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vii ELBOW INJURIES

Elbow injuries are common in sports like boxing, martial arts, snowboarding, skateboarding, tennis, ice hockey, hockey, handball, volleyball and similar sports. The injuries listed below are just some of those that can typically affect the elbow. If in any doubt, always consult a specialist.

The figures below show the elbow from medial and lateral views with marking reflecting the location of symptoms for the injuries described. Note that some of these injuries can co-exist and secondary symptoms can occur that may blur the clinical symptoms and signs.

SYMPTOMS There is acute or gradual onset of exercise-induced pain around the elbow with recurrent locking or pseudo-locking or extension and flexion lag.

AETIOLOGY This is a cartilage injury in the elbow joint, which can occur by repetitive stress or direct impact, causing mechanical blocking and synovitis. CLINICAL FINDINGS There is diffuse tenderness on palpation in the elbow joint. INVESTIGATIONS X-ray and MRI may be normal unless there is a loose or uneven bony component. TREATMENT Arthroscopic excision of the loose fragments.

REFERRALS Refer to orthopaedic surgeon if this diagnosis is suspected or if the diagnosis is not clear.

EXERCISE PRESCRIPTION Many sports can be maintained. Running, cycling and swimming are good alternatives to keep up general fitness. Gym training can be maintained. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs and good elbow function. Compare with other elbow. DIFFERENTIAL DIAGNOSES OCD, synovitis (MRI and arthroscopy differentiate). PROGNOSIS Excellent, if treated appropriately.

2. DISTAL BICEPS TENDON RUPTURE

Fig. 210 Anatomical illustration of biceps tendon rupture

SYMPTOMS There is acute pain in the elbow and sudden weakness in elbow flexion. AETIOLOGY This is an acute injury, where the tendon usually ruptures close to the distal insertion at the radius during an excessive elbow extension or flexion manoeuvre.

CLINICAL FINDINGS Pain and weakness is provoked by resisting elbow flexion. There is often significant swelling, bruising and/or haemarthrosis. INVESTIGATIONS X-ray should be taken, to rule out fracture of the elbow. MRI verifies the diagnosis. TREATMENT A complete tear of the biceps tendon at this site usually requires surgical re-fixation in physically active people. A partial tear may be treated with partial immobilisation, since surgery can be performed later if healing does not occur. REFERRALS Refer to orthopaedic surgeon if this diagnosis is suspected or if the diagnosis is not clear.

Fig. 211 Resistance test for biceps

EXERCISE PRESCRIPTION Many sports can be maintained during healing but the inability to exert force from elbow flexion rules out most racket sports if the dominant arm is affected. After surgery most activities can be back to normal within 12 weeks. Running and cycling (when the wound is healed after surgery) are good alternatives to keep up general fitness. Gym training can be maintained. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs and good elbow function, including strength and flexibility. Compare with other elbow. DIFFERENTIAL DIAGNOSES This is a clinical diagnosis, verified by MRI, but fractures must be suspected.

PROGNOSIS Excellent, if treated appropriately.

Fig. 212 Anatomical illustration of medial elbow flexor muscle origin

SYMPTOMS There is gradual onset of exercise-induced pain around the medial epicondyle of the elbow that is aggravated by hyper-extension. AETIOLOGY This is an over-use type injury of unknown aetiology, often affecting the wrist flexor muscle origins at the medial epicondyle in racket sports players, javelin throwers and cricket bowlers. Despite the name, such injury to golfers is rare.

CLINICAL FINDINGS There is tenderness on palpation over the medial humerus epicondyle and pain and weakness is caused by resisted elbow hyper-extension.

INVESTIGATIONS X-ray and MRI are normal. TREATMENT Temporary partial immobilisation avoiding hyper-extension may relieve symptoms. Address aspects such as bowling technique, errors in

Fig. 213 Resistance test for extensor muscles and palpation at muscle origin top spin or throwing, etc. Cortisone injections may be considered. A soft neoprene type of brace may decrease symptoms.

REFERRALS Refer to physiotherapist if this diagnosis is suspected or if the diagnosis is not clear. EXERCISE PRESCRIPTION Many sports can be maintained during healing but the duration of symptoms is usually long. Running, cycling and swimming are good alternatives to keep up general fitness. Gym training can be maintained. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs and good elbow function. Compare with other elbow. DIFFERENTIAL DIAGNOSES Loose bodies, OCD, synovitis (MRI can usually differentiate). PROGNOSIS Excellent, if treated appropriately.

4. LATERAL EPICONDYLITIS (TENNIS ELBOW)

Fig. 215 Tennis elbow, as shown by MRI with surrounding bone oedema

Fig. 214 Extensor muscle origin at lateral humerus condyle

SYMPTOMS There is gradual onset of exercise-induced pain around the lateral epicondyle of the elbow aggravated by hyper-flexion and supination of the wrist.

AETIOLOGY This is an over-use type injury of unknown aetiology, affecting the wrist extensor muscle origin at the lateral epicondyle in racket sports players, javelin throwers and cricket bowlers.

Fig. 216 Waiter's test - a resisted dorsiflexion of the wrist causes pain at muscle origin

Fig. 215 Tennis elbow, as shown by MRI with surrounding bone oedema

Despite the name, tennis players are an absolute minority of patients. And in further contrast with its name, there is no local inflammation. CLINICAL FINDINGS There is tenderness on palpation over the lateral epicondyle and pain and weakness on a resisted Waiter test. INVESTIGATIONS X-ray and MRI are normal. TREATMENT Temporary partial immobilisation may relieve symptoms. Address bowling technique, errors in racket grip or throwing, etc. Recommend double backhand in tennis. Cortisone injections may be considered. A soft neoprene brace may decrease symptoms.

REFERRALS Refer to physiotherapist if this diagnosis is suspected or if the diagnosis is not clear. Only in persistent cases or when symptoms are severe is surgery (Homan's operation) needed. EXERCISE PRESCRIPTION Many sports can be maintained. Running, cycling and swimming are good alternatives to keep up general fitness. Gym training can be maintained.

EVALUATION OF TREATMENT OUTCOMES

Normal clinical symptoms and signs and good elbow function. Compare with other elbow. DIFFERENTIAL DIAGNOSES Loose bodies,

OCD, synovitis (MRI can differentiate). Referred pain from the cervical spine (examine the neck).

PROGNOSIS Excellent, if treated appropriately.

5. OLECRANON BURSITIS

Fig. 217 Olecranon bursitis, typical appearance

SYMPTOMS There is gradual or acute onset of localised swelling and inflammatory signs over the olecranon.

AETIOLOGY It can occur after direct trauma and bleeding, from repetitive stress causing synovial fluid to fill the bursa, 'student's elbow' or pus in the bursa from infected superficial skin wounds. CLINICAL FINDINGS Localised tender fluctuating swelling over the olecranon but no effusion of the elbow.

INVESTIGATIONS This is a clinical diagnosis. X-ray is normal. MRI or ultrasound will confirm the diagnosis. If septic bursitis is suspected tests for infections (temperature, CRP, ESR and bacterial cultures) must be performed. TREATMENT If the swelling is caused by a bleeding or temporary over-use this injury responds to conservative treatment including ice and compression and avoiding direct impact. There is seldom any indication for surgery. If it is caused by infection antibiotics and/or open drainage of the bursa should be considered. In chronic cases, surgery may also be indicated for cosmetic reasons. REFERRALS Refer to orthopaedic surgeon to determine the cause of the bursitis. EXERCISE PRESCRIPTION Rest, if the cause is infection. Otherwise, most sports could be considered.

EVALUATION OF TREATMENT OUTCOMES

Normal clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Soft tissue tumour (MRI can differentiate). Septic arthritis (elbow effusion and painful movement). PROGNOSIS Good-Fair. Once the bursa has been affected, it will be more sensitive to further knocks and the bursitis can recur independent of the initial cause.

Fig. 218 Pronator teres muscles and median nerve branch

SYMPTOMS There is gradual onset of exercise-induced pain around the anterior proximal arm with paraesthesia of the radial three and a half fingers. AETIOLOGY This is an injury often affecting the wrist in weightlifters, players in racket sports, javelin throwers and cricket bowlers. It is an entrapment of the median nerve between the two bulks of the prona-tor teres muscle or in some cases in the fascia between the pronator teres and flexor carpi radialis muscles. CLINICAL FINDINGS There is a positive Square test.

INVESTIGATIONS X-ray and MRI are normal. TREATMENT Stretching and correction of technique. Surgical nerve release in severe cases. REFERRALS Refer to physiotherapist if this diagnosis is suspected or if the diagnosis is not clear. Refer to orthopaedic surgeon for consideration of surgery in severe cases.

Fig. 219 Square test is positive in pronator teres syndrome

EXERCISE PRESCRIPTION Many sports can be maintained. Running, cycling and swimming are good alternatives to keep up general fitness. Gym training can be maintained. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs and good elbow function. Compare with other elbow. Square and Benedict's tests should be negative. DIFFERENTIAL DIAGNOSES Radiating pain from the cervical spine (examine the neck). PROGNOSIS Excellent, if treated appropriately.

7. RADIAL TUNNEL SYNDROME

Fig. 220 Supinator muscles and radial nerve entrapment

Fig. 221 Pain on resisted extension of the middle finger

SYMPTOMS There is gradual onset of exercise-induced pain around the elbow. AETIOLOGY This is an entrapment of the radial nerve between the supinator muscle bulks, often affecting players in racket sports and spin bowlers. CLINICAL FINDINGS There is pain around the elbow on resisted extension of the middle finger. Tinel's sign is positive.

INVESTIGATIONS Nerve conduction test is positive. TREATMENT Address bowling technique, errors in top spin or throwing, etc. Stretching and a soft neoprene brace may decrease symptoms. REFERRALS Refer to physiotherapist if this diagnosis is suspected or if the diagnosis is not clear. If the symptoms are severe, refer to orthopaedic surgeon.

EXERCISE PRESCRIPTION Many sports can be maintained. Running, cycling and swimming are good alternatives to keep up general fitness. Gym training can be maintained. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs and good elbow function. Compare with other elbow. Resistance test and Tinel's sign should be negative. DIFFERENTIAL DIAGNOSES Loose bodies, OCD, synovitis (MRI can differentiate). PROGNOSIS Excellent, if treated appropriately.

Fig. 222 Triceps muscle ruptures most often occur close to the musculo-tendinous junction

SYMPTOMS There is acute onset of pain and bleeding around the triceps, tendor insection at the olecranon of the elbow, and loss of extension power. AETIOLOGY This is an injury occurring from an excessive eccentric contraction or direct impact to the elbow, often affecting players in contact sports. Occasionally an avulsion fracture may occur. CLINICAL FINDINGS There is tenderness on palpation over the olecranon and pain and weakness on resisted elbow extension. INVESTIGATIONS X-ray and MRI are usually normal.

TREATMENT Partial tears can be treated with two to four weeks' immobilisation, followed by progressive rehabilitation over three months. A complete rupture requires surgical re-fixation.

Fig. 223 Resisted elbow extension causes weakness and pain

REFERRALS Refer to orthopaedic surgeon if this diagnosis is suspected or if the diagnosis is not clear. EXERCISE PRESCRIPTION Many sports can be maintained during healing but throwing manoeuvres are not allowed. Running and cycling are good alternatives to keep up general fitness. EVALUATION OF TREATMENT OUTCOMES Normal clinical symptoms and signs and good elbow function. Compare with other elbow. DIFFERENTIAL DIAGNOSES Avulsion fracture, which is treated surgically. PROGNOSIS Excellent, if treated appropriately.

ID O

EXERCISE ON PRESCRIPTION DURING INJURY TO THE ELBOW

This table provides advice on forms of exercises that may or may not be recommended for athletes with different injuries. The advice must be related to the severity and stage of healing and take the individual's situation into account.

This activity is harmful or risky.

This activity can be done but with care and with specific advice.

This activity can safely be recommended.

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