Evaluation of elbow pain in adults
- Francis G O'Connor, MD, MPH, FACSM
Francis G O'Connor, MD, MPH, FACSM
- Section Editor — Sports-Related Injuries; Symptom Assessment and Physical Examination; Medical Issues Related to Sports and Exercise
- Professor of Military and Emergency Medicine
- Uniformed Services University of the Health Sciences
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Elbow pain may be due to disorders involving the joint itself, the surrounding soft tissue structures, or a referred source (eg, neck, shoulder, or wrist). Joint and soft tissue structures that are common sources of pain include the epicondyles (medial and lateral), the olecranon bursa, and the radial and ulnar nerves, which course near the elbow joint. Referred pain most commonly arises from a cervical radiculopathy or from the shoulder.
This topic will discuss how to systematically approach the adult patient with nontraumatic elbow pain, and identify the most common causes for such pain. Discussions of specific problems affecting the elbow are found separately. (See "Epicondylitis (tennis and golf elbow)" and "Bursitis: An overview of clinical manifestations, diagnosis, and management" and "Overview of upper extremity peripheral nerve syndromes".)
The elbow joint is formed by the articulation of the distal end of the humerus with the proximal radius (radial head) and ulna (figure 1 and figure 2 and figure 3 and figure 4). Flexion/extension occurs at the ulnohumeral joint and is powered by the biceps and triceps muscles, respectively. The normal arc of motion ranges from full extension or 0 degrees, to 135 degrees of flexion. Some individuals demonstrate the ability to extend the elbow beyond normal; this condition is referred to as "cubitus recurvatus" or cubital recurvatum (picture 1).
Supination/pronation (rotation) occurs at the radiohumeral and proximal radioulnar articulations of the elbow joint. The biceps muscle supinates and the pronator teres muscle pronates the elbow. The elbow can rotate from 0 to 180 degrees.
The epicondyles are bony prominences easily palpated on the medial and lateral sides of the distal humerus, proximal to the elbow joint, and they are a common source of pain. The tendinous origin of the muscles that flex and extend the wrist and fingers are located at the medial and lateral epicondyle, respectively.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Gunn CC, Milbrandt WE. Tennis elbow and the cervical spine. Can Med Assoc J 1976; 114:803.
- Appelboam A, Reuben AD, Benger JR, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ 2008; 337:a2428.
- Jie KE, van Dam LF, Verhagen TF, Hammacher ER. Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma. Ann Emerg Med 2014; 64:74.
- Behr CT, Altchek DW. The elbow. Clin Sports Med 1997; 16:681.
- Hoppenfeld S. Physical examination of the spine and extremities, Prentice Hall, Upper Saddle River 1976.
- Dawson DM. Entrapment neuropathies of the upper extremities. N Engl J Med 1993; 329:2013.
- Miller RG. The cubital tunnel syndrome: diagnosis and precise localization. Ann Neurol 1979; 6:56.
- van Saase JL, van Romunde LK, Cats A, et al. Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Ann Rheum Dis 1989; 48:271.
- Woods GW, Tullos HS. Elbow instability and medial epicondyle fractures. Am J Sports Med 1977; 5:23.
- Sachar K, Mih AD. Congenital radial head dislocations. Hand Clin 1998; 14:39.
- Krogh TP, Fredberg U, Christensen R, et al. Ultrasonographic assessment of tendon thickness, Doppler activity and bony spurs of the elbow in patients with lateral epicondylitis and healthy subjects: a reliability and agreement study. Ultraschall Med 2013; 34:468.
- Radunovic G, Vlad V, Micu MC, et al. Ultrasound assessment of the elbow. Med Ultrason 2012; 14:141.
- Field LD, Altchek DW. Elbow injuries. Clin Sports Med 1995; 14:59.
- CLINICAL ANATOMY
- ETIOLOGY AND COMMON PRESENTATIONS
- Lateral elbow pain
- Medial elbow pain
- Elbow swelling
- Impaired range of motion
- Referred pain
- PHYSICAL EXAMINATION
- Range of motion
- Elbow instability
- Motor and sensory examination
- Special tests
- - Lateral epicondylitis (tennis elbow) test
- - Medial epicondylitis (golfer's elbow) test
- - Radial tunnel syndrome
- - Tinels sign
- Examination of related areas
- Examination pearls
- DIFFERENTIAL DIAGNOSIS
- Olecranon bursitis
- Triceps tendinopathy
- Nerve entrapment
- Ligamentous injury
- Distal biceps tendon rupture
- Congenital dislocation of the radial head
- DIAGNOSTIC IMAGING
- Plain radiographs
- Additional ultrasound resources
- CONFIRMATORY TESTS
- Olecranon bursa aspiration
- Radiohumeral joint aspiration
- Diagnostic injections
- - Suspected lateral or medial epicondylitis
- - Radial tunnel syndrome
- SUMMARY AND RECOMMENDATIONS