1. Elbow Update Dr. Neil Dilworth CCFP (EM, SEM), MScCH HPTE
University of Toronto Primary Care Sports Medicine Conference
May 26, 2017

2. Disclosures
Grant from Canadian Academy of Sports and Exercise Medicine for Pediatric Sport-related Concussion Study
No other disclosures

3. Case 1

4. Case 2

5. Objectives To expand differential considerations for elbow complaints
To understand importance of mechanism of injury
To be able to describe neurological considerations

6. Lateral Epicondylitis
Aka Tennis elbow,Tendinopathy/enthesopathy of the extensor carpi tendons
Duration months
OE: Tender over lateral epicondyle, pain with activation v. resistance extensors
Ix: Clinical (Xray, US, MRI may be helpful in ruling out other conditions)
Variety of differentials (including radicular pain)
Mgt: Variety of treatments (See next slide)

7. Lateral Epicondylitis Treatments ….
PRP +-
Per. Radiofrequency thermal +
Cortisone
Botulinum
Leeches?
Surgery +
Activity Modification +
Physiotherapy +
Accupuncture +
Extracorporeal shockwave
Bracing
Laser
GTN +
PRP – 2 level 1 studies v. cortisone showed favourable results – RCT however of PRP v. Saline v. Cortisone – no difference
GTN favourable results up to 6 months, Botulinum – inconclusive and potenial weakness …. Leeches – 1 application better than diclofenac. (n=40),

8. Lateral Elbow Differentials!

9. Radial Tunnel Syndrome
Radial nerve branch (Posterior Interosseous Nerve) entrapped in tunnel
Motor innervation to extensors
OE – Weak Extensors 2o Pain, tender supinator
Pain with supination v. resistance, passive pronation & flexion of wrist
Ix: Diagnostic injection (NCS, EMG not helpful)
Mgt – avoid extension, wrist pronation/flexion, cortisone injection US- guided, failure at 1 year – consider surgery
NCS,EMG not particularly useful as pain sensation with syndrome no motor weakness, MRI not useful.

10. Capitellar osteochondral injury
Occurs in pitchers, overhead sports – tennis, ping poing
Repetitive valgus stress, MCL/UCL may be involved
OE: Loss of range of motion, effusion posterior and anterior capitellar pain
Ix: MR Arthrogram to assess for stability
Rx: Rest, protection, UCL tear (consider surgical reconstruction), Therapy – focus on flexor strengthening, ROM

11. Capitellar osteochondral injury

12. Elbow Osteoarthritis
Arthritis of elbow, could be idiopathic, secondary to trauma or prolonged immobilization. Associated with pain and crepitus.
OE: Loss of range of motion, effusion, pain over radiocapitellar joint line
Ix: Xray
Mgt: Physio, ROM, sleeve, NSAIDs, cortisone, arthroscopy, arthroplasty

13. Medial Epicondylitis
Gofler’s elbow, tendinopathy/enthesopathy of flexor carpi origin
OE: Tender over medial epicondyle, pain with activation v. resistance of flexor carpi muscles
Ix: Clinical (Xray, US, MRI may be helpful in ruling out other conditions (see following slides)
Mgt: Variety of treatments (See lateral epicondylitis)

14. Snapping Triceps Syndrome
Rare, may be associated with ulnar subluxation
Medial triceps tendinous insertion snaps over medial epicondyle ~115 degrees of flexion
Treatment: ART/Graston/Roller, avoid hyperextension, if still persists consider surgeon
In flexion tendon becomes thinner and broader allowing it to snap over medial epicondyle

15. Ulnar Nerve Subluxation

16. Ulnar Nerve Subluxation
Rare, shallow ulnar groove
May also occur in patients with rapid muscle atrophy
OE: Ulnar nerve subluxes out of groove and over medial epicondyle ~70-90 deg of flexion, +ve Tinel’s, weakness in D4,5 may exists (incl. grip strength)
Ix: Dynamic US
Mgt: Wt resistance training (if atrophy), surgical fixation

17. Ulnar Collateral Ligament - injuries
Valgus overload – traumatic, or more commonly repetitive valgus stress – throwing, overhead sports
Associated with radio-capitellar osteochondral injuries
OE: +ve milk test, pain on palpation, gapping +- pain with valgus stressing at 30deg flexion
Ix: Xray (R/O avulsion), US, MRI, MRA (if suspicious of OCD)
Mgt: Partial tears treat conservatively – rehab geared at ROM, flexor strengthening. PRP may be considered. Bracing consideration.
Complete tears in overhead athletes (includes climbing) consider surgical opinion for reconstruction.

18. Case 3

19. Triceps Rupture
Eccentric overload of tendon, associated with anabolic steroid use
OE: Swelling, bruising, pain with flexion of elbow and supination.
Ix: Xray – avulsion fracture, US, MRI (extent of tear +- associated ligamentous injuries)
Mgt: Immobilization, Surgical repair

20. Distal Biceps Rupture
Eccentric overload of biceps tendon, associated with anabolic steroid use
OE: Hook test, weakness/pain on supination, proximal migration of biceps muscle bulk
Ix: Xray (Radial tuberosity avulsion), US, MRI
Mgt: Sling, Surgical repair

21. Summary
Always consider differential for lateral and medial elbow presentations
Exam should include palpation, ROM (active and passive), neurovascular
Other common issues of elbow olecranon bursitis, posterior impingement may be considered