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Common Elbow Injuries
By Anne C. Terry, RN, MSN, ARNP
Climbers are likely to encounter an elbow injury of some form in their mountaineering career. The elbow joint is the center of articulation between the humerus, bone of the upper arm, and the radius and ulna of the forearm. It is an important joint for range of motion and mobility of the upper extremities. As compared to the wrist and shoulder, the elbow provides less weight bearing activity. Below is an overview of the most common causes of elbow pain likely to be encountered by the mountaineer. This article is intended to be informative and is not a substitute for medical evaluation.
Acute Elbow Injuries
Acute injuries to the elbow are generally recognized as less than 2 weeks in duration and may or may not be associated with direct trauma. Acute trauma to the elbow is likely to involve a fracture, dislocation or tendon rupture. Pain is typically well localized and a mechanism of injury is apparent. The climber may experience swelling, bruising and/or loss of elbow function.
One of the most serious acute elbow injuries is an elbow dislocation. Typically this results from falling on an outstretched or extended arm, most commonly as a result of a contact sport or fall from a height. The patient experiences an immediate loss of range of motion in combination with acute pain over the elbow surface. The elbow may also appear deformed. In this situation the elbow joint needs to be reduced, or the joint needs to be put back in alignment. Since the patient likely needs sedation and pain management, the reduction should only be performed by a medical provider at an emergency clinic. An x-ray is also required since the climber may have also suffered a fracture of the olecranon and/or radial head in this situation [1,2].
Fractures of the elbow also cause acute pain, swelling, bruising and potential joint deformity. Elbow fractures need to be recognized and treated early to minimize long term complications such as loss of elbow range of motion and chronic stiffness. Direct trauma or a fall on an outstretched hand may indicate an olecranon (proximal ulnar) fracture. Fractures of the radius often occur over the radial head (at the elbow joint) and are associated with elbow dislocations. Pain with elbow flexion may indicate a fracture to the distal humerus. In these scenarios, an x-ray is required to determine a possible fracture. Surgery is often required for a fracture that is severely displaced. Additional damage to the nerves and blood vessels of the upper extremities may also be apparent. Patients may complain of numbness or tingling of the digits of the forearm or hand indicating potential nerve damage. Injury to the blood vessels may decrease perfusion to the forearm and hand as indicated by diminished temperature and/or a weakened or absent pulse at the wrist [1,2].
Biceps Tendon Rupture
Typically, a rupture of the biceps tendon occurs in the older athlete. Sharp pain and the sensation of muscle tearing often occur after repetitive lifting or acute injury. The hallmark of biceps tendon rupture is the sudden contraction of the biceps muscle. Often, there is minimal pain in these individuals after the tear. Surgery is usually required for reattachment of the tendon. However, older athletes may elect not to repair this injury .
Chronic Elbow Injuries
Chronic elbow injuries are typically the result of repetitive injuries, general inflammatory conditions and/or post trauma. They are recognized as greater than 2 weeks in duration. Patients often describe recurrent pain, stiffness and/or loss of elbow range of motion.
Arthritis describes chronic joint pain. The most common forms encountered in the elbow include osteoarthritis (OA), postraumatic arthritis (PA) and rheumatoid arthritis (RA). OA is the result of calcification of cartilage in the joint spaces. Occurring most often in older age, OA is characterized by pain, stiffness and restricted range of motion. Patients with OA often experience a feeling of locking or catching in the joint which is related to loose cartilage pieces. PA often follows a history of a fracture, dislocation or cartilage injury and results in recurrent pain, stiffness and/or limited motion. RA often presents with pain and symmetrical swelling of multiple joints. Joint deformity may occur [1,2].
Acute or chronic swelling over the tip of the elbow with increased pain during movement is a sign of the development of olecranon bursitis. Bursitis describes the inflammation of the bursa, the connective tissue structure surrounding the joint space. Typically, blood and serous fluid collect in this subcutaneous structure. It is caused by chronic overuse of the joint, previous injury or infection. People often encounter this condition after leaning on the elbow surface for long periods of time; this condition is also known as minerís elbow. A single, acute episode of trauma to the tip of the elbow, such as a fall on a hard surface, may precede this condition. The condition can be either inflammatory, infectious or both. The olecranon region often appears red and is warm to palpation. Initial treatment involves use of NSAIDS (non-steroidal anti-inflammatory agents, such as ibuprofen, aleve, naprosyn) to control inflammation and swelling. Fluid collection over the olecranon is easily infected with a simple abrasion, insect bite or cut. If infection is suspected, the region is aspirated to drain infected fluid and perform a bacterial culture. Further treatment with antibiotics and immobilization is required. Without treatment, more serious infections, such as osteomyelitis, bone infection, or septic arthritis can occur [1,2].
There are three main forms of tendinitis, inflammation of a tendon, encountered in the elbow. These include lateral epicondylitis, often known as tennis elbow, medial epicondylitis, often known as golferís elbow and biceps tendinitis . Each condition is usually the result of repetitive motion injuries to the elbow joint. Tendinosis, on the other hand, is a chronic condition that occurs when the tendon is never allowed adequate time to heal properly, and can linger for months to even years. Climbers who repeatedly return to the climbing wall too soon can suffer from this chronic state for life.
Lateral Epicondylitis (LE)
Lateral epicondylitis is a result of microscopic tears and scarring of the extensor carpi radialis brevis tendon located on the lateral (outer) aspect of the elbow. Overuse of the elbow caused by repeated wrist extension against resistance results in lateral pain. Treatment modalities include electrotherapeutic modalities, such as high voltage stimulation or laser treatment, massage, NSAIDS, and/or stretching. Muscle strengthening involving the wrist extensor is important for repair . If unsuccessful, steroid injections are considered for refractory cases. In severe cases, surgery may be required to excise degenerative tissue causing the discomfort. Modifications to both job and sport activities may also be needed.
Medial Epicondylitis (ME)
Also known as golferís elbow, this condition is the result of chronic wrist flexion. It causes inflammation in the forearm flexor muscles and the pronator teres tendon. Pain is localized over the medial (inner) aspect of the elbow and is increased with wrist flexion. Climbers tend to experience ME more frequently than LE, although anyone who must hold the wrist still and extended backwards for long periods of time (i.e. while using a computer mouse, performing a back hand, or painting a ceiling) may overuse the forearm flexors. Treatment modalities are similar to that of lateral epicondylitis and also involve neural stretching to prevent damage to the ulnar nerve that courses across the medial elbow surface .
Inflammation of the biceps tendon results in pain over the anterior aspect of the elbow and is associated with recurrent flexion of the biceps muscle, such as with dips and bench pressing. Patients present with local tenderness over the biceps tendon, there may also be chronic thickening of the tendon with muscle tightening of the biceps . Treatment involves use of NSAIDS, as well as local massage therapy and limiting activity.
While teaching at rock 2 on Mt Erie this year, I talked with a fellow intermediate student who had recently suffered an injury to the arm while ice climbing. Mark graciously accepted my offer for an interview. In September of 2002, Mark was doing an ice climb on the Nisqually glacier. He was top roped via an ice screw and was on his way up the pitch using his front points and ice tools. He slipped and began to fall placing all of his weight temporarily on his outstretched left arm. He then proceeded to fall a few more feet. At the time, he had some mild aching over the upper arm and anterior shoulder and felt this was likely a mild muscular strain or bruise. He continued to climb that day and through the fall. However, he began to notice intense pain in the elbow and shoulder with specific movements such as lateral and overhead movements of the arm. This was especially pronounced with activities such as throwing a rope. A few months after the injury, he sought the care of an orthopedist who diagnosed 2 separate tears in the biceps tendon. One of the tears was also accompanied by an avulsion or chip fracture. Mark had surgery to repair the tears in March and is recovering nicely. He was placed in an immobilization splint for a few weeks and continues with physical therapy. It looks like a year after the incident his strength and mobility will be back to normal. Mark will concentrate on glacier and alpine climbs this year with minimal rock and ice work.
This case shows that not all acute injuries result in severe pain, deformity or loss of motion. In fact, Mark states that he did not notice significant pain or swelling at the time of the injury. Markís accident also confirms the importance of seeking care for an injury even if limitations seem minimal.
Anne Terry is a nurse practitioner at the University of Washington with interests in orthopedics, wilderness medicine and womenís health. She is a first year intermediate climbing student, a triathlete and cyclist. She has been a member of the Seattle Mountaineers since 1994. She can be contacted at firstname.lastname@example.org.
1. Elbow and Forearm Pain. IN: Clinical Sports Medicine, second edition, Brukner, P, Khan, Kharim, Australia, McGraw-Hill Book Company, 2001, p. 274-291.
2. Elbow Pain. IN: Essentials of Musculoskeletal Pain, p. 164-197.
3. Jobe, FW, Ciccotti, MG. Lateral and Medial Epicondylitis of the Elbow. J Am Acad Orthop Surg 1994 Jan; 2(1): 1-8.