Sporting Elbow - Clinical Reasoning and Differential Diagnosis

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Anatomy of the Elbow

The elbow joint is where the distal humerus meets the proximal radius and ulna bones. It is known as a trochleogingylomoid joint as it can flex and extend as a hinge (ginglymoid) joint as well as pivot around an axis (trochoid motion) known as pronation and supination. It is an extremely congruent and stable joint. The stability of the elbow is provided by the osseus anatomy, capsuloligamentous structure and the musculotendinous units that cross the elbow.

Joints

The humerus, radius and ulna articulate to form the 3 joints that make up the elbow.

Table 1: Anatomical overview of the elbow

	Humeroulnar Joint	Radiohumeral Joint	Proximal Radioulnar Joint
Active range of motion norms	Flexion 140° Extension 0 - 10°	Flexion 140° Extension 0 - 10°	Pronation 80 -90° Supination 80 -90°
Capsular pattern	Flexion and extension	Flexion and extension	Equal limitations of supination and pronation
Ligaments	Ulnar collateral ligament (UCL -anterior oblique bundle; posterior oblique bundle; intermediate bundle; transverse ligament) Lateral ulnar collateral ligament (LUCL)	Radial collateral ligament (RCL)	Annular ligament Quadrate ligament Oblique cord Interosseous membrane

Ligaments and Capsule

1. Medial Collateral Ligament Complex/Ulnar Collateral Ligament
   • Comprises an anterior and posterior bundle and a supporting transverse ligament (ligament of Cooper)
   • Anterior bundle (AMCL):  
     • most important stabiliser of the elbow, provides valgus and posteromedial stability
     • anterior bundle divided into anterior and posterior bands:
       • anterior band is more taught in extension and relaxes into flexion
       • posterior band tightens in flexion and releases in extension
       • Thus the anterior band is more vulnerable to valgus stress in elbow extension and posterior band of the AMCL is more vulnerable to valgus stress in elbow flexion
2. Lateral Collateral Ligament Complex (LCLC)
   • Primary stabiliser against varus and external rotation stresses
   • LCLC is formed by the lateral ulnar collateral ligament, the radial collateral ligament and the annular ligament
     • Lateral ulnar collateral ligament is important in maintaining posterolateral rotatory stability as well as stabilising against varus stresses.
     • Radial collateral ligament contributes to posterolateral rotational stability.
     • Annular ligament surrounds radial head, but does not attach to it. It is an important stabiliser of the proximal radioulnar and radiocapitellar joint.
3. Joint capsule
   • Surrounds all 3 joints of the elbow
   • Thickening medially and laterally of joint capsule that blend with MCLC and LCLC respectively and contributes to the stability of the elbow (ref)

Muscles

There are 4 main muscle groups at the elbow. The anterior biceps group, the posterior triceps group, the lateral extensor-supinator group and the medial flexor-pronator group.

Each muscle group applies a compressive load to the elbow joint when they contract.

• Primary Elbow Flexors
  • Brachialis
  • Biceps brachii
    
  • Brachioradialis
• Secondary Elbow Flexors
  • Pronator teres
  • Extensor carpi radialis longus
  • Flexor carpi radialis (at elbow angles 50 degrees or more)
• Primary Elbow Extensors
  • Triceps
  • Anconeus
• Secondary extensors
  • Flexor Carpi ulnaris
  • Extensor carpi ulnaris
• Pronation
  • Pronator teres
  • Pronator quadratus
• Supination
  • Mainly Biceps
  • Assistance from supinator
  • Lesser degree finger and wrist extensors

Differential Diagnosis

It is important to consider both form (structures) and function in the differential diagnosis of the elbow. (Ref – Ian Gatt course)

Cervical Radiculopathy (Referred pain) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788378/

Kang KC, Lee HS, Lee JH. Cervical radiculopathy focus on characteristics and differential diagnosis. Asian Spine Journal. 2020 Dec;14(6):921.

Systemic Conditions (e.g Rheumatoid Arthritis) https://bjgp.org/content/bjgp/65/640/610.full.pdf Javed M, Mustafa S, Boyle S, Scott F. Elbow pain: a guide to assessment and management in primary care. British Journal of General Practice. 2015 Nov 1;65(640):610-2.

Anterior Elbow:

Biceps Strain/Tear/ Tendinopathy Bauer TM, Wong JC, Lazarus MD. Is nonoperative management of partial distal biceps tears really successful?. Journal of shoulder and elbow surgery. 2018 Apr 1;27(4):720-5.

Myositis Ossificans in Brachioradialis https://journals.lww.com/acsm-csmr/fulltext/2018/09000/myositis_ossificans_in_sport__a_review.7.aspx?casa_token=Vmz2RrS9TogAAAAA:fcv57AD-6vzfASqr6G8CXtY2-lmdZFxzCwPW6_91h6bbDWRM3nAdOOwmZb7pX3cZJx-USwoF9gPuGQ2kdh7x2Hv_ Devilbiss Z, Hess M, Ho GW. Myositis ossificans in sport: a review. Current sports medicine reports. 2018 Sep 1;17(9):290-5.

Osteochondritis Dissecans (Trochlea) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896885/

Churchill RW, Munoz J, Ahmad CS. Osteochondritis dissecans of the elbow. Current reviews in musculoskeletal medicine. 2016 Jun;9(2):232-9.

Posterior Elbow

Triceps strain/tears/tendinopathy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478494/ Shuttlewood K, Beazley J, Smith CD. Distal triceps injuries (including snapping triceps): a systematic review of the literature. World journal of orthopedics. 2017 Jun 18;8(6):507.

Olecranon bursitis Nchinda NN, Wolf JM. Clinical Management of Olecranon Bursitis: A Review. The Journal of Hand Surgery. 2021 Apr 9.

Osteochondritis Dissecans (Olecranon) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896885/

Churchill RW, Munoz J, Ahmad CS. Osteochondritis dissecans of the elbow. Current reviews in musculoskeletal medicine. 2016 Jun;9(2):232-9.

Olecranon Spurs/Loose bodies Robinson PM, Watts AC. Boxer’s Elbow: Internal Impingement of the Coronoid and Olecranon Process. InSurgical Techniques for Trauma and Sports Related Injuries of the Elbow 2020 (pp. 189-193). Springer, Berlin, Heidelberg.

Radial side:

Synovial Plica Lubiatowski P, Wałecka J, Dzianach M, Stefaniak J, Romanowski L. Synovial plica of the elbow and its clinical relevance. EFORT Open Reviews. 2020 Sep;5(9):549-57.

Lateral Epicondylalgia (involvement of ECRB)

Osteochondritis dissecans (Radio-capitellum) same reference as above

Instability – Postero-lateral rotatory  - Radiocarpal ligament combined with lateral ulnar collateral ligament Conti Mica M, Caekebeke P, van Riet R. Lateral collateral ligament injuries of the elbow–chronic posterolateral rotatory instability (PLRI). EFORT open reviews. 2016 Dec;1(12):461-8. And Fedorka CJ, Oh LS. Posterolateral rotatory instability of the elbow. Current reviews in musculoskeletal medicine. 2016 Jun;9(2):240-6.

Nerve entrapment: Posterior interosseus nerve (Radial tunnel syndrome) Moraes MA, Goncalves RG, Santos JB, Belloti JC, Faloppa F, Moraes VY. Diagnosis and treatment of posterior interosseous nerve entrapment: systematic review. Acta ortopedica brasileira. 2017 Jan;25:52-4.

Ulnar side:

Medial epicondylalgia (Golfer’s Elbow) Barco R, Antuña SA. Medial elbow pain. EFORT open reviews. 2017 Aug;2(8):362-71.

Instability UCL ligament Rossy WH, Oh LS. Pitcher’s elbow: medial elbow pain in the overhead-throwing athlete. Current reviews in musculoskeletal medicine. 2016 Jun;9(2):207-14.

Nerve entrapment of ulnar nerve McCarty LP. Approach to medial elbow pain in the throwing athlete. Current reviews in musculoskeletal medicine. 2019 Mar;12(1):30-40.

Dislocations can cause injury to ulnar nerve

Fractures

It is evident that there is a plethora/overabundance of conditions related to form that should be considered with the differential diagnosis of elbow pain. One way to perhaps sort it is to distinguish between traumatic and non-traumatic mechanisms. (Ian Gatt)

 

Special Investigations

Ultrasound

Assists in management of stubborn cases of lateral epicondylalgia by characterising the extent of the tendon tearing and identifying the presence of concomitant RCL injury Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: part 2. Clinical applications. PM&R. 2009 Feb 1;1(2):162-77.

MRI

Injection (lignocaine or Marcaine) Hsieh LF, Kuo YC, Lee CC, Liu YF, Liu YC, Huang V. Comparison between corticosteroid and lidocaine injection in the treatment of tennis elbow: a randomized, double-blinded, controlled trial. American journal of physical medicine & rehabilitation. 2018 Feb 1;97(2):83-9.

Clinical Tests

Lateral Epicondylalgia

Middle Finger Strength test/Maudsley’s Test

Modifications of this test –

pt keeps middle finger bent at the proximal phalangeal joint and examiner applies resistance to the distal aspect of proximal phalanx. This places more bias on extensor carpi radialis brevis, instead of testing the whole complex, including extensor digitorum communis (Ian Gatt)

Test can also be done with the second finger to examine extensor carpi radialis longus – with straight finger and/or bend (Ian Gatt)

Mill’s test

Patient in a seated position, elbow extended, and forearm pronated. The examiner stabilises the elbow while palpating the lateral epicondyle, with the other hand grab the patient’s wrist and move wrist passively into palmar flexion.

Cozen’s test

Chairlift test – pt is asked to lift a chair with shoulder forward-flexed, elbow extended and forearm pronated – if this provokes lateral elbow pain it may indicate lateral epicondylalgia

Modification of this test – using weight plates/ plated weights and investigating different aspects

For higher intensity provocation – use bigger/heavier weights and low repetitions

Endurance test – just holding weight and seeing how long before fatigue – use a low weight and measuring time to fail

Low weight with more repitions – does this provoke pain

Use clinical reasoning from what patient or athlete is telling you to determine which modification you want to use, rather than doing all three modifications. Is the onset of pain with something strenuous, or when they do something over time (Ian Gatt)

Polk’s test lateral

Grip strength test

Ligament stress tests

MCL insufficiency

The medial collateral ligament of the elbow is also referred to as the ulnar collateral ligament (ucl). Important to remember that these tests can be done with the patient in different positions such as supine or sitting. Ensure that when you are doing these tests for the ucl/mcl that the ligament is stressed – make sure that it is not just the shoulder being pulled into external rotation. (Ian Gatt)

Moving valgus stress test

Patient is seated, 90 degrees shoulder abduction, maximum elbow flexion

Examiner stabilises humerus and holds the wrist

Apply valgus stress until shoulder reaches maximum shoulder external rotation. Maintain valgus stress and quickly extend elbow to 30 degrees

Distinctive pain, max between 120 and 70 degrees flexion indicates MCL insufficiency

Valgus stress test

Patient seated, 0 degree elbow flexion, maximum forearm supination

Examiner stabilises humerus and holds forearm, applies valgus stress. Distinctive pain or laxity indicates MCL insufficiency

Milking manoeuvre

LCLC

Posterolateral rotatory instability

Some tests are really great functional tests as well such as the chair push-up test and the push-up test.

Table-top relocation test

Stand-up test/chair push up test

Patient is seated, both elbows 90 degrees flexion, holding armrests with shoulder abduction and forearms supinated. Examiner asks patient to arise from the chair by pushing down, pain that slowly extends while patient rises indicates PLRI

Push-up test

Patient lies with chest down on floor/plinth, elbows flexed at 90 degrees shoulders abducted and forearms supinated. Examiner ask patient to perform a push-up, apprehension or radial head dislocation indicates PLRI

Lateral pivot shift test

Total distal biceps rupture

Hook test

PFP test

Supination-pronation test

Biceps squeeze test

BCI

BA flex test

Total distal triceps rupture

Triceps squeeze test

Posteromedial impingement syndrome

Arm bar test

Valgus overload test/posteromedial impingement test

Medial epicondylalgia

Epicondylitis medialis test/ Golfer’s elbow test

Polk’s test medial

Whatever clinical test that you are doing, always consider the amount of stress being applied to the structure and the element of safety (Ian Gatt)

Differential Diagnosis Function

Often in athletes with elbow injuries it is evident that although the form/structures might be compromised, the althetes still show a high level of function in the injured area.

As part of the differential diagnosis, it is key to not only identify the structures involved but also to have a clear picture of function – ie. What the athlete can do, the 24 h pattern and the pattern of pain in the past weeks or months. Is the injury traumatic vs non-traumatic and urgency vs non-urgency surgical management. (Ian Gatt)

Factors to consider related to function

Kinetic chain

Knowledge and understanding of the kinetic chain and how different components could be affected is important. For example in when a boxer throws a punch with his lead arm – the force is coming from the feet driving up into the hip. Approximately 50% of the force will come from the lower legs and into the trunk (30%) and into the upper limb (20%)

Keep in mind that these percentages may be different in different athletes, for instance – wheelchair based athletes and swimmers.

The key consideration is to acknowledge and understand the whole body contribution in an injury, pathology or dysfunction.

Strength Testing

Isometric testing

Examiner applying resistance with hand in different ranges will provide quality i.e pass or fail information

Isometric testing with a handheld dynamometer will provide quantitative information in different ranges

Isokinetic testing

Testing strength through range of motion

Strength testing in tennis elbow

Dorf et al investigated the effect of elbow position on grip strength in the evaluation of lateral epicondylitis. There was no difference in grip strength in elbow flexion and extension for the healthy extremity. Grip strength was 29% stronger in elbow flexion than extension for the affected extremity. When comparing the healthy extremity with the affected extremity the affected extremity was 50% weaker in elbow extension compared to the healthy extremity. In elbow flexion the affected extremity was 31% weaker than the health extremity. This is significant especially with regards to elbow extension providing a mechanical advantage in grip strength of the hand. Using strength testing in people with tennis elbow will provide better objectivity.

Range of motion

Movements at the elbow to consider and measure:

Flexion and Extension

Elbow average total range of motion from flexion to extension has been shown to be from 143 degress +_ 5.6 to 1 degree +_ 3.1 degrees

Pronation and Supination

Elbow motion for pronation to supination has been shown to be from 76 degrees +- 5.1 to 82 degress +_ 3.8 degrees

Smartphone apps are available to help clinicians measure elbow range of motion.

Measuring flexion and extension

Patient rests arm flat on table to have humerus parallel to the horizontal plane, forearm in neutral. Inclinometer set to zero on table, patient flexes elbow maximally. Smartphone placed parallel to forearm and value can be read.

For elbow extension the smartphone is aligned to the forearm in maximal extension

Add images from Ian Gatt

Also refer to the hand and wrist courses and pages

End Feel

From a manual therapy perspective, especially when range of motion is similar is to consider end feel of the elbow joints.  Consider the type of end feel as well as the athletes reaction with this type of provocation

PRUJ and HR Joints in LE

It is important to consider the proximal ulnar joint and the humeral joints in relation with lateral epicondylalgia

ECRB – arises from the lateral epicondyle and annular ligament

RCL – radial collateral ligament also originates from lateral epicondyle and inserts into the ligament

Close relationship between ECRB and RCL

Concomitant injuries occurring

Potential instability around this region may provoke tennis elbow

Therefore having a good understanding of the close relationship between ecrb and rcl as well as the mobility of the radiohumeral joint will have an impact on tennis elbow management.

It is also good to be aware of the open and close-packed positions of the joint to avoid confusion when palpating or mobilising joints around the elbow.

Add image or table here from slides

Medial epicondylalgia and pronator teres

Hypertrophy of pronator teres may lead to symptoms around the medial epicondyle

Pronator teres syndrome – median nerve being trapped between the two heads of pronator – this will mainly produce symptoms distally rather than locally

General guidelines

Diagnosis

Consider traumatc vs non-traumatic injuries

Prognosis = Function

What can or can’t the athlete do?

Strength

Rom

End feel

With non-traumatic injuries consider contributions from the shoulder and forearm, as well as hand and wrist

For LE and ME – consider surrounding structures

Elbow can be tricky – if insure get a 2nd opinion!

Resources

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