Bilateral Elbow Pain: Causes and Treatment
1. Pathophysiology of the Region:
Elbow and forearm pain can arise from several different intrinsic and
extrinsic factors. In the case described earlier, this patient's elbow pain presents
in both the medial and lateral aspects of her arm. This individual presents with
an overuse condition associated with repetitive trauma from playing an
instrument. In the case of medial elbow pain, the patient's discomfort is arising
from the common flexor tendon. The common flexor tendon is part of the
anterior compartment of the forearm and consists of the pronator teres, flexor
carpi ulnaris, flexor carpi radialis, palmaris longus, and flexor digitorum
superficialis muscles. Repetitive trauma related to overuse can effect all or one
of these muscles, most commonly at the musculotendonous junction and/or the
insertion of the common flexor tendon on the medial epicondyle of the
humerus. Other causes of medial elbow pain, or medial epicondylitis, include:
forearm flexor muscle weakness, forearm extensor muscle tightness, proximal
and distal radio-ulnar joint hypomobility, elbow joint hypomobility, wrist joint
hypomobility, carpal joint restriction within the hand, and even glenohumeral
(shoulder) joint instability.
In the lateral elbow region, pain can be caused by traumatic injury or
overuse of the common extensor tendon, specifically the tendonous origin of
the extensor carpi radialis brevis of the lateral epicondyle of the humerus.
Lateral epicondylitis is typically caused by repetitive wrist extension against
resistance which is common in the backhand motion of tennis, thus giving this
condition the common name "tennis elbow". Other environmental and
ergonomic-related causes of this condition include (but are not limited to):
excessive keyboard height during typing activity and repetitive writing.
2. Research-Based Contribution:
- Struijs P, Kerkhoffs G, Assendelft W, Van Dijk C. Conservative treatment of
lateral epicondylitis: brace versus physical therapy or a combination of both-a
randomized clinical trial. The American Journal Of Sports Medicine [serial
online]. March 2004;32(2):462-469. Available from: MEDLINE Complete,
Ipswich, MA. Accessed July 16, 2014.
This study, conducted in 2004, examined the clinical effectiveness of
Physical Therapy treatment vs. conservative bracing techniques on the
treatment of lateral epicondylitis (tennis elbow). 180 patients were randomly
assigned to three separate treatment groups: brace-only treatment, Physical
Therapy treatment, and a combination of the two. The patient follow up
was conducted one year after intervention. Upon conclusion of the study,
combination treatment was found to be superior in all aspects of the condition
including subjective pain level, severity of complaints, disability, and patient
satisfaction. It is also important to note that after full healing has taken place at
26 weeks, no statistically significant differences were noted between patients in
relation to functional ability to complete daily activities.
It is hypothesized that the combination of Physical Therapy treatment
and orthopedic bracing, either recommended by a MD or DPT, can allow for
faster initial pain relief and return to function versus rest alone.
Examples of effective Physical Therapy treatment for medial and lateral elbow
pain:
* Ultrasound therapy for tissue healing (1/3 mHz, .5 w/cm2, 5-7 minutes)
* Soft tissue mobilization to the wrist flexor and extensor muscle groups
* Manual joint mobilization to the proximal and distal radioulnar joints to
promote proper wrist and elbow flexion, supination and pronation.
* Static stretching techniques to the wrist flexor and extensor muscle groups
* Electric stimulation for decreasing pain levels and allow for optimal tissue
healing (pre-modulated stimulation, interferential stimulation, TENS therapy)
* Manual cross friction massage to the irritated tendon (both at the origin site
on the humerus and the musculotendonous junction) to treat tissue adhesions
and fibrosis.
* Shoulder rotator cuff strengthening exercises to decrease unwanted force
transmitted to the elbow joint during dynamic/sport activity
* Bracing/splinting to allow for tissue healing in the acute and early sub acute
phases of the rehabilitation program.
Special Tests for the Elbow Joint:
- Lateral epicondylitis test
- Medial epicondylitis test
- Valgus stress test
- Varus stress test
- Biceps load test