Featured professor:  Skye Donovan | PT, PhD, OCS

Episode 2: Elbow Differential Diagnosis

Notes by Alexis Lancaster, SPT

General information

  • Tennis elbow: lateral epicondylitis
    • “Thumb side”
  • Golfers elbow: medial epicondylitis
    • “Pinky side”
  • Country club elbow: both medial & lateral epicondylitis

Symptoms

  • Pain on medial or lateral side

Causes

  • Does not need to be tennis or golf
  • Grip usually causes these conditions
  • Driving & gripping steering wheel too tight
  • Weight lifting with too much gripping
  • Swimmers can be affected (pointing their fingers)

Differential diagnosis

  • Bursitis: bursa sits under olecranon
  • Pronator teres syndrome: painful/achy on lateral side
  • Osteoarthritis of elbow joint
  • Rheumatoid arthritis
  • C-spine radiculopathy (especially C6-C7)
  • Ulnar nerve pathology
    • What does the pain feel like? Nerve pain? Think nerve injury/problem
  • Tendinopathy
    • Overuse
    • Lateral epicondylitis: usually due to excessive grip, excessive wrist extension→ seen in racquet sports, occupation and work-related tasks that have a lot of vibration (jack-hammering)
    • Medial epocondylitis: usually due to excessive grip while in pronation, or excessive wrist flexion

Anatomy

  • Lateral: wrist extensors (common extensor origin)
    • Usually associated with extensor carpi radialis brevis (ECRB) involvement. ECRB attaches to 3rd digit
    • Extensor carpi radialis longus inserts on 2nd digit
    • It could be any muscle that shares the common extensor origin that is involved (ex. brachioradialis and extensor digitorum)
    • The radial nerve supplies extensor carpi ulnaris, radialis brevis & longus
  • Medial: wrist flexors (common flexor origin)
    • “Pass/fail/pass/fail”: pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris
      • Not everyone has a palmaris longus
      • Median nerve: pronator teres, flexor carpi radialis, palmaris longus
      • Ulnar nerve: flexor carpi ulnaris
      • Deep to these= flexor digitorum profundus and superficialis
      • “Medial side of forearm”

Special tests

  • Lateral epicondylitis
    • “Tennis elbow test”: MMT for wrist extensors
      • Can add some radial deviation
      • Can lift the third finger to see if it is ECRB
      • Look for provocation of pain at the lateral epicondyle  
  • Medial epicondylitis
    • “Golfer’s elbow test: MMT for wrist flexion
      • Look for provocation of pain at the medial epicondyle
  • Cervical spine testing to rule out the spine
  • Grip testing (will be weak)

Treatment examples

  • Modalities
  • Corticosteroid injections
  • TherEx:
    • Loosen grip
    • Eccentrics
    • Take pressure off the origin, start with forearm supported to shorten lever arm
  • Don’t have pt exercise into pain
  • Bracing
    • More common with lateral epicondylitis compared to medial
  • Education/prevention: pts don’t understand their grip may be the problem

Sample question:

If your patient comes to you with lateral epicondylitis, where is the best position that you would put their brace?

  1. Superior to the elbow
  2. Inferior to the elbow
  3. Superior to the wrist
  4. At the wrist

Answer: Inferior to the elbow

Why:

  • You can have a brace that is giving compression, so you put it at the joint. However, in this case, if you are bracing to decrease the force that is coming through something, you need to cheat the body into thinking that the muscle’s origin is coming from a different place so it is not getting pull where it is getting damaged. You can place a brace here because the part of the muscle that is inflamed is a tendon, not contractile tissue.
  • If you put the brace superior to the elbow, it would likely increase pain. You’re putting compression on the damaged part, so you aren’t changing the lever arm.
  • If you had an answer of “at the elbow”, the compression will be great, but it won’t be the best answer if “inferior to the elbow” is also a choice,
  • Superior to the wrist/at the wrist: missing the point of the brace for the condition