Musculoskeletal Conditions

Lateral Epicondylitis

What is it?
Irritation of tissues on the lateral aspect of the elbow

causing pain
Most common muscle effected: Degeneration of the extensor
carpi radialis brevis tendon
Weakens the tendons attachment to the bone, causing stress
1-3% of adult population has condition
Equal amongst sexes, highest prevalence in the 40-50 year age
range

Causes
Overuse and repetitive and forceful forearm motions

such as supination and pronation.

Weakness of extensor carpi radialis, and other
forearm extensors
Imbalance in strength between the forearm flexors
and forearm extensors
Poor forearm mechanics during stressful or
repetitive activities

Symptoms
Pain in the extensor tendons of the forearm, and

around the lateral elbow when the wrist is extended

against resistance
Minor pain/soreness upon palpation of the area

Diagnosis/Imaging
Imaging diagnosis is becoming more prevalent for

lateral tendon injuries and pain

Microscopic Evaluation of the tendons usually do not
show signs of inflammation
Imaging usually shows angiofibroplastic
degeneration and collagen degeneration
Light microscopy has been shown to present an
excessive amount of fibroblasts and blood vessels

This is consistent with angiogenesis, a sign that degenerative

mechanisms did take place

Special Tests
Mills Test
Clinician palpates the patients lateral epicondyle with one
hand, while pronating the patients forearm, fully flexing the
wrist, then extending the elbow. A positive test is a
reproduction of pain at the area of insertion at the lateral
epicondyle
Cozens Test
Clinician stabilizes the patients elbow with their thumb while
palpating the lateral epicondyle. The patient then is asked to
actively make a fist, pronate their forearm, and radially deviate
and extends the wrist against resistance from the clinician. A
positive test is reproduction of pain near the lateral epicondyle

Differential Diagnosis
Impingement of radial plica
Chondromalacia in radial compartment
Compression of peripheral branches of the radial

nerve

Treatment and Prognosis

80% of individuals are symptom free within 1 year of

onset
No standard protocol for treating lateral
epicondylitis
Nonsurgical therapy supported in literature for
initial treatment
Corticosteroids have had minor positive results if
traditional therapy does not relieve symptoms

Surgery
Between 4-11% of patients require surgery
No conclusive evidence on what surgical method is

most effective

Possibly due to lack of studies, as well as no consistent

outcome measures

Data suggests that patients without resolution of

symptoms after 6 months may need surgical

intervention
Less invasive surgical procedures are associated with
higher patient satisfaction and clinical outcomes

References
Kniesel, B., Huth, J., Bauer, G., & Mach, F. (2014).
Systematic diagnosis and therapy of lateral elbow
pain with emphasis on elbow instability.
Archives Of Orthopaedic And Trauma Surgery,
134(12), 1641-1647. doi:10.1007
s00402-014-2087-4
Sanders, Thomas L., Hilal Maradit Kremers, Andrew J.
Bryan, Jeanine E. Ransom, Jay Smith, and Bernaard
F. Morrey. 2015. The Epidemiology and Health
Care Burden of Tennis Elbow: A Population-Bases
Study. American Journal of Sports Medicine 43, no.
5: 1066-1071. SPORTDiscus with Full Test,
EBSCOhost

Medial Epicondylitis

What is it?
Tendinosis that affects the origin of the flexor carpi

radialis and pronator teres muscles

Five times less likely than lateral epicondylitis

Causes
Stress caused from repeated muscle contraction of

the flexor pronator group

May be associated with valgus forces during

activities such as swinging or throwing (golf or

throwing overhead)
Micro tears cause abnormal healing, resulting in

disorganized collagen with immature fibroplastic

and microvascular components

Symptoms
Patients usually describe a gradual onset of pain

localized to the medial epicondyle, or just distal to

the flexor-pronator muscle

Differential Diagnosis
Ulnar collateral ligament injury
Medial elbow intra-articular pathology
Ulnar nerve pathology
Ulnar neuritis
Coexisting

ulnar nerve symptoms are present in between

23%-60% of patients

Examination and Special Tests

Tenderness over the medial epicondyle
Pain on resisted pronation and wrist flexion

Treatment/Prognosis
Results are less predictable than lateral epicondylitits
Nonsurgical therapy is the most commonly used treatment
Most cases subside with non-operative treatment
If symptoms do not settle with 6-12 months of conservative

treatment, surgery may be required

Outcomes after intervention are not predictable, and

persistent symptoms and scar sensitivity can contribute to

poor patient satisfaction

Surgery
Results following surgery have been reported as good

to excellent in 86%-97% of patients

However, very few long-term results studies have been

conducted on surgical interventions

Surgical Options
Percutaneous epicondylar muscle release
Debridement and reattachment
Resection of the angio-fibroplastic tissue and drilling
Incision and debridement without reattachment

References
McMurtrie, A., & Watts, A. (2012). (vi) Tennis elbow
and Golfers elbow. Orthopaedics & Trauma,
26(5), 337-344 8p. Doi:10.1016/j.mporth.
2012.09.001
Mishra, A., Pirolo, J.M, & Gosens, T. (2014).
Treatment of Medial Epicondylar Tendinopathy
in Athletes. Sports Medicine & Arthoplasty
Review, 22(3), 164-168

Elbow Flexion Contracture

What is it?
Reduction in elbow extension greater than 30

degrees and/or a reduction in elbow flexion smaller

than 120 degrees.
Moderate elbow contracture- range of elbow motion
from 60 degrees to 90 degrees
Severe elbow contracture- range of elbow motion
from 30 degrees to 60 degrees.
The structure obstructing elbow motion or the
etiology and its anatomic location are used to
classify the type of elbow contracture

Causes
The causes of elbow contracture are diverse. They

are commonly linked to diseases of bone, soft tissue,

or a combination of the two following a traumatic
event
List of potential causes:
Trauma, surgery, arthritis, cerebral palsy, traumatic brain
injury, burns, arthrogryposis, congenital radial head
dislocation

Causes Continued
Pathoanatomical Causes
Intrinsic
Joint

incongruity, synovitis, loose bodies, intra-articular fractures,

osteochondritis dissecans, post-traumatic athritis

Extrinsic
Formation

of eschar following a burn, heterotopic ossification,

adhesions/contraction of the capsul, ligament contractures
(scarring of posterior oblique portion of medial ulnar collateral
ligament)

Potential Symptoms
May or may not be painful
Decreased motion
Often limits activities of daily living
Scars
Inflammation
Neural symptoms

Imaging
Radiograph
Findings depend on pathology
CT scan
Loose bodies in joint
Non-unions
Joint incongruity
Abnormal bony anatomy
MRI is rarely used

Treatment
Nonoperative
Physical Therapy (ex. AROM/PROM exercises)
NSAIDs
Splinting
Operative
Osteophyte excision
Distraction Interpositional Arthroplasty
Total elbow arthroplasty
Capsular release
Musculocutaneous neurectomy

Rare Cause of Elbow Contracture

Intra-articular entrapment of the ulnar nerve after

acute elbow dislocation

EMNG showed slower conduction of the ulnar nerve at the
level of the elbow after dislocation
Results in a withdrawal type flexion response due to the intraarticular entrapment of the ulnar nerve
The nerve was extracted from the join, decompressed, and
transposed subcutaneously
Functional recovery was achieved in 6 months post op

Well Know Cause of Elbow Contracture

Brachial plexus injury at birth
Prevalence has not been established
Nonoperative treatment involving splinting has not been vastly
studied
2012 study by Sheffler et al.
319 patient with brachial plexus birth palsy were studied
Elbow contracture was present in 48% (152) of participants
No improvement of contracture with splinting, but contracture
increase was prevented
Their

conclusion: Prevalence of elbow flexion contracture in

patients with brachial plexus injury may be higher than previously
thought. Serial casting may initially improve severe contractures,
and may prevent contracture progression in milder contractures

Further Thoughts
Researchers state that elbow flexion contractures could

affect more movements than loss of elbow extension

This suggests that a protocol should be proposed for the objective

evaluation of upper-extremity function in these patients

Early intervention could be key to preventing progression

of elbow contractures
Surgical interventions can result in serious complications

References