Elbow Pain Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of all patients presenting with painful elbows

This guidance does not cover:

  • Under 18s (Wakefield) Under 16s (North Kirklees)

Assessment

Signs and Symptoms

TENNIS ELBOW

  • Pain over lateral epicondyle +/- radiation into forearm, pain on gripping
  • Pain on resisted wrist extension /supination
  • Symptoms come after repetitive activity of wrist extension e.g. using computer keyboard
  • No neurological features (no pins & needles)
  • Reduced/painful wrist flexion

GOLFER'S ELBOW

  • Pain over medial epicondyle +/- radiation into forearm, pain on gripping
  • Pain of resisted wrist flexion
  • Symptoms come after repetitive activity of wrist flexion e.g using screwdriver, opening jar
  • Can be associated with ulnar neuropathy (eg tingling in 4th/5th fingers)
  • Reduced/painful wrist flexion
  • Differential – ulnar nerve entrapment

OSTEOARTHRITIS

  • Pain over joint, mainly at the end of flexion/extension
  • Stiffness after immobility
  • Hx of manual work/strenuous elbow activity
  • Reduced ROM esp on terminal extension
  • Crepitus
  • Effusion may be seen over the lateral aspect of the joint

ULNAR NERVE ENTRAPMENT (at cubital tunnel)

  • Pain over medical epicondyle
  • Sensory loss at little finger and ring finger, exacerbated by prolonged periods of elbow flexion or direct pressure on elbow
  • Can be worse at night
  • Wasting of intrinsic muscles of hand, if severe can produce involuntary abduction of little finger and clawing of little and ring fingers

RADIAL NERVE ENTRAPMENT

  • Of posterior interosseus branch
  • Weakness or paralysis of the wrist and digital extensors.
  • Pain may be present, but it usually is not a primary symptom.
  • Attempts at active wrist extension often result in weak dorsoradial deviation. These patients do not have a sensory deficit.

DISTAL BICEPS TENDINOPATHY

  • A history of unaccustomed elbow flexion loading (may include a sudden increase in usual activities e.g. an extra gym session) resulting in pain anteriorly in the cubital fossa.
  • Patient may have a very manual job or lift heavy weights.
  • Localised pain in the area of the distal biceps tendon; no bruising.

DISTAL BICEPS RUPTURE

  • A history of forceful contraction involving the biceps resulting in pain and bruising over the anterior aspect of the forearm
  • Localised swelling in the area and if the tendon has retracted a lump may be seen in the upper arm.

History and Examination

Should include:

  • History of trauma (fracture, previous surgery)
  • Pain in elbow on movement
  • Tenderness of lateral or medial side of elbow
  • Reduction in grip strength
For additional information on signs and symptoms please click here - Signs and Symptoms

Differential Diagnoses

  • Consider shoulder or neck pathology

Red flags

Seek immediate or urgent specialist advice/treatment if:

DISTAL BISCEPS TENDON RUPTURE

  • History of forceful contraction (e.g. lifting weights) – pain and bruising over anterior aspect of forearm
  • Localised swelling in the area
  • Swelling where tendon has retracted

If signs of infection, urgent admission via T&O

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

  • Consider X-ray if elbow has loss of range of movement

Management

Clinical Management

  • Olecranon Bursitis (with no sign of infection)
  • Tennis Elbow & Golfers Elbow - (Usually self-limiting and 89% resolve after 1 year)
    • Stretching, strengthening.
    • Activity modification
    • Ice pack
    • Drainage +/- steroid injection if expertise* exists (Olecranon Bursitis)
    • Monitor – and advice on RICE & modification of activities
    • Analgesia
    • Physiotherapy
    • If diagnostic uncertainty, may need further Ix e.g. EMG

Ulnar Nerve entrapment (at cubital tunnel) consider

  • Bloods to rule out causes of neuropathy (FBC, ESR, glucose/hbA1c, TFTs, Autoimmune
  • Analgesia
  • Conservative management successful if paraesthesia is transient/cause is malposition of elbow e.g. not resting elbows at work
  • Extracorporeal Shock Wave Therapy (ESWT) - Wakefield only

Referral

Referral Criteria

  • Red Flags
  • Elbow Instability - History of previous dislocation/surgery, feeling of elbow giving way. Unable to do press ups or push up off the chair – refer to Orthopaedics
  • North Kirklees (MSK, Trauma and Orthopaedics and Physiotherapy)
    • All MSK referrals (excluding red flags) should be made to Connect Community MSK who will undertake clinical assessment and triage and refer on as appropriate (including to physiotherapy). Choice of provider will be offered following triage
    • Please click here to open the Clinical Decision Making Aid for further guidance on which part of Connect's pathway to refer into i.e. Physioline, Physio or CATs
  • Wakefield – MSK
    • Those not presenting with red flag symptoms or where diagnosis or treatment is unclear should be referred to Connect Community MSK who will undertake clinical assessment and treatment and/or refer on to physiotherapy or secondary care as appropriate. Choice of provider will be offered for onward referrals.
  • Wakefield - Physiotherapy
  • Wakefield – Trauma and Orthopaedics
    • Patients should be offered choice of provider for trauma and orthopaedics.

Referral Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 04.2017
  • Publication Date: 05.2017
  • Updated Date: 06:2018
  • Review Date: 04.2019
  • Ref No: MSK3 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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