Elbow Pain Patient presents with Elbow Pain

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for MSK Triage

Epicondylitis Medial/Lateral

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Red Flag Symptoms - manage as per suspected

pathology

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GP Advised Self-Management

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Refer to Physiotherapy/ MSK triage

Stiff and Painful Elbow– no recent history of

trauma

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If suspectedOsteoarthritis Refer for X-ray

OsteoarthritisConfirmed

Osteoarthritis notConfirmed

Treat in line withpathology

Refer to MSK triage if symptoms significant and conservative

treatments ineffective

Stiff Elbow Post Injury >3 months

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Refer to MSK triage

Refer to Physiotherapy

History and ExaminationClick for

more info

If not resolving with self-care consider steroid

injection

Advise on self-care including pain relief

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Advise on conservative measures

Consider x-rayClick for

more info

Manage as per x-ray results

Olecranon Bursitis(non-septic)

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Conservative measuresClick for

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If conservative measures fail refer to MSK triage

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History and Examination

History -

1. Exclude Red Flag signs and symptoms

· RED HOT SWOLLEN JOINT - Septicarthritis - Usually acute-subacute onset, joint affected is red, hot swollen with reduced function. Patient may also have systemic symptoms.

· MASS/LUMP INCREASING IN SIZE - Mass/lump increasing in size, weight loss. Patient may also be systemically unwell. Bone pain might also be evident.

·If sarcoma/malignancy suspected - Please refer to sarcoma CCG guidance.

·Soft tissue sarcoma - likely with mass/lump increasing in size

·Bone sarcoma - likely if along with mass increasing in size there is bone pain/swelling

· SIGNIFICANT TRAUMA -Trauma might result in a fracture, dislocation, or tendon rupture e.g. distal biceps.

· Ulnar neuropathy (rarely secondary to malignancy, and can be a red-flag if clinician concerned) - Malignancies usually do not present with ulnar neuropathy, but at times a tumour can invade the brachial plexus and the patient may present with a clinical presentation similar to a distal mononeuropathy.

Malignancy should be considered in patients who are at risk of malignancy and present with signs and symptoms of ulnar neuropathy.

In the history the presence of the following suggest risk of malignancy as opposed to other causes of ulnar neuropathy - Horner’s syndrome, severe pain radiating from the neck or shoulder, marked thenar eminence wasting of affected hand with weakness of thumb abduction without median sensory involvement.

2. Assessment of pain -a focused history on nature, onset, duration of pain, and associated symptoms, activities and mechanism of injury if patient presented within context of trauma.

· Lateral epicondylitis - Traumatic pain affecting dominant arm localised to lateral epicondyle radiating to forearm. Usually affects tennis players, manual workers, carers of young children.

· Medial epicondylitis (Golfer’s elbow) - Pain localized to medial epicondyle, worse on gripping objects, history of repeated stress and trauma should be explored.

· Osteoarthritis - chronic worsening pain and restriction of extension, with catching, click, locking.

· Inflammatory arthritis - Bilateral elbow pain, stiffness, restricted full range of movement, involvement of other joints and systemic symptoms.

20-50% of patients with rheumatoid arthritis present with elbow pain.

Other symptoms - Rule out referred pain to neck/shoulder as could be due to rheumatoid arthritis.

3. Examination - Examine the neck, cervical spine, both shoulders, back, arms/forearms, wrists and hands to rule out referred pain due to cervical radiculopathy/rheumatoid arthritis.

NB: if there is muscle wasting/atrophy/or swelling.

· Elbow examination –Inspection -assesses if both elbows symmetric, swelling, atrophy redness, gross deformity.

· Palpate for tenderness, if localized on medial epicondyle - Medial epicondylitis.

· If tenderness is localized to the lateral epicondyles this is likely lateral epicondylitis.

· Palpate area distal to radial head if tenderness present there is likely posterior intraosseous nerve compression.

· Feel for crepitation/click-which could indicate radial head fracture osteoarthritis.

· Check range of movement.

Reference https://cannockchaseccg.nhs.uk/news-events/documents/62-micats-gp-elbow-pain-pathway/file 2014

Reference - Elbow pain: a guide to assessment and management in primary care.

Royal Surrey County Hospital Non-Traumatic elbow pain pathway.

Reference NICE CKS guidelines -September 2015 guidelines.

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Red Flag Symptoms - manage as per suspected pathology

Exclude Red Flag signs and symptoms

· RED HOT SWOLLEN JOINT - Septicarthritis - Usually acute-subacute onset, joint affected is red, hot swollen with reduced function. Patient may also have systemic symptoms.

· MASS/LUMP INCREASING IN SIZE - Mass/lump increasing in size, weight loss. Patient may also be systemically unwell. Bone pain might also be evident.

·If sarcoma/malignancy suspected - Please refer to sarcoma CCG guidance.

·Soft tissue sarcoma - likely with mass/lump increasing in size

·Bone sarcoma - likely if along with mass increasing in size there is bone pain/swelling

· SIGNIFICANT TRAUMA -Trauma might result in a fracture, dislocation, or tendon rupture e.g. distal biceps.

· Ulnar neuropathy (rarely secondary to malignancy, and can be a red-flag if clinician concerned) - Malignancies usually do not present with ulnar neuropathy, but at times a tumour can invade the brachial plexus and the patient may present with a clinical presentation similar to a distal mononeuropathy.

Malignancy should be considered in patients who are at risk of malignancy and present with signs and symptoms of ulnar neuropathy.

· In the history the presence of the following suggest risk of malignancy as opposed to other causes of ulnar neuropathy - Horner’s syndrome, severe pain radiating from the neck or shoulder, marked thenar eminence wasting of affected hand with weakness of thumb abduction without median sensory involvement.

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Epicondylitis Medial/Lateral

This pathway refers to the management of Tennis Elbow (Lateral Epicondylitis) and Golfer’s Elbow (Medial Epicondylitis).Lateral epicondylitis:

· is strictly speaking a tendinopathy of the common extensor origin of the lateral elbow (particularly extensor carpi radialis brevis)

· histologically despite the suffix ‘-itis’ is felt not to be inflammatory but rather a partially reversible degenerative tendinosis

Clinical features include:

· tenderness at the lateral epicondyle

· normal elbow range of motion (consider other diagnoses if range restricted)

· elbow pain on resisted wrist extension, and middle finger extension

Medial epicondylitis:

· describes a similar pathological process at the medial side of the elbow, affecting the flexor tendons and the tendons of pronator teres.

Clinical features include:

· tenderness at the medial epicondyle

· normal elbow range of motion

· elbow pain on resisted wrist flexion and resisted forearm pronation

This condition may develop following activities involving repetitive use of the muscle groups of the forearm, including sporting, recreational and occupational activities.

An initial period of GP-advised self-management is appropriate (see box for details).

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GP Advised Self-Management

GP-advised self-management may include:

· limiting any identified provocative activity (sometimes this can be difficult when occupational activities are identified)

· relative rest of the elbow

· provision of analgesia

· ice packs

· use of a tennis elbow brace (correctly applied approximately 10cm below the elbow joint rather than on the painful part of the elbow) to unload the tendon

· provision of patient information leaflet

· discussion with the patient regarding the exercises on the leaflet – once symptoms begin to settle (likely after cessation of any significant provoking activity and thus the acute tendon overload), stretching and strengthening / eccentric rehabilitation is appropriate

· advice to the patient to attend for review if symptoms persist beyond 4-6 weeks for reassessment and consideration of referral to Tier 1 physiotherapy

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Olecranon Bursitis

Suspect olecranon bursitis if:

· There is swelling over the olecranon process (elbow) that:

· Appears over several hours to several days.

· May be tender or warm (but may be painless).

· Is fluctuant (movable and compressible).

· Movement at the elbow joint is painless except at full flexion when the swollen bursa is compressed.

· There is a history of preceding trauma or bursal disease.

· There is evidence of local skin abrasion.

· There is a history of associated medical conditions such as rheumatoid arthritis or gout.

It may be difficult to clinically differentiate between septic and non-septic bursitis.

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Conservative measures

Advise the person to use conservative measures until symptoms improve. These include:

· Rest, ice, and reduced activity. Avoiding trauma or direct pressure to the elbows and/or the use of protective elbow pads is recommended.

· Ice may be used to reduce swelling. It can be applied topically to the area for 10 minutes at a time, every few hours (but not directly onto the skin; a thin towel can be placed between ice and skin).

· Compressive bandaging (for example an elasticated tubular bandage such as Tubigrip®, Comfigrip®, EasiGRIP®, Eesiban®) if tolerated.

· Considering the use of an analgesic for pain relief — paracetamol or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen. For more information, see the CKS topic on NSAIDs - prescribing issues.

If not resolving with self-care consider steroid injection

A note about steroid injections:

· steroid injections have been used to treat these conditions for a long time. Many GPs continue to inject tennis elbows and patients report successful outcomes. For this reason the MSK steering group felt it appropriate to include the option for GPs to continue this practice currently at their discretion.

· NICE CKS advises that injections may be repeated 2-3 times at 3-6 month intervals at same site if previous injection successful. Do not give more than three injections in total

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Stiff and Painful Elbow – no recent history of trauma

Causes of painful stiff elbow:

· the commonest cause is injury/trauma

· other causes include:

· primary osteoarthritis

· inflammatory arthritis

· joint infections (if suspected urgent hospital assessment is required)

· post fracture malunions

Clinical features of elbow osteoarthritis include:

· elbow pain

· elbow stiffness / decreased range of motion

· grating / locking / swelling

· signs and symptoms of ulnar neuropathy secondary to osteophytic encroachment

· history of elbow trauma (follow 'Stiff Elbow Post Injury' part of the pathway if relatively recent injury)

· occupation / hobby with repetitive stress to elbow joint

Give patient information leaflet

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Stiff Elbow Post Injury >3 months

Causes of painful stiff elbow:

· the commonest cause is injury/trauma

· other causes include:

· primary osteoarthritis

· inflammatory arthritis

· joint infections (if suspected urgent hospital assessment is required)

· post fracture malunions

This pathway refers to those patients who present with a stiff elbow post injury. Factors that may predict increased stiffness include severity of the initial injury and length of elbow immobilisation following injury.

Since elbow stiffness is very common post-injury, a period of observation for three months is appropriate because usually this will improve. If stiffness persists after three months, a referral to Tier 1 physiotherapy is appropriate to assist and advice on exercises to regain a normal range of motion. If there is no improvement, Tier 1 physiotherapy will refer to MSK triage, who may refer onward to a surgeon.

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Referral information for HCT MSK Triage Service

The administration team are based at the New QE2 hospital.

Appointments and General Enquires: 01707 247411 or 01707 247412 or 07884 547579

E- referral enquiries via the MSK e-referral administration on: 01707 247416 or 07884 547579

Referral to the service is via the NHS e-referral system (previously Choose and Book). Electronic screening of referrals takes place on a daily basis by clinicians. The referrals are either referred directly to secondary care where they manage the Choose and Book process, or seen for clinical assessment by the team to decide the appropriate pathway of care.

Clinics for assessment are held at The New QE2, Hertford County Hospital, Cheshunt Community Hospital and Lister Hospital.

The MSK Triage Service and the MSK Physiotherapy Service are both part of the whole integrated HCT MSK Service, and as such can refer directly to each other as appropriate.

The MSK Physiotherapy Service is a team of therapists specialised in the treatment and management of MSK Conditions and based over 6 sites in East and North Herts. (Referral for this team is via generic email – mskphysio.enherts@nhs.net).

The MSK Triage Service is a team of ESP (Physiotherapists by background) but with training and advanced skills for specialist assessment, referring for diagnostics and providing injection therapy. This team meets regularly for 3 MDT meetings with the appropriate Consultant Surgeons for the upper limb, lower limb and spine. Complex cases are discussed at these meetings to provide integrated care as necessary.

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Advise on self-care including pain relief

Give patient advice as per Versus Arthritis leaflet