Differential diagnosis of lateral elbow pain. Multiple modalities such as magnetic resonance imaging MRI , computed tomographic CT imaging, ultrasonography and EMG have been described following initial elbow radiography. An initial x-ray evaluation should be taken in three views: anterior-posterior AP , lateral, and lateral oblique view. The AP graphy is performed with the elbow fully extended, palm of the hand pointing upward exorotation and forearm supinated to display medial and lateral epicondyles as well as radiocapitellar and ulnotrochlear articular surfaces. Articulation between the distal humerus and proximal forearm is seen on these X-rays. Moreover the lateral oblique view is similar to the AP view, however the hand and forearm are fully externally rotated to obtain the views of the radiocapitellar joint, medial epicondyle, radioulnar joint and coronoid process.
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Differential diagnosis of lateral elbow pain. Multiple modalities such as magnetic resonance imaging MRI , computed tomographic CT imaging, ultrasonography and EMG have been described following initial elbow radiography. An initial x-ray evaluation should be taken in three views: anterior-posterior AP , lateral, and lateral oblique view.
The AP graphy is performed with the elbow fully extended, palm of the hand pointing upward exorotation and forearm supinated to display medial and lateral epicondyles as well as radiocapitellar and ulnotrochlear articular surfaces.
Articulation between the distal humerus and proximal forearm is seen on these X-rays. Moreover the lateral oblique view is similar to the AP view, however the hand and forearm are fully externally rotated to obtain the views of the radiocapitellar joint, medial epicondyle, radioulnar joint and coronoid process.
Radiographic evaluations show normal results in most cases, and are mainly useful for ruling out other abnormalities such as arthrosis, osteochondritis dissecans and intra-articular free bodies. Sonography is an inexpensive, accessible and radiation-free test.
Moreover high-frequency probes has an advantages of improved resolution, allowing application to extraarticular soft tissues for which it is increasingly used as an alternative to MRI [ 18 ]. Dynamic sonography is also an ideal method of image-guided intervention and can be used to provide real-time guidance of injections of local anesthetic, steroids, or platelet-rich plasma.
However, its value is debatable because it is examiner-dependent. In many cases MRI can be useful in evaluating the soft tissues for tears, fluid, inflammation, or other changes within the joint or surrounding tissues. It is a great tool to evaluate soft tissue damage due to chronic overuse injuries of the elbow. However the bony cortex is not as well evaluated at MR imaging compared with CT, but the ability to detect subtle signal intensity changes in the marrow and periosteal soft tissues increases sensitivity to early stress changes in bone.
Patients positioning can be either prone or supine, with the arm held at the side in anatomical position. The following examination steps are tendons, muscles, ligaments, and the three major nerves of the elbow [ 19 , 20 ]. CT imaging is particularly useful in demonstrating intraarticular extension of fractures, the distribution of small fracture fragments within and adjacent to the joint space, as well as any associated bony malalignment.
CT can also be useful in evaluating chronic pain following injury and can readily identify abnormal ossifications or calcifications which can be seen as a sequela of trauma, including osteochondral bodies, heterotopic ossification, or myositis ossificans.
Intraarticular contrast material can be injected for improved visualization of joint bodies and cartilage. Osseous manifestations of secondary degenerative change are also well evaluated with CT. Less often, CT arthrography is performed for evaluation of ligamentous integrity in patients with contraindications to MR imaging [ 18 ]. This test consists of two parts, and utilizes needle EMG to test the muscles in the extremity.
It may be helpful in nerve compressive processes. The needle EMG may reveal the differentiation between denervation versus nerve injury or compression [ 21 ]. However future diagnosing studies are essential for this test. In case of significant swelling or fever, blood work should be indicated whether the reason is systemic inflammation or not. This would help direct the treatment toward a systemic, rheumatologic, or infectious etiology [ 21 , 22 ].
Five muscles flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis and pronator teres share the same origin and form the conjoined flexor tendons Figure 3 [ 7 ]. The MCL, or known as ulnar collateral ligament, is formed by anterior, posterior, and oblique bands, which creates a triangular shape along the medial aspect of the elbow, deep to the pronator mass Figure 4. MCL injury, specifically anterior band injury, is included in the differential diagnosis of medial elbow pain, and therefore the MCL must be evaluated.
The MCL is also prone to concurrent injury with me- dial epicondylitis. Figure 3. Illustration shows the medial elbow musculotendinous anatomy. Figure 4. Picture shows the ligamentous anatomy of the medial aspect of the elbow. Medial epicondylitis is a tendinopathy of conjoined tendon due to overload or overuse.
The pain is worse with forearm motion, hand gripping and throwing. It usually resolves with cessation of activity [ 4 , 7 , 23 ]. On physical examination, there may be tenderness, swelling, erythema or warmth. Test is positive when the patient endorses pain with this maneuver. Due to similar symptoms and associated valgus forces, C6—C7 radiculopathies, cubital tunnel syndrome, ulnar neuritis, anterior interosseous nerve entrapment, tardy ulnar palsy and MCL instability, as well as other causes of medial elbow pain capsulitis, arthrofibrosis, loose bodies, or medial epicondyle avulsion fracture should be considered in the differential diagnosis Table 2.
The Tinel sign distal pain and tingling during direct compression of the nerve at the elbow should be used to evaluate for ulnar neuropathy, and the ulnar collateral ligament should be stressed especially in athletes [ 23 ]. The elbow valgus stress test is used to assess the integrity of the medial collateral ligament by palpating the medial joint line and stabilizing the distal humerus in 20 degrees of elbow flexion, [ 23 ].
The tests are considered positive if the patient experiences pain or excessive laxity along the MCL compared to the contralateral side. MCL İnjury.
Elbow arthritis. Cervical nerve root entrapment. Radial tunnel syndrome - this is due to compression of the posterior interosseous nerve, and tenderness is more distal and more anterior. Radiation of pain from shoulder or wrist injuries. Carpal tunnel syndrome. However, it is not clear whether these treatments work or if the pain simply goes away on its own. Despite its common nature, there is no universally accepted, evidence-based management regime.
Medial Epicondylitis (Golfer’s Elbow)
Signs and symptoms[ edit ] Pain on the outer part of the elbow lateral epicondyle Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow Pain from gripping and movements of the wrist , especially wrist extension e. In addition, the extensor carpi radialis brevis muscle plays a key role. However, studies show that trauma such as direct blows to the epicondyle, a sudden forceful pull, or forceful extension cause more than half of these injuries. From a technical perspective, leading a backhand with your elbow, excessive pronation of the forearm when putting topspin on a forehand, and excessive flexion of the wrist on a serve can all greatly lead to tennis elbow. Other things that can be improved are: racquet type, grip size, string tension, type of court surface, and ball weight. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which replaces normal tissue with a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as tendinosis or tendinopathy rather than tendinitis.
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