Elbow pain is a frequent complaint in primary care settings. While elbow pain can originate from various structures within and around the joint, including tendons, bursae, bones, and nerves, anterior elbow pain presents a unique diagnostic challenge. This article focuses specifically on the differential diagnosis of anterior elbow pain, providing a structured approach for healthcare professionals.
Understanding Anterior Elbow Pain
Anterior elbow pain refers to discomfort localized to the front of the elbow joint, often involving the antecubital fossa. Patients may describe pain that is sharp, dull, aching, or burning. Accurate diagnosis is crucial for effective management, as anterior elbow pain can stem from a range of conditions, from common tendinopathies to less frequent nerve compressions or referred pain.
Red Flags in Anterior Elbow Pain
Certain symptoms warrant immediate attention and referral to specialist care. Red flags associated with anterior elbow pain include:
- Trauma: Significant injury with swelling, deformity, or suspected fracture.
- Rapidly Increasing Mass: A palpable and growing mass in the anterior elbow region.
- Signs of Infection: Redness, warmth, swelling, and tenderness, suggesting septic arthritis or cellulitis.
- Neurological Deficits: Progressive weakness or sensory loss in the forearm or hand.
History Taking for Anterior Elbow Pain
A detailed history is paramount in differentiating the causes of anterior elbow pain. Key aspects to explore include:
- Pain Characteristics: Onset (sudden or gradual), location (point tenderness or diffuse), nature (sharp, aching, burning), severity (pain scales), and aggravating/relieving factors.
- Mechanism of Injury: Specific trauma, overuse, repetitive activities, or insidious onset.
- Pain Duration and Progression: Acute, subacute, or chronic pain.
- Associated Symptoms:
- Stiffness: Morning stiffness, stiffness after rest, or stiffness limiting range of motion (flexion vs. extension). Anterior elbow pain with stiffness may suggest underlying joint pathology.
- Neurological Symptoms: Numbness, tingling, paresthesia, or weakness in the forearm or hand. Specifically, inquire about median nerve distribution symptoms (palmar aspect of thumb, index, middle, and radial half of ring finger) as it relates to pronator teres syndrome and anterior interosseous nerve syndrome.
- Referred Pain: Consider neck or shoulder pain radiating to the elbow. Cervical radiculopathy or shoulder pathology can manifest as anterior elbow pain.
Physical Examination of the Anterior Elbow
A systematic physical examination is essential. Remember to compare findings to the contralateral, asymptomatic elbow.
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Inspection: Observe for:
- Swelling: Localized swelling in the antecubital fossa or diffuse elbow swelling.
- Redness (Erythema): Suggestive of inflammation or infection.
- Bruising (Ecchymosis): Indicates recent trauma.
- Muscle Atrophy: Wasting of biceps or forearm muscles.
- Deformity: Gross deformity may indicate dislocation or fracture.
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Palpation: Carefully palpate the anterior elbow structures to identify the source of pain:
- Biceps Tendon: Palpate the biceps tendon in the antecubital fossa for tenderness. Tenderness anteriorly in the antecubital fossa is a key sign of biceps tendinopathy or distal biceps rupture.
- Brachialis Muscle: Palpate the brachialis muscle belly, located deep to the biceps, for tenderness, which may indicate a brachialis strain.
- Medial Epicondyle and Common Flexor Tendon Origin: While medial epicondylitis typically presents with medial elbow pain, pain can radiate anteriorly. Palpate just anterior to the medial epicondyle for tenderness.
- Ulnar Nerve: Palpate the ulnar nerve in the cubital tunnel, posterior to the medial epicondyle, to assess for tenderness or Tinel’s sign (tingling sensation radiating into the ulnar nerve distribution upon percussion). While primarily related to medial elbow pain, ulnar nerve issues can sometimes contribute to referred anterior elbow discomfort.
- Lateral Epicondyle and Common Extensor Tendon Origin: Palpate the lateral epicondyle. While lateral epicondylitis is primarily lateral elbow pain, referred pain patterns can be complex.
- Radial Head: Palpate the radial head for tenderness, crepitus, or clicking, which may indicate radial head fracture or radiocapitellar joint arthritis (less common as a primary cause of anterior pain, but should be considered in the differential).
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Range of Motion (ROM): Assess both active and passive ROM:
- Flexion and Extension: Note any limitations or pain with flexion and extension. Restriction of extension may be more indicative of intra-articular pathology.
- Pronation and Supination: Assess pronation and supination, as pain with resisted pronation might suggest pronator teres syndrome.
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Strength Testing: Evaluate muscle strength:
- Biceps Strength: Resisted elbow flexion in supination to assess biceps brachii strength.
- Brachialis Strength: Resisted elbow flexion in pronation to isolate brachialis strength.
- Wrist Flexion and Pronation Strength: Assess wrist flexion and pronation strength to evaluate the muscles originating from the medial epicondyle and potentially involved in pronator teres syndrome.
- Hand and Finger Strength: Assess grip strength and finger flexion/extension to rule out neurological deficits.
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Neurological Examination:
- Sensation: Test sensation in the median, radial, and ulnar nerve distributions. Pay particular attention to the median nerve distribution in the hand for pronator teres syndrome and anterior interosseous nerve syndrome.
- Motor Function: Assess motor function of the median, radial, and ulnar nerves. Specifically, test:
- Anterior Interosseous Nerve (AIN): Test the ability to make an “OK” sign (opposition of thumb and index finger tip-to-tip). Weakness in this motion suggests AIN syndrome.
- Pronator Teres and Quadratus: Assess pronation strength.
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Special Tests:
- Spurling’s Test: Perform Spurling’s test to assess for cervical radiculopathy as a source of referred pain.
- Resisted Biceps Curl Test: Resist elbow flexion in supination to assess biceps tendinopathy.
- Pronator Teres Syndrome Tests:
- Resisted Pronation Test: Resist pronation with the elbow flexed to 90 degrees. Pain provocation suggests pronator teres syndrome.
- Pronator Compression Test: Apply pressure over the pronator teres muscle in the proximal forearm while supinating and extending the patient’s forearm. Reproduction of symptoms suggests pronator teres syndrome.
Differential Diagnoses for Anterior Elbow Pain
Based on history and physical examination, consider the following differential diagnoses for anterior elbow pain:
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Biceps Tendinopathy and Distal Biceps Rupture:
- Mechanism: Overuse, eccentric loading, or sudden forceful extension against resistance. Rupture typically involves a sudden, pop sensation.
- Pain: Anterior elbow pain, often localized to the antecubital fossa. Pain may worsen with resisted elbow flexion and supination.
- Examination: Tenderness over the biceps tendon, potential palpable defect in biceps muscle belly with rupture, weakness in elbow flexion and supination. “Popeye” deformity may be present with rupture.
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Brachialis Strain:
- Mechanism: Direct blow to the anterior elbow, forceful or repetitive elbow flexion.
- Pain: Deep anterior elbow pain, worsened by resisted elbow flexion in pronation.
- Examination: Tenderness to palpation over the brachialis muscle belly, pain with resisted elbow flexion in pronation.
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Medial Epicondylitis (Golfer’s Elbow):
- Mechanism: Overuse of wrist flexors and pronators, repetitive wrist flexion and pronation activities.
- Pain: Pain primarily at the medial epicondyle, but can radiate anteriorly down the forearm and sometimes into the anterior elbow.
- Examination: Tenderness to palpation over the medial epicondyle, pain with resisted wrist flexion and pronation.
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Pronator Teres Syndrome:
- Mechanism: Compression of the median nerve by the pronator teres muscle. Repetitive pronation activities, direct compression.
- Pain: Vague anterior forearm and elbow pain, paresthesias in the median nerve distribution (thumb, index, middle, radial ring finger). Pain may be exacerbated by pronation and resisted pronation. Night pain is common.
- Examination: Tenderness over the pronator teres muscle in the proximal forearm. Positive pronator teres syndrome tests (resisted pronation, pronator compression test). Sensory deficits in median nerve distribution.
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Anterior Interosseous Nerve (AIN) Syndrome:
- Mechanism: Compression or injury to the AIN, a motor branch of the median nerve.
- Pain: Deep, aching pain in the proximal forearm and anterior elbow. Pain is often not the primary complaint; weakness is more prominent.
- Examination: Motor weakness of muscles innervated by AIN: flexor pollicis longus (FPL), flexor digitorum profundus (FDP) to index and middle fingers, and pronator quadratus. Inability to make a tip-to-tip “OK” sign (pinch grip weakness). No sensory deficits.
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Referred Pain:
- Cervical Radiculopathy: C6 or C7 radiculopathy can refer pain to the elbow and anterior elbow region.
- Shoulder Pathology: Conditions like rotator cuff tendinopathy or impingement can refer pain distally to the elbow.
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Radiocapitellar Joint Arthritis (Osteoarthritis or Inflammatory Arthritis):
- Mechanism: Degenerative or inflammatory joint changes in the radiocapitellar joint.
- Pain: Less commonly a primary cause of anterior pain, but can contribute to anterior elbow discomfort. Pain with joint loading, stiffness, crepitus.
- Examination: Tenderness over the radiocapitellar joint (lateral elbow, but can refer anteriorly), crepitus, limited ROM, particularly extension.
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Less Common Causes:
- Anterior Elbow Bursitis (Bicipitoradial Bursitis): Inflammation of the bursa between the biceps tendon and radial tuberosity.
- Tumors or Masses: Rarely, tumors or masses in the anterior elbow can cause pain.
Investigations for Anterior Elbow Pain
Investigations are guided by the suspected diagnosis:
- Plain Radiographs: Initial imaging to rule out fracture, dislocation, or advanced arthritis. Not typically helpful for tendinopathies or nerve compression syndromes. Standard anteroposterior and lateral radiographs should be obtained if trauma or arthritis is suspected.
- Ultrasound (US): Useful for evaluating biceps tendon pathology, medial epicondylitis, lateral epicondylitis, and for guiding injections. Operator-dependent sensitivity and specificity.
- Magnetic Resonance Imaging (MRI): Gold standard for soft tissue evaluation. Excellent for assessing ligament injuries, tendon ruptures (biceps), nerve compression, and intra-articular pathology. Considered in secondary care settings or when diagnosis is unclear after initial assessment.
- Electromyography (EMG) and Nerve Conduction Studies (NCS): Indicated when nerve compression syndromes (pronator teres syndrome, AIN syndrome, cubital tunnel syndrome if considering referred pain) are suspected. Help to confirm nerve dysfunction, localize the site of compression, and assess severity.
- Blood Tests: If inflammatory arthritis is suspected, consider full blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), and antinuclear antibodies (ANA).
Treatment of Anterior Elbow Pain
Treatment strategies are tailored to the specific diagnosis and aim to alleviate pain, restore function, and prevent recurrence.
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Conservative Management: First-line treatment for most anterior elbow pain conditions.
- Rest and Activity Modification: Avoid aggravating activities. Relative rest to allow tissue healing.
- Pain Management: Analgesics (acetaminophen, NSAIDs), topical pain relievers.
- Physical Therapy: Crucial for rehabilitation. Includes:
- Pain and Inflammation Control: Modalities like ice, heat, ultrasound.
- Range of Motion Exercises: Gentle stretching and mobilization to restore full ROM.
- Strengthening Exercises: Progressive strengthening of biceps, brachialis, forearm muscles, and shoulder girdle muscles. Eccentric strengthening is particularly beneficial for tendinopathies.
- Ergonomic Advice: Modify activities and work environment to reduce stress on the elbow.
- Counterforce Bracing: May be helpful for medial epicondylitis (although primarily for medial pain, it can indirectly reduce stress in the anterior elbow region in some cases).
- Steroid Injections: Corticosteroid injections may provide short-term pain relief for tendinopathies and bursitis, but long-term outcomes may not be superior to conservative management and there are potential risks of tendon weakening. Use judiciously.
- Platelet-Rich Plasma (PRP) and Botulinum Toxin: Emerging treatments for tendinopathies, but evidence of superiority over placebo is limited.
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Surgical Management: Considered for refractory cases after failed conservative treatment (typically 6-12 months) or in cases of acute biceps tendon rupture. Surgical options may include:
- Distal Biceps Tendon Repair: For complete biceps tendon ruptures.
- Pronator Teres Release: For recalcitrant pronator teres syndrome.
- Cubital Tunnel Release or Ulnar Nerve Anterior Transposition: If ulnar nerve compression is contributing to anterior elbow pain (less common primary cause).
- Arthroscopic or Open Debridement: For intra-articular pathology or recalcitrant tendinopathies.
Conclusion
Anterior elbow pain presents a diagnostic challenge requiring a systematic approach. A thorough history and physical examination are critical to narrow the differential diagnosis. Understanding the anatomical structures and common pathologies in the anterior elbow region, combined with appropriate investigations when needed, will guide effective management and improve patient outcomes. Primary care management focuses on conservative measures and rehabilitation, with referral to specialist care for persistent symptoms or when surgical intervention is considered.
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