Abstract
Elbow pain secondary to degenerative arthritis is frequently encountered in clinical practice. Osteoarthritis is the most common form of arthritis that results in elbow joint pain. Tendinitis and bursitis may coexist with arthritis pain, which makes the correct diagnosis more difficult. The olecranon bursa lies in the posterior aspect of the elbow joint and may become inflamed as a result of direct trauma or overuse of the joint. Bursae susceptible to the development of bursitis also exist between the insertion of the biceps and the head of the radius, as well as in the antecubital and cubital areas.
In addition to pain, patients suffering from arthritis of the elbow joint often experience a gradual reduction in functional ability because of decreasing elbow range of motion that makes simple everyday tasks, such as using a computer keyboard, holding a coffee cup, or turning a doorknob, quite difficult. Most patients with elbow pain secondary to osteoarthritis or posttraumatic arthritis complain of pain that is localized around the elbow and forearm. Activity makes the pain worse, whereas rest and heat provide some relief. The pain is constant and is characterized as aching; it may interfere with sleep. Some patients also complain of a grating or popping sensation with use of the joint, and crepitus may be present on physical examination.
Keywords
elbow, osteoarthritis, rheumatoid arthritis, gout, crystal deposition disease, intra-articular elbow injection, ultrasound guided procedures, intra-articular steroid, nonsteroidal anti-inflammatory agent, adhesive capsulitis
ICD-10 CODE M19.90
The Clinical Syndrome
Elbow pain secondary to degenerative arthritis is frequently encountered in clinical practice. Osteoarthritis is the most common form of arthritis that results in elbow joint pain. Tendinitis and bursitis may coexist with arthritis pain, which makes the correct diagnosis more difficult. The olecranon bursa lies in the posterior aspect of the elbow joint and may become inflamed as a result of direct trauma or overuse of the joint. Bursae susceptible to the development of bursitis also exist between the insertion of the biceps and the head of the radius, as well as in the antecubital and cubital areas.
In addition to pain, patients suffering from arthritis of the elbow joint often experience a gradual reduction in functional ability because of decreasing elbow range of motion that makes simple everyday tasks, such as using a computer keyboard, holding a coffee cup, or turning a doorknob, quite difficult ( Fig. 37.1 ). With continued disuse, muscle wasting may occur, and adhesive capsulitis with subsequent ankylosis may develop.
Signs and Symptoms
Most patients with elbow pain secondary to osteoarthritis or posttraumatic arthritis complain of pain that is localized around the elbow and forearm. Activity makes the pain worse, whereas rest and heat provide some relief. The pain is constant and is characterized as aching; it may interfere with sleep. Some patients also complain of a grating or popping sensation with use of the joint, and crepitus may be present on physical examination.
Testing
Plain radiographs should be obtained in all patients who present with elbow pain. Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, erythrocyte sedimentation rate, and antinuclear antibody testing. Computerized tomography may be useful to identify bony abnormalities ( Fig. 37.2 ). Magnetic resonance and/or ultrasound imaging of the elbow is indicated if joint instability, nerve entrapment, tumor, or other soft tissue abnormality is suspected ( Fig. 37.3 ).
Differential Diagnosis
Rheumatoid arthritis, posttraumatic arthritis, and psoriatic arthritis are common causes of elbow pain. Less common causes of arthritis-induced elbow pain include collagen vascular diseases, infection, and Lyme disease. Acute infectious arthritis is usually accompanied by significant systemic symptoms, including fever and malaise, and should be easily recognized; treatment is with culture and antibiotics rather than injection therapy. Collagen vascular diseases generally manifest as polyarthropathy rather than as monarthropathy limited to the elbow joint; however, elbow pain secondary to collagen vascular disease responds exceedingly well to the intraarticular injection technique described later.
Treatment
Initial treatment of the pain and functional disability associated with arthritis of the elbow includes a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may also be beneficial. For patients who do not respond to these treatment modalities, intraarticular injection of local anesthetic and steroid is a reasonable next step.
Intraarticular injection of the elbow is carried out with the patient in the supine position, the arm fully adducted at the patient’s side, the elbow flexed, and the dorsum of the hand resting on a folded towel. A total of 5 mL local anesthetic and 40 mg methylprednisolone is drawn up in a 12-mL sterile syringe. After sterile preparation of the skin overlying the posterolateral aspect of the joint, the head of the radius is identified. Just superior to the head of the radius is an indentation that represents the space between the radial head and the humerus. Using strict aseptic technique, a 1-inch, 25-gauge needle is inserted just above the superior aspect of the head of the radius through the skin, subcutaneous tissues, and joint capsule and into the joint. If bone is encountered, the needle is withdrawn into the subcutaneous tissues and is redirected superiorly. After the joint space has been entered, the contents of the syringe are gently injected. Little resistance to injection should be felt. If resistance is encountered, the needle is probably in a ligament or tendon and should be advanced slightly into the joint space until the injection can proceed without significant resistance. The needle is then removed, and a sterile pressure dressing and ice pack are applied to the injection site. Recent clinical experience suggests that the intraarticular injection of platelet-rich plasma may provide improved healing of elbow joint pathology. Ultrasound guidance may improve the accuracy of needle placement in patients in whom anatomic landmarks are hard to identify ( Fig. 37.4 ).
