just above the medial epicondyle and attaches to the outer side of the radius; the main function is flexion and pronation; it is the main culprit for golfer’s elbow
  • Extensor Carpi Radialis Brevis- starts on the humerus just above the lateral epicondyle and attaches to the middle of the back of the hand; the main function is extension of wrist and elbow; it is the culprit for tennis elbow

Muscles assist with movement of bones. They attached to bones by way of tendons. Muscles have the most blood supply which allows for quicker healing.  Tendons, on the other hand, have less blood supply which is why healing is often slower. When a tendon is acutely irritated it is called tendinitis, when there is chronic wear and tear it is called tendinopathy.

Ligaments attach bone to bone and provide stability but offer a small amount of flexibility to allow the joint to move. There are three main ligaments in the elbow: medial collateral, lateral collateral, and annular. The medial ligament, also called ulnar collateral ligament, is on the inside of the elbow. The lateral collateral, also called radial collateral, ligament is on the outside of the elbow. Finally, the annular ligament encircles the radius and helps maintain the humeroradial joint.

The main goal of the ligaments is to ensure there is stabilization of the joint. It prevents extra or unwanted movement of the joint, yet maintains joint space, and holds the bones together. Just as with muscles and tendons, ligaments can become irritated, inflamed, or even torn. They have the least amount of blood supply which means healing may be slow.

Within the joint structure, cartilage and a bursa sac are present. The cartilage covers the end of each bone within the elbow which allows for smooth movements of the joint.   Additionally, it protects the bones from wear and tear. The bursa sac in the elbow is fluid-filled and lays over the olecranon to protect it.

The cartilage and bursa can also cause problems. Over time or with an injury, the cartilage can be damaged causing pain with elbow movements. Also, the bursa sac can become irritated and inflamed causing swelling and pain at the olecranon.

Along with bones and soft tissue that make up the elbow, nerves run through the joint. There are three main nerves which travel from the neck down the arm and through the elbow to the hands. The nerves are the pathway of how the brain communicates with the muscles to make movement happen.  Nerves also conduct sensation, such as pressure, pain, vibration, and temperature.

The three main nerves of the elbow and their roles are:

  • Radial nerve- responsible for elbow, wrist, and finger extension as well as forearm supination; affects motor and sensory of the thumb and first two fingers on the back of the hand
  • Ulnar nerve- responsible for wrist and finger flexion as well as adduction (pulling together) of the fingers; affects motor and sensory of the ring and pinky fingers.
  • Median nerve-allows for wrist flexion and pronation of forearm; affects motor and sensory of the thumb, pointer, and middle finger (mostly on palm side of hand)

What causes elbow pain?

Elbow pain is commonly caused by wear and tear, overuse, or from trauma. Any structures within the elbow can break down or be damaged. With trauma, the humerus, ulna, or radius bones can fracture or dislocate. Frequently, with that type of injury, there is damage to surrounding ligaments, tendons, cartilage, and sometimes the nerves.

Soft tissue injuries are typically related to overuse of the elbow, wrist, and hand. Common overuse injuries involve tendinitis, which is inflammation of the tendon or bursitis, inflammation of the bursa. In some cases, the inflammation may be so severe it compresses one of the nearby nerves causing numbness, tingling, and sometimes weakness.

Just like tendons, ligaments can get irritated or inflamed from overactivity or chronic stresses. Severe sprains of the elbow in which the ligaments tear, is often the result of a traumatic event.

Nerve injuries can also be a cause of elbow pain. Elbow fractures or trauma commonly cause a radial nerve injury. Overuse may cause irritation or compression.  Symptoms are typically on the outside of the elbow and may radiate down to the hand affecting wrist and finger extension.

Ulnar nerve injuries are commonly caused by entrapment which means the ulnar nerve is compressed. This nerve injury commonly occurs at the elbow joint. Compression of the nerve may be caused by fractures, dislocations, or inflammation. Symptoms are typically on the inside of the elbow and may radiate down the hand affecting wrist and finger (ring and pinky fingers) flexion.

Median nerve injuries are the most common cause of carpal tunnel syndrome, which is where the median nerve becomes “pinched” or inflamed at the wrist affecting the hand. The median nerve can also have trauma elsewhere, but at the wrist is most common.

The most common causes of elbow pain are:

  • Arthritis
  • Bursitis (bursa is inflamed)
  • Compressed or trapped nerve
  • Dislocation
  • Fracture
  • Overuse
  • Strains or sprains
  • Tendinitis
  • Trauma

Less common causes of elbow pain include:

  • Osteochondritis Dissecans (uncommon disease where cartilage breaks down)
  • Tumor

Symptoms of Elbow Pain

Symptoms will vary depending on the injury. Seek medical attention if any of the following symptoms are occurring:

  • Deformity of the joint
  • Loss of sensation in the hand
  • Loss of range of motion or “locking”
  • Numbness or tingling that won’t go away
  • Protruding bone
  • Severe swelling, pain, and possibly redness
  • Weakness in the hand

Elbow pain can range from a mild ache to severe, sharp pain. It can also occur during activity or get worse after activity.  People often report their symptoms worsen at night when they are trying to fall asleep.

Nerve injuries can be very uncomfortable and usually are coupled with weakness, numbness, tingling, and loss of sensation.  The location of the symptoms on the forearm and hand typically indicates which nerve is the injured one.

With bursitis, typically there is not nerve involvement. People with elbow bursitis will sometimes see redness and will often see swelling at the olecranon. The elbow may look unusually deformed due to the swelling around the olecranon. Pain is localized and can range from mild to severe. Rarely will the range of motion be affected, but on occasion, people will report pain with movement.

How is elbow pain diagnosed?

A good place to begin is with a medical provider or a physical therapist. Occupational therapists also are highly skilled at treating conditions of the arm.  The provider will ask about the patient’s medical history and the current symptoms, and will do a physical exam of the elbow.  This will include measurements of the range of motion, testing of reflexes and strength, measurements of swelling if present, and special tests to determine if certain symptoms are produced or reduced with specific movements.  Sometimes, if the clinical examination reveals that more information is needed, further testing such as an X-Ray or MRI (magnetic resonance imaging) may be needed. When imaging is needed, a physician is looking for fractures, joint integrity, or further damage to other soft tissues.

If swelling is present, the physician may drain some fluid off the area and view it under microscope.   Blood may be drawn to test for inflammation or infection.

In all states, people can be seen by a physical therapist (PT) first, without a physician’s order. However, the guidelines for every state are different and can be found by clicking here: Physical Therapy Direct Access By State.

If a physical therapist feels the patient requires additional medical assessment or is concerned that the findings of the exam indicate a more serious condition, the PT will communicate with the patient’s medical provider and refer the patient accordingly.

Occupational Therapists (OT) are trained in treating the elbow; however, most require a physician order before he or she can begin treatment for your elbow. It is common for a physician to refer OT or PT for the treatment of elbow pain.

Treatment of Elbow Pain

Treatment of elbow pain depends on the cause and the clinical findings during the examination. The key is to get a diagnosis and start treatment early. With early intervention, elbow pain can often be treated conservatively.

Early conservative treatment following an injury can include a short period of rest and ice and control of swelling.  Applying a cold pack for 10 minutes at a time, while protecting the skin, can help control symptoms of both pain and swelling.   Avoiding aggravating activities by resting can initially be beneficial, although movement will need to be restored when the injured area is ready.

A main goal of PT and OT is to manage symptoms of swelling and pain and return the patient to functional daily activities. After a complete evaluation, which includes a medical history review and physical exam of the elbow, the PT or OT will establish a treatment plan together with the patient, and set goals to achieve throughout the course of care.  Exercises that are specific and appropriate to the individual patient will be introduced as appropriate and other therapy interventions may be performed, depending on the needs of the individual.

In rare situations, injections or surgery may be needed.  Injections may be used to address localized inflammation or pain, but therapy is usually continued as the two can work well together to help the patient improve.  Sometimes there may be an interruption for a few days immediately following the injection, but that depending on the protocol of the doctor who administered the injection.   Medications or injections are not the cure for the elbow pain, so PT or OT is highly recommended in conjunction with these treatments.

Surgery may be needed in cases where the elbow is dislocated or fractured.  Surgery may also be indicated if the conservative treatment was not helpful.  A surgeon will discuss the specifics of surgery including the type of surgery, the expected length of recovery, and the anticipated return to functional activities, and the risks and benefits of having surgery.

Next Steps

Early intervention to elbow pain is the key to managing it.  The sooner symptoms are addressed, the more likely conservative care will help.

Finding a PT with good outcomes in treating elbow pain and related conditions can be done by clicking here: Find A Clinic .

 

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