GGC - MSK Index
Osteoarthritis of the elbow is usually due to Rheumatoid Arthritis (RA), primary OA or posttraumatic arthritis. Typically it presents with pain and stiffness of the joint. With RA the patient often describes pain through range of movement which is often restricted especially into rotation particularly in latter stages of disease progression. Instability is frequently associated with these patients. With primary OA this often present with end range flexion and extension impingement pain. It is strongly associated with strenuous use of the arm, i.e. with manual workers/ labourers. Post Traumatic Arthritis presents similarly to RA with pain throughout available range, but there is not often associated instability (Soojian and Kwon, 2007).
Warning
Clinical presentations in earlier stages of OA are of loss of terminal extension and flexion, with a progression in the loss of range of movement and pain in mid arc of motion. In latter stages of the disease there can be ulnar nerve symptoms presenting (Cheung, 2008).
X-Ray will confirm the presentation of osteophyte formation and loose body presence in patients with OA.
Overview
- Optimise pain management
- Maximise range of movement
- Adaption of activities
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
Pharmacology
Advice re: NSAIDS/Analgesia. Patient to discuss with pharmacist/GP if sub-optimal. For those patients with RA appropriate DMARD’s or appropriate Anti-TNF medication would be indicated (Papatheodorou, 2013).
CSI
CSI has been indicated as effective for the management of Rheumatoid flares. There does not appear to be good evidence for use of CSI in OA elbow pain (Soojian and Kwon, 2007).
Physiotherapy
Physiotherapy is aimed at the maintenance of range of movement and adaption of ADL’s to reduce pain, minimize further deterioration and conserve energy (Soojian and Kwon, 2007).
General management guidelines for Osteoarthritis can be found on: http://pathways.nice.org.uk/pathways/osteoarthritis
Non-evidence based strategies
Electrotherapy
Insufficient evidnce to support use from recent literature search
Acupuncture
Insufficient evidence to support use from recent literature search (Manheimer et al, 2010).
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
If conservative management of the patient’s symptoms fails then the escalation is to a surgical opinion where deemed appropriate. There are no set timescales with regards to this escalation, surgical decisions are made in relation to age, functional demands, and aetiology and severity of elbow arthritis (Gallo, 2008).
Cheung, E.V., Adams, R. and Morvey, B.F. 2008. Primary Osteoarthritis of the elbow: current treatment options. Journal of American Academy of Orthopaedic Surgeons 16:77-87 Link Here (link correct as of 16/08/19).
Gallo, R.A., Payatakes, A. And Sotereanos, D.G. 2008. Surgical options for the arthritic elbow. Journal of Hand Surgery 33A (5):746 – 759 Link Here (link correct as of 30/10/2015).
Manheimer, E., Cheng, K., Linde, K., Lao, L., Yoo, J., Wieland, S., van der Windt, D.A.W.M., Berman, B.M. and Bouter, L.M. 2010. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews Issue 1. Art. No: CD001977.DOI: 10.1002/14651858.CD001977.pub2 Link Here (link correct as of 30/10/2015).
Papatheodorou, L.K., Baratz, M.E. and Sotereanos 2013. Elbow Arthritis: Current Concepts. Journal of Hand Surgery 38A (3):605–613 Link Here (link correct as of 30/10/2015).
Soojian, M.G. and Kwon, Y.W. 2007 Elbow Arthritis. Bulletin of the NYU Hospital for Joint Diseases 2007; 65(1):61-71 Link Here (link correct as of 16/08/19).
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