Less common intra articular

Synovitis

A patient can present with any of the following: pain, swelling, loss of ROM (capsular pattern), heat, and discolouration. Check other joint involvement for possible underlying systemic inflammatory pathology (Joshua et al, 2007).

Plica

This uncommon entity is also called elbow synovial fold syndrome, posterolateral impingement or snapping elbow. Plicae have no known function and are usually asymptomatic. But as they are richly innervated, the plicae may play a role in nociception and proprioception. They can cause symptoms when they become hypertrophied or inflamed due to direct trauma, repetitive (sports) activities, overloading or other pathological elbow conditions that incite an inflammatory response. The most common synovial plica of the elbow is the posterolateral radiohumeral fold (Cerezal et al, 2013).

Synovial fold syndrome is most common in athletes and young adults and in sports that require repetitive flexion-extension. The nonspecific symptoms can consist of a snapping pain (usually located posterolaterally) and the development of catching and locking through flexion and extension.

Radial Head Instability

This is an uncommon condition and may present with a history of previous elbow dislocation or previous surgery. There may be a feeling of giving way of the elbow (unable to do press-ups or push up off a chair) (Anakwenze et al, 2014).

Synovitis

Observation, palpation and ROM. Check joint effusion/swelling.

Blood tests should be considered if an inflammatory component is suspected (see escalation).

Plica

• Range of movement can be decreased in both flexion and extension.
• Pain is usually posterolaterally (not along the lateral epicondyle or CEO).
• Reproduction of symptoms during flexion-extension of the pronated forearm should lead the examiner to consider the possibility of a pathological synovial plica (Kim et al, 2006).

Radial Head Instability

Varus or valgus stress test may be positive.

Varus test

The procedure involves the clinician positioning the patient’s elbow into approximately 20° flexion and applying a varus force, attempting to gap the lateral joint line of the elbow (Day et al 2009).  A positive test would be excessive in comparison to the other side.

Valgus test

The procedure involves the clinician positioning the patient’s elbow into approximately 20° flexion and applying a valgus force, attempting to gap the lateral joint line of the elbow (Day et al 2009).  A positive test would be excessive gapping in comparison to the other side.

https://www.youtube.com/watch?v=Hh4QQsniiy4 [This video isn't available any more]

Lateral pivot shift test

There is some evidence to suggest you could do a lateral pivot shift test as part of diagnostic testing.

• The patient is positioned in supine on a plinth. Their shoulder is in approximately 160° of flexion, the elbow in 20-30 of flexion and supinated. The clinician stands at the top of the plinth, one hand supporting the patient’s forearm distal to the elbow joint and applying the axial force down through the line of the ulna. Their other hand is grasping the patient’s wrist and applying the valgus stress to the elbow and maintaining the supinated position of the wrist. When this positioned is maintained the clinician gently moves the elbow joint into further flexion (Day et al 2009).

https://www.youtube.com/watch?v=ra7ruRA_rN0

Synovitis

X-ray can be considered to assess articular surfaces and effusion.

Plica

Ultrasound (static and dynamic) and MRI can be considered to clarify.

Radial Head Instability

Plain X-ray (AP and lateral) of the elbow exclude fracture.

Overview

• Optimise pain management
• Basic range of movement
• Education

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status.  Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved.

Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Plica

• Rest and modification of activity
• CSI can be considered

Non-evidence based strategies

Synovitis

CSI is not indicated (Joshua F, et al, 2007).

Manual Therapy
Insufficient evidence to support use from recent literature search

Acupuncture
Insufficient evidence to support use from recent literature search

Plica

Manual Therapy
Insufficient evidence to support use from recent literature search

Acupuncture
Insufficient evidence to support use from recent literatre search

Radial Head Instability

CSI
Is not indicated (Anakwenze et al, 2014).

Manual Therapy
Insufficient evidence to support use from recent literature search

Progressing as expected (up to 3 Rxs) before discharge or onward referral. 

Refer to ortho, GP, other

Synovitis

If synovitis is suspected or confirmed then refer on to GP or Rheumatology.

Plica

Referral to orthopaedics can be considered for orthopaedic opinion including appropriate imaging if the patient is not progressing and would consider orthopaedic intervention (arthroscopic confirmation of the diagnosis and subsequent removal of the synovial plica).

Radial Head Instability

Referral to orthopaedics can be considered for orthopaedic opinion if the patient is not progressing and would consider orthopaedic intervention.

Anakwenze, O.A., Kancherla, V.K., Lyengar, J., Ahmed, C.S. and Levine W.N. 2014. Posterolateral rotatory instability of the elbow. American Journal of Sports Medicine, 42(2), pp. 485-491 Link Here (link correct as of 16/08/19).

Cerezal, L., Rodriguez-Samartino, M., Canga, A., Capiel, C., Arnaiz, J., Cruz, A. and Rolon, A. 2013. Elbow Synovial Fold Syndrome. AJR 2013; 201: W88-96 Link Here  (link correct as of 16/08/19).

Day et al, 2009. Neuro-musculoskeletal clinical tests. A clinicians guide. Elsevier.

Joshua, F., Lassere, M., Bruyn, G.A., Szkudlarek, M., Naredo, E., Schmidt, W.A., Balint, P., Filippucci, E., Backhaus, M., Lagnocco, A., Scheel, A.K., Kane, D., Grassi, W., Conaghan, G., Wakefiled, R.J. and D’Agostino, M.A. 2007. Summary findings of a systematic review of the ultrasound assessment of synovitis. Journal of Rheumatology, 34(4), pp. 839-847. Link Here (link correct as of 16/08/19).

Kim, D.H., Gamardella, R.A., El Attrache, N.S., Yocum, L.A. and Jobe, F.W. 2006. Arthroscopic treatment of posterolateral elbow impingement form lateral synovial place in throwing athletes and golfers. American Journal of Sports Medicine 2006; 34: 438-444

Steinert, A., Goebel, S., Rucker, A. and Barthel, T. 2010. Snapping elbow caused by hypertrophic synovial plica in the radiohumeral joint : a review of three cases and review of literauture. Archives of Orthopeadic and Trauma Surgery 130:347-351. Link Here (link correct as of 07/10/2015).

NHS GGC Physiotherapy Service - Elbow

NHS Inform - Elbow Problems