Click here to view next page of this article

Olecranon Bursitis of the Elbow

Olecranon Bursitis of the Elbow. In the elbow, several structures can be involved. The first is the olecranon bursa, which is right over the point of your elbow. The most common thing that I see is olecranon bursitis due to trauma. Stroke patients use their arms a lot, especially initially to get mobilized. A lot of times they lean on their elbows and about once a month we see a patient in the hospital with olecranon bursitis due to this type of activity. The history may be that the patient doesn’t even know it’s there or they notice that it’s swollen, doesn’t bother them. Sometimes the doctors are more concerned that there is a problem. Although there can be some pain and if it’s just due to trauma, not much warmth or anything else, you have to be concerned that there could be an infection there. Even in a patient with just trauma. Sometimes that can somehow "seed" it with staph, the most common bacteria. Or patients who have rheumatoid arthritis or gout can get inflammatory involvement of this bursa. In that case it will be quite red and swollen, tender. The main thing to remember though is that the range of motion of the elbow is intact. You have good rotation of the radial head, usually near normal extension. Sometimes if it is very swollen the patient won’t be able to extend it comfortably, because of the fact that you are putting pressure on the bursa. But otherwise the range of motion is normal. If you feel over the elbow joint it is pretty free of tenderness and there is no pain there.

Basically, treatment is just aspiration if it’s just a non-inflammatory situation. Occasionally if the patient has a lot of symptoms I will inject some corticosteroids. Sometimes in a patient who is having repetitive trauma, such as they are recovering from a stroke and I know they are going to continue using that elbow, just have the physiatrist prescribe elbow pads to protect a little bit. If you draw this fluid out and it looks a little bit cloudy, be concerned about an infection. I’ll send it off to the lab. If the white count is more than 1,000 I’ll be concerned. And of course, gram stain and culture. Unlike a septic arthritis, this is not necessarily something that needs to be treated aggressively with IV antibiotics.

Epicondylitis, I’m sure some people came here with the idea of playing either golf or tennis. I’m a tennis player - I guess 50/50 tennis and golf are both very popular. But lateral and medial epicondylitis are commonly associated with golf and tennis. Although, there are many other situations where you can get this disorder. Lateral epicondylitis is sometimes called "tennis elbow". Medial epicondylitis is sometimes called "golfers elbow." And that’s because the activity, the actual swing of the golf club and the stroke of the tennis racquet you put stress on these respective structures. Of course it’s a repetitive thing. If you go out and play golf or tennis you do this hundreds and hundreds of times. One thing that I’ve noticed is that if you have ever bought one of these computer desks or a cabinet from one of these furniture companies where it comes in a box and you have to put it together yourself. You figure you will just do it with your hand screwdriver and you turn and turn and turn. You know, hundreds of screws. And there’s always a big bag of parts left over and you don’t really know what they are for, but at the end of a day like that sometimes you will feel it in your elbow because of the constant pressure on the muscles where they insert on the elbow; either the ulna or the radius. One thing to remember, this is not a true tendonitis. The bellies of the muscles actually insert on the bone and what happens is there are sort of micro-evulsions and hemorrhage and that’s what causes the pain. Patients often complain of pain when they shake hands, when they try to open or close a door or a jar, or any repetitive motion like turning a screw, or if they are golfers or tennis players. Those are their biggest concerns. They want to get back on the court or the course and do the thing that they really like to do.

When you examine them you will find point tenderness over the respective epicondyle and also if you do certain maneuvers. For epicondylitis - and that’s what this is showing. In my experience that’s more common, and that’s not because my patients are big tennis players. I don’t know why it is but I think it’s just maybe the activities that they do at home cause it more. What you can see here is the forearm is supinated and the wrist is extended. You ask the patient to push up on your hand to fully extend that wrist and they will have a lot of pain right over the lateral epicondyle and if you do the exact opposite maneuver.

The treatment of these things is to refrain from these activities. If they are a tennis player or a golf player, tell the patient not to do it for a few weeks and give it a chance to heal up. If it’s like a one-time episode, it may not come back again. Antiinflammatory drugs are very helpful if the patient can tolerate them. Injections - now this is one instance where I prefer not to use an injection unless the more conservative measures don’t help. Because, if you just feel over your elbow, the lateral and medial epicondyle, there is hardly any soft tissue there. If you stick corticosteroids and lidocaine, corticosteroids can cause a little bit of a reaction. Sometimes it will even make the symptoms worse. So I don’t necessarily do this right off the bat. Again, there are other rheumatologists and orthopedists who, when they see a patient like this, they just give an injection. If you have a patient who has persistent or recurrent symptoms - say they play golf, and particularly with tennis - this forearm splint can help. What it does is it’s a tight, basically a Velcro band around your forearm and it just relieves the tension that you would normally put on the place where these muscles insert on the epicondyle. I don’t know if they work as well for golf. I haven’t seen many patients with what I would call "golfers elbow". What it does is the stress is put on the area where that band is placed.

When a patient has epicondylitis related to an occupation, that’s a little more difficult problem, especially if their employer is hard-driving. Sometimes modifying what they do can help. If they can use their other hand for that activity - it depends on their job. What I would like is to rest them until they are symptom-free. Because if they still have symptoms that means there is still some hemorrhage and inflammation there. That might take a couple of weeks. On the other hand, employers might even be reluctant to have them go back because they don’t want to have a disability situation on their hands. Obviously, each employer is going to be different. Some of them will just try to find them a job where they don’t have to do the same exact thing. Others of them care a lot less and just make them go back again and again. But I would wait until they are symptom-free. Probably ten days to two weeks. So antiinflammatory drugs, maybe and injection. Again, the forearm brace may help those patients.

De Quervain’s tenosynovitis  is inflammation of the extensor pollicis brevis and the abductor pollicis longus. Two tendons go over the radius styloid and help to abduct and extend the thumb. This is pretty important. You’ve got to be able to move your thumb to be able to do almost anything. This is very painful. Patients will complain of pain in the area of the radial styloid. It may radiate to the base of the thumb and up into the forearm, the distal forearm where the muscle bellies are located. The tendon sheath does course for several inches. It occurs more commonly in people with osteo and rheumatoid arthritis who may have disease at the radial styloid or the base of their thumb, depending on the type of arthritis. I have seen occasionally women who have just delivered a baby and then they are responsible for doing all this work at home, diapers, carrying.

The physical examination - this is one of my medical student who offered to pose for me - and what you can see is the two tendons. If you extend your thumb out the tendons kind of pop out and sometimes you can actually see them separately, but often it’s difficult. But the two tendon sheaths are right over the radial styloid going to the base of the thumb and then extending into the forma more proximally. If you examine a patient you will find that it’s very tender right over those tendon sheaths from the base of the thumb all the way back, probably a couple of inches above the radial styloid. The most useful test is called the Finklestein’s test where you have the patient make a fist with their thumb inside the fingers and then you just gently stretch those tendons. If a patient has this they will let you know.

The treatment is rest, splinting. If you are going to truly splint these tendons you have to have a special splint made that extends up to the thumb, but it’s very hard to use your hand with this type of splint. Often what I do is I just order like a Futuria splint, which is more for the wrist, but that sometimes helps enough to get the patient by. Again, injection can be useful. I don’t always do it right away. It depends on the patient. If someone is really really in a lot of pain and they can’t function I’ll want to do something that works quickly. If they are getting by and I get the sense that they are not needle-happy then I’ll just try a little antiinflammatories and some rest for awhile, then I’ll see them back. Again, you are injecting in the tendon sheath and you do run the risk of tendon rupture, although there is not a tremendous amount of stress on this tendon like there is in Achilles tendon or a rotator cuff.

Occasionally surgery is required. I’ve seen a couple of patients in which nothing else worked and what the surgeons do is either strip the tendon sheath or transpose the tendon so it’s not going over the radial styloid, which again has a tendency to cause irritation. Sometimes they even shave that down.