The elbow is a complicated hinge joint formed by the humerus bone of the upper arm and the radius and ulna bones of the forearm. The radius and ulna bones also form the proximal radio-ulnar joint. The bones are covered with cartilage which allows them to slide more easily and acts as a shock absorber. The bones are held together with ligaments that strengthen the joint capsule. The capsule is a fluid filled fibrous sac that surrounds and lubricates the elbow joint and includes the upper radio-ulnar joint.
The movements that occur at the true elbow joint are flexion (the palm of the hand moves up towards the shoulder), and extension (the hand is moved away from the shoulder towards the floor). The range of movement is usually between 0-150 degrees flexion. The rotation or turning movement of the forearm (pronation and supination) occurs at the upper (proximal) and lower (distal) radio-ulnar joints. Pronation is where the forearm and palm face the floor and supination where the forearm and palm face towards the ceiling.
The main extensor muscles of the elbow are triceps and anconeus. The main flexor muscles are brachiali, brachio-radialis and biceps. The latter 2 also have a role in supination of the forearm and to a lesser extent the initiation of protraction. The biceps tendon inserts into the radius and ulna at the front and the triceps tendon inserts at the back of the elbow into the olecranon. The muscles in the forearm that flex the fingers towards the palm, attach as the common flexor tendon on the medial epicondyle of the humerus. This part of the arm is nearest to the body when the palm is facing away from you. The muscles in the forearm that extend or straighten the wrist and fingers, attach as the common extensor tendon on the lateral epicondyle of the humerus. This part of the arm is furthest away from your body.
The 2 main ligaments are the medial collateral ligament, on the inside of the arm and the lateral collateral ligament, on the outside. They are made up of various smaller ligament parts which function to stabilise the elbow joint. The annular ligament holds the radial head tight against the ulna.
Bursae are small fluid filled sacs that help to reduce friction between tendons and bones. The 3 main bursae in the elbow area are one within the tendon of triceps; one between the olecranon process (bump on the back of the elbow) and the triceps tendon and another between the olecranon and the overlaying soft tissue.
Common elbow complaints and injuries
An elbow fracture is when there is a break in one or more of the three bones that make up the elbow joint. Fractures at the elbow occur as the result of a fall, a direct impact, or a twisting injury to the arm. Sprains, strains or dislocations may occur at the same time as a fracture.
Radial head fractures are the most common fractures around the elbow joint in adults, whereas radial neck fractures occur more commonly in children. These are most commonly caused by a fall on to an outstretched arm.
Olecranon fractures are low-energy fractures which occur most commonly in the elderly and result from indirect trauma caused by a sudden pull of the triceps and brachioradialis muscles. In younger patients, olecranon fractures usually follow a direct blow to the point of the elbow and are often comminuted, and there may be an associated ulnar shaft fracture.
Distal humerus fracture: these are more common in children and the elderly. They are often associated with nerve or artery damage. Supracondylar/transcondylar - most of these are extension-type injuries from a fall on to an outstretched arm. The former is more common in the young while the latter is more common in the elderly. Intercondylar fractures are T or Y shaped fractures with varying displacement between the condyles and the humerus. Condylar fractures-Lateral (outside edge) condyle fractures are more common than medial.
Capitellum fractures: These fractures are usually caused by a fall on to the outstretched hand or by direct trauma.
Dislocations at the elbow account for 10-25% of injuries to the elbow and they are the most commonly dislocated joint in children.
Elbow dislocation is the second most common major joint dislocation after the shoulder. without a fracture they are termed simple, whereas dislocations with a fracture are termed complex. A common cause of this injury is falling on the hand with the elbow bent. A backward dislocation is the most common and may be combined with a fracture.
Dislocations always involve trauma to the surrounding soft tissues, such as the medial and lateral collateral ligaments so consequently it can take time for complete healing to occur.
Ligaments are short tough bands of fibrous connective tissue. They are attached to bones or cartilage and are responsible for holding bones together and preventing excess movement and thus stabilise joints. Although ligaments are strong and rigid by nature, it is possible to injure them when their fibres become stretched or torn, or even completely ruptured. Ligaments sprains can be classified 1-3: Grade 1 is a stretching or mild tear and would not usually result in any instability of the joint. Grade 2 is a more severe tear of the ligament and will result in some joint laxity or loss of stability. Grade 3 is a complete tear or rupture of the ligament. This will result in the joint being unstable and unable to bear weight.
There are three main ligaments in the elbow joint; the medial collateral ligament (found on the inside of the elbow) this ligament is very important in elbow stability, so damage to it may impact the stability of the joint. Medial collateral ligament injuries are often associated with overuse, specifically overhead throwing: The lateral collateral ligament (found on the outer aspect of the elbow) injuries to this ligament are generally as a result of trauma (fracture or dislocation) or forceful movements following falls or forced twisting of the arm: The annular ligament (this encircles and stabilises the head of the radius) disruption of this ligament occurs especially after a fracture of the radial head.
Muscles and tendons can become strained or torn, this frequently occurs as a result of participation in sports, where the muscle becomes overloaded and consequently more likely to be injured usually through a sudden forced over stretch but can be the result of muscle fatigue. Strains are graded from grade 1 where a few fibres are torn, to a grade 3 with a complete rupture.
Symptoms vary between a cramp, tightness, pain on stretch or muscle contraction through to immediate stabbing/burning pain, bruising and swelling, difficulty moving the arm.
Biceps tendon tears
can be either partial or complete. Partial tears damage the soft tissue but do not completely sever the tendon. Whereas a complete tear will detach the tendon completely from its attachment point at the bone. Most commonly, the biceps tendon is torn at the shoulder. Tears of the biceps tendon at the elbow are uncommon and usually occur when the elbow is forced straight against resistance.
Tendonitis (Tennis elbow and Golfer's elbow)
Tennis elbow is a term used to describe pain over the lateral epicondyle. Despite the name, there are only a very small percentage of people who acquire this injury as a result of playing tennis. It is often the result of overuse or repetitive activity. Consequently painters, plumbers, and carpenters are particularly prone to developing tennis elbow due to the repetitive nature of their work. Direct trauma to the area can also be the cause of the problem.
Tennis elbow or lateral epicondylitis, involves the muscles and tendons of the forearm that are responsible for the extension of the wrist and fingers. Your forearm tendons (extensors) attach the muscles to the bone on the outside edge of the elbow. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).
Tennis elbow is inflammation or, in some cases, microtearing of the extensor tendon.
The symptoms of tennis elbow (Pain or burning on the outer part of your elbow and reduced grip strength) often develop gradually. In most cases, the pain begins as mild and slowly worsens over weeks and months.
Golfer's elbow or medial epicondylitis, is similar to tennis elbow, and like tennis elbow, it doesn’t just affect golfers. It is caused by damage to the muscles and tendons that control your wrist and finger flexors. In this instance the tendon joins to the bone on the inside (medial aspect) of the elbow.
Cubital tunnel syndrome
Cubital tunnel syndrome is a condition that affects the ulnar nerve as it travels down the arm passing through the cubital tunnel at the elbow. At the elbow the nerve is especially vulnerable to compression because it travels through a narrow space with very little soft tissue to protect it and can become compressed or irritated at this point. The ulnar nerve provides the feeling to the little and ring finger and power to the small muscles of the hand. Compression or irritation of the nerve can cause symptoms of pain, numbness or pins and needles in the ring and little finger and weakness in the hand. In many cases the exact cause of cubital tunnel syndrome is not known. However, keeping your elbow bent for long periods or repeatedly bending your elbow can cause symptoms as can prolonged leaning on your elbow. Following a fracture or dislocation of the elbow or arthritis at the elbow can also increase the risk of nerve irritation, particularly if there is local swelling.
Degeneration of the elbow joint can occur as a result of many systemic forms of arthritis, including rheumatoid arthritis, osteoarthritis, gouty arthritis, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis. Generally, they are associated with signs of inflammation of the elbow joint, including heat, warmth, swelling, pain, tenderness, and decreased range of motion.
Osteoarthrosis: When a joint develops this, some of the cartilage covering the ends of the bones roughens and thins so the joint doesn’t move as smoothly as it should. All the tissues within the joint become more active than normal; the body is trying to heal itself. The bone underneath the cartilage can react by growing. Bony outgrowths are called osteophytes.
The symptoms of osteoarthritis can include: pain, stiffness, a grating or grinding sensation when the joint moves (crepitus), swelling (either hard or soft) and heat. You are at more risk of having OA if you are female, over 40, over weight, have had a previous injury or repetitive trauma and because of certain genetic factors.
Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints, the tissue around the joints, as well as other organs in the body. In the early stages of RA, people may only feel pain when they lift objects or strain the elbow joint. However, the pain often becomes worse over time. It is also possible for RA to cause permanent damage to the elbow joint. Chronic inflammation can damage the synovial tissue that lines the joint and cause bone erosion and joint deformity. In more advanced forms of RA, rheumatoid nodules can form on the elbow. These are small lumps that appear just below the surface of the skin and are generally painless.
Gout and hyperuricemia are caused by uric acid crystals building up in the body. Gout symptoms and signs include joint pain and swelling.
Bursitis is an inflammation of a bursa. Bursae are small fluid filled sacs that help to reduce friction between tendons and bones. They can become inflamed, painful, swollen and warm due to a sudden injury eg fall or direct blow; from recurrent minor trauma; due to infection eg skin break or as part of Rheumatoid arthritis or Gout. The most commonly affected bursa in the elbow is the olecranon- Olecranon bursitis is typically associated with swelling over the tip of the elbow, while range of motion of the elbow joint is maintained.
Osteochondritis dissecans is a joint condition in which a variable amount of bone and its adjacent cartilage loses its blood supply. Osteochondritis dissecans can involve the bone and cartilage of virtually any joint however elbows and knees are most commonly affected. In the elbow it can lead to locking, pain, and loss of range of motion. Osteochondritis dissecans most commonly affects boys between 9 and 18 years of age.
Elbow surgery can be challenging, because the elbow is relatively small and complex, and because patients need long-lasting, durable treatments. Surgery is only considered when medications and other measures don’t relieve severe joint pain and loss of motion or when fractured bones need repairing with metal work.
Elbow arthroscopy (keyhole surgery) is a procedure used to examine, diagnose and treat problems affecting the elbow. The surgeon uses a miniature camera, inserted through small incisions to see inside the elbow.
Using an arthroscope, a surgeon can remove bony growths in the elbow along with any loose bits of bone or cartilage. Sometimes the upper end of the radius is also removed. Debridement is used for posttraumatic and primary osteoarthritis (OA) in the elbow.
The main surgical procedures for the elbow tend to be performed post fracture eg open reduction and internal fixation of the bones
Other surgical procedures may be performed to alleviate the pain associated with Rheumatoid arthritis or osteoarthrosis eg elbow arthroplasty or joint fusion.
Tendon surgery includes repairs, release and tenotomies
Your physiotherapist will access you and determine what the likely cause of your elbow pain is. They may feel that additional investigations are necessary such as X-rays or scans and can contact your doctor to request these as appropriate. Your treatment programme will be tailored to you but is likely to include some of the following strategies.
Advice, strengthening, stretching and proprioception exercises, management strategies, mobilisations- soft tissue and joint mobilisations, Acupuncture, shockwave therapy, PNF, taping
If you would like to book an appointment or request further information, please contact your nearest clinic or click here.
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