Elbow pain is a frequent complaint, not just among athletes, but also in professions that demand repetitive arm movements and physical strain, such as auto repair. Understanding the potential causes of elbow pain is crucial for effective self-care and knowing when to seek professional medical advice. This guide provides a differential diagnosis approach to elbow pain, helping you differentiate between common conditions and understand possible underlying issues.
HISTORY
Elbow pain can manifest at any age and present with a variety of symptoms. For auto repair professionals, the onset and nature of elbow pain can often be linked to work-related activities.
Figure 1.
Elbow pain management algorithm. DMARDs = disease-modifying anti-rheumatic drugs. MRI = magnetic resonance imaging. NSAIDs = non-steroidal anti-inflammatory drugs. PRP = platelet-rich plasma. ROM = range of movement. Rx = medication prescribed. USS = ultrasound scanning.
Red Flags: When to Seek Immediate Attention
Certain symptoms require prompt medical attention. Be aware of these red flags:
- Swelling and Deformity after Injury: If your elbow pain follows a significant impact or twisting motion and is accompanied by swelling or visible deformity, it could indicate a fracture or dislocation.
- Intense Pain at Rest: Severe elbow pain that is present even when you are not using your arm and is associated with swelling and warmth could signal an infection or inflammatory arthritis.
- Rapidly Growing Mass: A noticeable lump that is growing quickly around your elbow needs to be evaluated to rule out tumors or other serious conditions.
If you experience any of these red flags, it is essential to seek urgent medical evaluation.
Assessing Your Elbow Pain
To understand your elbow pain better, consider these questions:
- Nature of Pain: Is it sharp, dull, aching, burning, or throbbing?
- Onset: Did the pain start suddenly or gradually? Can you relate it to a specific activity or incident at work?
- Duration: How long have you been experiencing the pain? Is it constant or intermittent?
- Aggravating Activities: What movements or tasks at work worsen your elbow pain? Examples might include lifting heavy parts, repetitive wrenching, or prolonged gripping.
- Relieving Factors: What makes your elbow pain feel better? Rest, ice, or over-the-counter pain medication?
Associated Symptoms
Pay attention to other symptoms that accompany your elbow pain, as they can provide valuable clues:
- Elbow Stiffness: Stiffness, particularly in the morning or after periods of rest, can be a sign of arthritis or previous injury. Difficulty straightening your elbow (extension) is often more limiting than difficulty bending it (flexion).
- Neurological Symptoms: Numbness, tingling, or a “pins and needles” sensation in your forearm, hand, or fingers can indicate nerve involvement. Ulnar nerve issues are common in medial epicondylitis (golfer’s elbow) and elbow arthritis.
- Referred Pain: Pain originating from your neck or shoulder can sometimes be felt in your elbow. If you also have neck or shoulder pain, or limited movement in those areas, the elbow pain might be referred.
EXAMINATION
Before focusing on your elbow, briefly assess your neck and shoulder mobility to rule out referred pain. If possible, have someone check your cervical spine by gently performing the Spurling Test – tilting your head towards the painful side while applying slight downward pressure. Pain during this test may suggest nerve compression in the neck.
Now, examine your elbow systematically, comparing it to your other arm:
- Look: Observe for any redness, swelling, muscle wasting (atrophy), differences in size or shape (asymmetry), or obvious deformities. Note your overall posture, as this can sometimes contribute to chronic pain.
- Feel: Gently touch around your elbow joint to pinpoint the location of tenderness. Check for any unusual masses or changes in skin temperature or texture.
- Front of Elbow (Antecubital Fossa): Tenderness here might suggest biceps tendonitis.
- Inner Elbow (Medial Epicondyle): Pain just in front of the bony bump on the inner elbow is typical of medial epicondylitis (golfer’s elbow). Tapping behind this bony bump can elicit ulnar nerve symptoms (Tinel’s sign), indicating ulnar neuropathy.
- Outer Elbow (Lateral Epicondyle): Point tenderness directly on the bony bump of the outer elbow is a hallmark of lateral epicondylitis (tennis elbow). Pain slightly further down from this point could be posterior interosseous nerve (PIN) compression, another cause of lateral elbow pain that can sometimes occur with tennis elbow.
- Back of Elbow (Olecranon): Tenderness at the bony tip of the elbow or the soft tissue behind it could be due to triceps problems, olecranon bursitis (inflammation of the bursa sac), or olecranon process issues. Feel for any clicking or grinding (crepitus) in these areas, which could indicate a radial head fracture, arthritis, or loose bodies in the joint.
- Move: Check your range of motion. First, try to move your elbow actively (on your own), then passively (with assistance).
- Extension: Hyperextension (elbow bending slightly backward) is normal in some people, especially women, if it’s equal on both sides and there’s no injury history. Limited extension can be a sign of osteoarthritis.
- Flexion, Supination, Pronation: Check if you can fully bend your elbow, turn your palm up (supination), and turn your palm down (pronation).
- Wrist Movements: Assess wrist movements as well, as the muscles controlling your wrist also attach at the elbow.
Finally, perform a basic neurovascular exam to check nerve and blood vessel function in your arm and hand, if necessary. Consider assessing other joints if you suspect systemic conditions like rheumatoid arthritis.
INVESTIGATIONS
While many elbow pain diagnoses can be made based on history and physical examination, investigations may be needed in some cases:
- Blood Tests: If inflammatory arthritis is suspected, blood tests like a full blood count, erythrocyte sedimentation rate (ESR), rheumatoid factor, and autoantibody tests may be ordered.
- Plain X-rays: X-rays are not typically helpful for tendon problems but are recommended if you suspect arthritis, fracture, or dislocation. Standard front and side views of the elbow are usually obtained.
- Ultrasound Scanning (USS): Ultrasound can visualize tendons, ligaments, and bursae. However, its accuracy depends heavily on the skill of the operator.
- Magnetic Resonance Imaging (MRI): MRI provides detailed images of soft tissues and bones. It is particularly useful for diagnosing ligament injuries and is often used in specialist settings.
- Electromyography/Nerve Conduction Velocity Studies: If nerve problems are suspected, these tests can assess nerve function.
TREATMENT
The goals of treatment are to reduce pain, restore normal elbow function, and allow you to return to your work and daily activities.
Initial treatment often involves:
- Rest: Avoid activities that worsen your elbow pain. Relative rest means modifying your activities, not complete immobilization.
- Pain Relief: Over-the-counter pain relievers like NSAIDs (non-steroidal anti-inflammatory drugs) can help reduce pain and inflammation.
- Steroid Injections: Corticosteroid injections can provide short-term pain relief but are not a long-term solution and may have potential side effects with repeated use.
For tendinopathies (like tennis elbow and golfer’s elbow), primary care management focuses on:
- Reducing Stress: Counterforce bracing (elbow straps) can help reduce strain on the affected tendons.
- Strengthening: Rehabilitative exercises and physiotherapy are crucial for improving tendon strength and function. Physiotherapy has been shown to be highly effective over time.
- Other Treatments: While treatments like botulinum toxin and platelet-rich plasma (PRP) are being explored, there is currently limited evidence to support their routine use.
If conservative treatments fail to provide relief after 6-12 months, referral to a specialist may be considered. Surgery is an option in some cases, but outcomes can be variable, and pain may persist in some individuals.
For arthritis, management includes:
- Activity Modification: Adjusting work techniques and avoiding aggravating movements.
- NSAIDs: Pain relievers to manage pain and inflammation.
- Disease-Modifying Agents: For inflammatory arthritis, medications to slow disease progression.
- Steroids: Oral or intra-articular (injected into the joint) steroids for pain and inflammation control.
- Splinting: To support and rest the elbow.
- Ice or Heat: To manage pain and stiffness.
Referral to a specialist is recommended for arthritis if non-surgical treatments are ineffective, daily activities are significantly affected, or if there is painful locking of the elbow joint.
Managing elbow pain, especially work-related conditions, often requires patience and persistence with conservative treatments, including exercises and physiotherapy. Consider taking short breaks from work to allow for rest and recovery. Regular follow-up with a healthcare provider is important to monitor progress and adjust treatment as needed.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
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