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Clinical: Elbow Pain - Are the Hoof Beats from Horses or Zebras?



by David W. Flatt, DC, DABCO

Did you know that “Tennis Elbow” (lateral epicondylopathy) is actually more common in golfers then “Golfer’s Elbow” (medial epicondylopathy)? Both of these tendonitis conditions can be quite painful and limit a person’s ability to perform their job, their sports and even interfere with activities of daily living in more severe cases. As the Midwest population gets into summer activities and sports, clinicians can expect to see more of these elbow pain cases.

Common Elbow Conditions:
Lateral Epicondylopathy: The lateral epicondyle of the humerus serves as the CEO of the elbow region. However, in this instance, CEO refers to common extensor origin. The muscles responsible for wrist and finger extension and radial deviation of the wrist attach proximally to the lateral epicondyle. Overuse and overload mechanisms are often the etiology behind the onset of pain in the lateral elbow. Patients will typically have pain over the lateral epicondyle and the adjacent tendon attachments. Usual age of affliction is 35-50 yo (seldom under 20 yo) and has a 1-3% population rate.

Medial Epicondylopathy: The medial epicondyle of the humerus is referred to as the CFO (common flexor origin) as it serves as the attachment site for muscles involved in wrist and finger flexion and pronation. Gripping and overuse are the common causes but the incidence rate is about one-third of lateral epicondylopathy. In both instances, micro tears develop in response to overload or overuse and inflammation develops setting the stage for fibrotic and granulation tissue to be laid down.

Radial Tunnel Syndrome: The radial nerve can become compressed at a variety of locations and therefore is the most commonly injured peripheral nerve. Radial nerve entrapment at the radial tunnel involves the deep branch as the extensor carpi radialis brevis and edge of the supinator tighten and compress around the nerve. Patients typically experience pain around the lateral elbow and forearm but the clinician should be aware that maximal tenderness to palpation is often 5 cm distal to the lateral epicondyle anterior to the radial neck.

Posterior Interosseous Nerve Syndrome: Five areas of potential compression have been cited in the literature. Symptoms include weakness of the MCP extension of any and/or all of the five digits. This weakness helps to distinguish this disorder from the other causes of lateral elbow pain.

Pronator Teres Syndrome: In addition to the carpal tunnel, the median nerve can also undergo compression in the pronator teres. Unlike carpal tunnel syndrome though, pronator teres compression of the median nerve will provoke symptoms (pain, paresthesia) in the palm on the radial side. Differentiation is further confirmed clinically by an absent Phalen’s and Tinel’s tests at the wrist. Tenderness 4 cm distal to the cubital crease is expected. Resisted pronation increases pain.

Cubital Tunnel Syndrome:
The ulnar nerve has proven vulnerable to compression and inflammation in the cubital tunnel in the medial elbow. The superficial nature of this nerve make it more susceptible to irritation. Paresthesia in the 4th and 5th digits highlight the clinical presentation along with decreased grip strength. Many patients will present with a subluxing ulnar nerve that slides over the medial epicondyle with end range elbow flexion followed by auto-reduction when the elbow is straightened. This repetitive irritant to the ulnar nerve can predispose the patient to peri-neural fibrosis at the cubital tunnel.

Treatment Options:
Most cases of the above conditions can be resolved with conservative care. Non-surgical protocols include the RICE (rest, ice, compression, elevation) method, modalities, soft-tissue treatment (Graston, ART, myofascial release, Nimmo), nerve mobilization and glides, kinesiotaping, stretching, splinting, bracing and activity modification. Rarely do these cases require surgical intervention. Having said that, chiropractic physician’s that possess expertise in soft tissue treatments are in a unique position to help many patients who otherwise might be influenced to consider pre-mature surgery.

Talking Points:
1. Confirm diagnosis for patients presenting with elbow pain.
2. Institute a thoughtful strategy for diagnosis resolution.
3. Learn Graston and/or Active Release Technique. Attend the workshops.
4. Engage in literature updates to keep yourself sharp.