Elbow conditions

Patient Resources

NHS Lothian MSK Self Help Resources Webpage

Edinburgh Orthopaedics

Definition

Tennis elbow is a soft tissue problem that causes pain and tenderness at the lateral elbow.  It is a tendinopathy of the common extensor origin. 

Golfer’s elbow causes pain and tenderness at the medial elbow. It is a tendinopathy affecting the common flexor origin. 

Typical signs and symptoms

Tennis elbow:

• Localised tenderness on palpation over the lateral epicondyle or surrounding area.
• Elbow and wrist joint active and passive range of movement is usually preserved. 
• Pain +/- weakness on resisted wrist extension and/or middle finger extension. 
• Grip strength may be reduced due to pain. 

Golfer’s elbow:

• Localised tenderness on palpation over the medial epicondyle or surrounding area.
• Elbow and wrist joint active and passive range of movement is usually preserved. 
• Pain +/- weakness on resisted wrist flexion and/or pronation.
• Grip strength may be reduced due to pain. 

Prevalence and risk factors

• Tennis elbow is more common than golfer’s elbow.
• Male = female; typically aged 35-54 years.
• Risk factors include: activities, sports or manual occupations that involve loading, repetitive movement or gripping; certain medical conditions and metabolic factors (e.g. high cholesterol, inflammatory conditions, diabetes, obesity), lack of quality sleep, stress, long term and excessive alcohol intake, smoking, genetics, diet and nutrition.

Prognosis/ risks factors for poor outcomes

Tennis elbow and golfer’s elbow are generally self-limiting conditions, and spontaneously improve in about 80–90% of people over 1–2 years.

Risks for poorer outcomes include: higher pain severity and disability at baseline, longer pain duration, multi-site pain, previous pain episodes, anxiety and/or depression, adverse coping strategies, low social support, poor self-efficacy, low expectations of recovery, contributing factors that affect tendon quality e.g. lifestyle - smoking, alcohol, physical activity levels; diabetes, inflammatory conditions, high cholesterol, obesity; occupational stress. 

Other considerations

Most cases of tennis elbow and golfer’s elbow resolve spontaneously.

Steroid injections are not recommended; they can help with short-term pain relief however, they can weaken tendons. Research has shown that after one year, people who have had an injection for tennis elbow tend to be worse off than those who have not.

Relevant standards and guidelines

NICE Clinical Knowledge Summaries: Tennis elbow

BESS: Patient Care Pathways and Guidelines

Patient resources

NHS Lothian MSK Self Help Resources Webpage

NHS Torbay and South Devon: Tendinopathy support video

Definition

Pain at the biceps or triceps insertion.

Typical signs and symptoms

• Biceps produces anterior elbow pain, typically deep in the antecubital fossa on resisted supination.
• Triceps produces well localised pain at the triceps insertion on resisted elbow extension
• Traumatic or atraumatic – usually due to a change in load
• Painful when starting a provocative activity
• May feel stiffness in the morning

Prevalence and risk factors

Biceps tendinopathy is relatively common.

Triceps tendinopathy is less common but occurs occasionally in weightlifters, or industrial workers, where repetitive elbow extension against resistance is required.

Other risk factors include: a change in load through the arm or elbow, certain medical conditions and metabolic factors (e.g. high cholesterol, inflammatory conditions, diabetes, obesity), lack of quality sleep, stress, long term and excessive alcohol intake, smoking, genetics, obesity; certain medications such as antibiotics (e.g. fluoroquinolones) and steroids.  

Prognosis/ risk factors for poor outcome

• Most patients improve with non-operative management.
• Can improve within weeks to months depending on contributing factors.
• May persist for several years.
• Risk factors for poor outcome may include: higher pain severity and disability at baseline, longer pain duration, multi-site pain, previous pain episodes, anxiety and/or depression, stress, adverse coping strategies, poor self-efficacy, low social support, low expectations of recovery, lack of quality sleep, lifestyle e.g. smoking, alcohol, physical activity levels; medical co-morbidities including diabetes, inflammatory conditions, high cholesterol, obesity; occupational stress; the use of medications such as antibiotics and steroids may also influence recovery.

Other considerations

It is key to exclude acute distal biceps tendon rupture as this is a red flag and requires urgent Orthopaedic opinion.

Differential diagnoses

• Elbow osteoarthritis
• Rheumatoid arthritis
• Gout
• Intra-articular loose body
• Olecranon bursitis
• Olecranon stress fracture
• Posterior elbow impingement

Patient resources

NHS Lothian MSK Self Help Resources Webpage

Versus arthritis: Osteoarthritis (OA) of the elbow and shoulder

Definition

Elbow joint osteoarthritis (OA) is characterized by age related changes of articular cartilage and subchondral bone with narrowing of the glenohumeral joint.

Typical signs and symptoms

• Pain, stiffness and loss of function
• Restriction of active and passive movement in a capsular pattern, typically loss of extension
• May have crepitus on movement
• Catching or locking may represent presence of loose fragments
• Symptoms may fluctuate with acute-on-chronic flares

A diagnosis of OA should be suspected if a person is 45 years or over with:

• Activity related joint pain.
• No morning joint-related stiffness, or morning stiffness lasting no longer than 30 minutes.
• Possible functional limitation.
• Examination findings may include: restricted and painful range of joint movement, bony swelling, joint deformity, mild synovitis or joint effusion, crepitus, and joint instability.

Prevalence and risk factors

The prevalence of OA varies depending on the joint(s) affected, the person’s age, sex, socio-economic group, and comorbidities.  Primary osteoarthritis is rare, secondary osteoarthritis accounts for the majority of cases such as following trauma, surgery, osteochondritis dissecans, synovial chondromatosis and valgus extension overload.

Risk factors include: advancing age, female > male, history of joint trauma/ fractures, obesity, lifestyle, occupational stresses, genetics, certain metabolic diseases e.g. diabetes, haemochromatosis, inflammatory arthritis; traumatic or degenerative rotator cuff tears.

Prognosis/ risks factors for poor outcome

• OA is not always a progressive condition
• Symptoms may fluctuate with intermittent acute-on-chronic flares
• Prognosis will depend on contributing factors - OA is a complex multi-factorial condition involving genetic, biological (age, obesity, metabolic health, genetics), lifestyle (physical activity, smoking, alcohol) and biomechanical (joint injury and structural changes) components

Other considerations

OA is largely a clinical diagnosis and doesn’t always require an x-ray.  Arrange an x-ray if there is diagnostic uncertainty, atypical features, or sudden worsening symptoms.

Relevant Standards and Guidelines

NICE Clinical Knowledge Summaries: Osteoarthritis

Patient resources

NHS Lothian MSK Self Help Resources Webpage

Edinburgh Orthopaedics

Definition

• Inflammation of the olecranon bursa
• Non-septic (most common): sterile inflammation resulting from various causes including trauma or overuse
• Septic: infection resulting from seeding of the bursal sac with micro-organisms, usually bacteria

Typical signs and symptoms

• Fluctuant (moveable and compressible) swelling over the olecranon
• Pain (although may be painless), redness, warm to touch
• Elbow joint movement should be painless except at full flexion when the swollen bursa is compressed
• Septic bursitis: painful, red, hot swelling, progressively worsening; localised cellulitis, abrasion at the elbow, systemic symptoms

Prevalence and risk factors

• Male > female, typically aged 30-60 years
• Non-septic bursitis: athletes who play sports which involve repetitive overhead throwing or elbow flexion/extension; jobs which involve risk of regular elbow trauma or pressure on the bursa e.g. gardeners and mechanics; systemic conditions, most notably gout and rheumatoid arthritis (RA)
• Septic bursitis: history of trauma/ open wound, immunocompromised

Prognosis/ risk factors for poor outcome

• 50% of non-septic cases settle within 2 weeks, 75% settle within 8 weeks
• 10% of people may still have swelling at 6 months
• Non-septic cases are more likely to recur or become chronic
• Risk factors include: occupations requiring repetitive activity increase the risk of recurrence and chronicity - activity modification should be advised

Other considerations

• If there has been a breakage to the skin, signs of infection, or any suspicion of a septic joint, this is a red flag and should be managed as an emergency
• Consider an x-ray if bony pathology is suspected e.g. history of trauma, sarcomas
• Aspiration is not routinely performed as the fluid reaccumulates, and the procedure can introduce infection
• Surgery rarely performed due to the bursectomy leaving a large scar which can be very sensitive, the swelling can come back after surgery and the elbow can become stiff and painful following the surgery

Differential diagnoses

Gout & RA are associated with olecranon bursitis

Relevant Standards & Guidelines

NICE Clinical Knowledge Summary: Olecranon Bursitis

The above list of elbow conditions is not exhaustive.  Please keep diagnosis under review and consider other potential causes.

The following article provides further differential diagnoses of elbow pain: Evaluation of elbow pain in adults