eMedicine Specialties > Sports Medicine > Upper Limb

Elbow and Forearm Overuse Injuries

Author: Vincent N Disabella, DO, FAOASM, Team Physician, Student Health Service, University of Delaware
Contributor Information and Disclosures

Updated: Feb 12, 2008

Introduction

Background

Overuse injuries of the elbow and forearm are very common in athletes.^1,2 Any sport that subjects an athlete to repetitive elbow flexion-extension or wrist motion can cause these syndromes. A simple way to approach these syndromes is to divide them into the different pathologies. Athletes can have tendinopathies of the triceps or biceps tendons.

Although lateral epicondylitis and medial epicondylitis are both overuse injuries, they are covered individually in other articles within this journal. Pronator syndrome is covered as a distinct entity of median nerve entrapment. Radial nerve injury is also in another article.³ This article includes injuries to the elbow capsule and olecranon area.

Overuse injuries to the forearm and elbow are very common in throwing and racquet sports.^{4,5,6,7,8,9,10} Any activity that entails repetitive flexion-extension of the elbow or pronation-supination of the wrist can lead to overuse injuries. As the number of recreational athletes increases, the incidence of these injuries increases.¹¹ The physician must obtain a very comprehensive history when dealing with these injuries because a subtle finding often can determine the proper diagnosis.^7,8,10,12,13 Obtaining a vocational history is also very important because many skilled laborers or assembly line workers perform the same offending motion at work.

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center and Sports Injury Center. Also, see eMedicine's patient education articles Repetitive Motion Injuries, Sprains and Strains, and Tennis Elbow.

Related eMedicine topics:
Biceps Tendinopathy
Little League Elbow Syndrome
Nerve Entrapment Syndromes

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Trauma
CME/CE Guidelines Issued for Overuse Injuries in Child and Adolescent Athletes
CME/CE Medical Interventions Effectively Treat Overuse Injuries in Adult Endurance Athletes
CME Tendinopathy -- From Basic Science to Treatment

Frequency

United States

The frequency of elbow and forearm overuse injuries is difficult to determine because of the multiple comorbid states and diagnoses that are possible (see Differentials and Other Problems to Be Considered). Some of these are covered in this article.

Functional Anatomy

The elbow is a complex joint that consists of 3 true joints that function as 1 joint.^1,2 The humeroulnar joint is a modified hinge joint and allows flexion and extension. The humeroradial joint functions not only as a hinge joint to allow flexion and extension, but also as a pivot joint that allows rotation of the radial head on the capitellum. The proximal radioulnar joint allows supination and pronation to occur. The combined motion of these joints allows a range of motion from 5-150º of flexion-extension and 75º of pronation to 80º of supination. Remember that the olecranon process of the ulna sits in the humeral olecranon fossa in 20º or less of flexion.

The ligamentous structures can be divided into the lateral and medial structures.^1,2 These ligaments are better described as thickenings of the capsule, rather than true ligaments. Of the 3 medial structures, the anterior medial collateral ligament (AMCL) is the most important, providing approximately 70% of the valgus stability of the elbow. On the lateral side, the lateral ulnar collateral ligament (LUCL) is the strongest of the 4 branches, providing varus support.

The annular ligament maintains the radial head position in the radial notch of the humerus. Dynamic stability is provided by 4 muscle groups that transverse the elbow. The biceps brachii, brachioradialis, and brachialis muscles are the major flexors of the elbow joint. The triceps and anconeus muscles achieve extension. The supinator and biceps brachii muscles provide supination. Pronation is achieved through the pronator quadratus, pronator teres, and flexor carpi radialis muscles.

Understanding where the 3 major nerves cross the elbow is also very important. Overuse injuries or direct trauma can affect these nerves. The median nerve crosses the joint medially between the 2 heads of the pronator muscle and consists of fibers from the C5-T1 spinal nerves. The ulnar nerve travels posterior to the medial epicondyle in the cubital tunnel, down the posterior medial side of the forearm and crosses the wrist in the Guyon canal. This nerve is composed of fibers from C8 and T1 spinal nerves. The radial nerve crosses the elbow laterally and branches into the superficial (sensory) and posterior interosseous nerve, which is purely motor in innervation. This branch goes deep through the arcade of Frohse, which is a common site of entrapment. The radial nerve is made up of branches from the C5-C7 spinal nerves.

Sport-Specific Biomechanics

Repetitive elbow flexion can cause biceps tendinosis or anterior capsule strain. Activity that involves forceful elbow extension can cause triceps tendinosis or posterior impingement syndrome. In addition, any activity that causes increased valgus stress on the elbow can also cause ulnar nerve injury, posterior impingement syndrome, or olecranon stress fractures. These injuries are common in throwing sports and overhead racquet sports. Sports that require a great deal of wrist flexion-extension or pronation-supination can lead to pronator syndrome or radial tunnel syndrome. Posterolateral rotatory instability is seen only after a posterior elbow dislocation.

Related eMedicine topics:
Biceps Tendinopathy
Elbow, Fractures and Dislocations - Adult
Little League Elbow Syndrome
Nerve Entrapment Syndromes
Ulnar Nerve Entrapment

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Trauma
CME Tendinopathy -- From Basic Science to Treatment

Clinical

History

• As with any injury, the patient's history is probably the most important part of the examination.
• Because the multiple injuries and syndromes of the elbow and forearm can mimic one another, a thorough history must be taken with every patient.
• Taking the patient's history at follow-up visits is also important because conditions can coexist or even develop during rehabilitation. The physician should ascertain exactly what activities aggravate the condition (occupational and recreational).
  • Determine if the onset of symptoms was insidious or after a distinct event. Inquire whether the symptoms are in the dominant or nondominant arm.
  • Inquire whether the symptoms resolve with cessation of the aggravating activity or how long the symptoms persist after cessation.
  • Determine if pain radiates to another site on the arm.
  • Determine if the athlete experiences clicking or catching with pain.
• Specific symptoms for each of the individual diagnoses covered in this article include the following:
  • Biceps tendinosis
    • Biceps tendinosis causes anterior elbow pain. Flexion or flexion-supination motions most often aggravate the pain.
    • Often, the athlete can remember a single distinct workout or change in activity that has caused the pain.
    • Frequently, the athlete complains of associated biceps weakness.
  • Anterior capsule strain
    • Patients with this injury also present with anterior elbow pain.
    • The anterior elbow pain is aggravated by repetitive hyperextension and is not affected by elbow flexion.
  • Pronator syndrome
    • Patients with pronator syndrome often complain of pain or paresthesias over the median nerve distribution. Most times, the pain is located over the anterior proximal forearm.
    • Note that decreased sensation over the thenar eminence distinguishes pronator syndrome from carpal tunnel syndrome because the sensory branch of the median nerve that innervates the thenar eminence does not pass through the tunnel.
    • Throwing or swinging a racquet often aggravates the pain.
  • Radial tunnel syndrome
    • Radial tunnel syndrome most often occurs after trauma to the distal humerus. Rarely, this syndrome can occur in athletes who repetitively pronate and supinate the forearm.
    • Night pain can be present.
    • The pain is often confused with lateral epicondylitis pain, but further questioning determines that the pain is distal to the epicondyle and radiates down the dorsum of the forearm.
  • Triceps tendinosis
    • Patients with triceps tendinosis complain of posterior elbow pain that is aggravated by resisted elbow extension.
    • Athletes often point to the triceps insertion on the olecranon when asked to pinpoint their pain.
  • Olecranon impingement syndrome
    • Athletes with olecranon impingement syndrome often complain of posterior elbow pain, with locking or snapping when throwing.
    • The athlete's pain is the worst when the elbow is extended.
    • Throwers often complain of loss of velocity and control, and these individuals feel as if their elbow is unstable.
  • Olecranon stress fracture
    • An olecranon stress fracture should be suspected when an athlete complains of chronic posterior elbow pain with extension.
    • Pain that is not relieved by a change of position indicates an olecranon stress fracture. Night pain is often present.
    • The pain can increase as the elbow is taken further into extension.
  • Radiocapitellar chondromalacia
    • Radiocapitellar chondromalacia is usually found in throwing athletes or people who play racquet sports that cause excessive valgus stress on the elbow.
    • Lateral elbow pain with swelling and locking are often presenting symptoms.
  • Posterolateral rotatory instability
    • Patients with posterolateral rotatory instability often remember a distinct traumatic event, most often a posterior dislocation.
    • The athlete has a sense of instability and reports a snapping sensation, which causes pain when throwing.

Physical

The physical examination should be systematic and complete. The presence of coexisting injuries is common. Therefore, take care to not focus only on one part of the physical examination and thereby possibly miss another coexisting overuse syndrome.

• Biceps tendinopathy
  • Tendinopathy of the biceps can be exacerbated with resisted elbow flexion and supination.
  • Pain is most often experienced over the distal biceps muscle and the tendon.
  • In severe cases, the athlete can have a flexion contracture.
  • Although it is very rare to rupture the biceps muscle distally, always be certain that the biceps is intact. Do not to be misled by the patient's ability to flex the elbow or supinate the forearm because this movement could be a contraction of the brachialis (flexion) and supinator (supination) muscles.
• Anterior capsule strain
  • An athlete with anterior capsule strain can present with painful swelling in the antecubital fossa.
  • Assess the neurovascular structure to rule out serious vascular compromise or nerve injury as the cause of the athlete's pain.
• Pronator syndrome
  • Patients with pronator syndrome often present with a hypertrophied pronator muscle on physical examination.
  • Median nerve symptoms with negative Tinel and Phalen tests at the wrist should raise a clinical suspicion of pronator syndrome. A Tinel sign over the proximal forearm (pronator muscle) and increased pain with resisted pronation should also be present.
  • Resisted flexion of the third finger can elicit pain if the median nerve entrapment is at the site of the flexor digitorum.
  • Athletes with pronator syndrome have difficulty with making the "okay sign," which is shown by the inability to touch the tips of the 1st and 2nd fingers to make a circle.
• Radial tunnel syndrome
  • This condition is often mistakenly identified as lateral epicondylitis upon examination.
  • Performing a Tinel test approximately 3 inches distal to the lateral epicondyle over the radial nerve can reproduce the patient's pain. Resisted supination with the forearm extended can cause also pain, which can often be augmented by flexing the wrist.
  • Rule out radial tunnel involvement any time a patient with lateral epicondylitis does not respond to conservative care.
• Triceps tendinosis: Patients with triceps tendinosis often present with point tenderness over the triceps tendon, which is provoked by resisted elbow extension.
• Olecranon impingement syndrome
  • Olecranon impingement is often exacerbated by forced extension on the physical examination. Many times, testing shows some degree of valgus instability.
  • The examiner can often feel crepitus, which blocks full extension of the elbow.
  • On occasion, loose bodies can be palpated around the olecranon fossa.
  • Many times, the posterior elbow is inflamed and has point tenderness.
• Olecranon stress fractures
  • Stress fractures of the olecranon cause pain with throwing motions and activities.
  • A simple test to help evaluate possible stress fractures is to assess pain on active extension versus resisted extension. Most often, resisted extension will intensify and localize the pain.
  • Often, the physician places a 126-Hz tuning fork on the athlete's olecranon. The vibrations often produce point tenderness over the fracture. The athlete frequently experiences sharp pain and pulls away from the examiner.
• Radiocapitellar chondromalacia
  • Athletes with radiocapitellar chondromalacia experience tenderness over the radiocapitellar joint and lateral elbow swelling.
  • Passive pronation-supination and an applied axial force produces crepitus, pain, and, occasionally, locking, as described by Field and Altchek.⁹
• Posterolateral rotatory instability
  • Patients with posterolateral rotatory instability present with elbow instability.
  • In severe cases, subluxation of the ulnohumeral joint with varus stress is present.
  • The posterolateral rotatory-instability test or lateral pivot-shift test, first described by O'Driscoll, is used to test the ulnar component of the lateral collateral ligaments of the elbow.¹⁴
    • The test is performed with the athlete supine, the shoulder externally rotated, the elbow extended overhead, and the forearm pronated.
    • Then, the elbow is flexed with supination of the forearm, and valgus stress is applied, along with simultaneous application of an axial load. The elbow subluxes laterally at approximately 20 º and reduces at 40 º of flexion. In the performance of this text, subluxing the elbow is not necessary; usually, the athlete shows apprehension at 15-20 º, constituting a positive test.

Causes

• Biceps tendinosis
  • This injury is caused by repetitive microtrauma in most cases. Occasionally, biceps tendinosis can be caused by an intense bout of exercise that produces tendon injury, which is never allowed to heal and perpetuates into a tendinosis.
  • This overuse syndrome is caused by repetitive elbow flexion against resistance or repetitive forearm supination.
• Anterior capsule strain: Either a single event or repetitive hyperextension of the elbow causes anterior capsule strain.
• Pronator syndrome
  • Pronator syndrome is a nerve entrapment syndrome and can occur at multiple sites along the course of the median nerve through the forearm.
  • The most common site of entrapment is under the hypertrophied head of the pronator muscle.
  • Entrapment can also occur under the lacertus fibrosus, or bicipital aponeurosis, at the elbow or under the flexor digitorum superficialis.
• Radial tunnel syndrome
  • This condition is another nerve entrapment syndrome; the radial nerve is most commonly entrapped at the arcade of Frohse.
  • The entrapment can also occur distally at the supinator muscle.
  • There have been case reports of nerve entrapment at the margin of the extensor carpi radialis brevis and under the fibrous band in front of the radial head.
• Triceps tendinosis: This tendinosis is an overuse syndrome caused by repetitive elbow extension against resistance.
• Olecranon impingement syndrome
  • Olecranon impingement syndrome is caused by repetitive elbow extension, in which a valgus stress is applied to the elbow.
  • This syndrome often occurs with overhead throwing and tennis strokes.
• Olecranon stress fractures
  • These stress fractures result from an explosive varus and valgus force that is put on the elbow during throwing.
  • These motions often occur in baseball pitchers and javelin throwers and cause the olecranon to be forced against the medial or posterior walls of the olecranon fossa.
• Radiocapitellar chondromalacia
  • This condition is caused by repetitive valgus stress, which compresses the radial head into the capitellum.
  • Radiocapitellar chondromalacia can result in bone bruises, osteochondral injury, or even loose-body formation.
• Posterolateral rotatory instability: This instability is a direct result of a posterior elbow dislocation and results in a laxity of the ulnar portion of the lateral collateral ligaments of the elbow.

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