eMedicine Specialties > Sports Medicine > Upper Limb

Elbow and Forearm Overuse Injuries

Vincent N Disabella, DO, FAOASM, Team Physician, Student Health Service, University of Delaware

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.

Differential Diagnoses

Other Problems to Be Considered

Anterior capsule strain
Degenerative joint disease (DJD)
Distal biceps rupture
Inflammatory arthropathy
Lateral epicondyle avulsion fracture
Loose body
Medial epicondyle avulsion fracture
Olecranon stress fracture
Pronator syndrome
Synovitis
Torn brachialis muscle

Workup

Laboratory Studies

• Laboratory studies are not indicated in the workup of overuse injuries.

Imaging Studies

• Radiography can be very helpful to the physician when evaluating an injured elbow.
  • Radiographs can help the physician to rule out medial or lateral epicondyle avulsions, loose bodies, or DJD.
  • Myositis ossificans of the brachialis muscle can be seen on radiographs, which often mimics anterior capsule strain.
  • Calcification of the tendons can be found in chronic cases of tendinosis.
  • Occasionally, olecranon stress fractures can show a translucent line on regular radiographs. This finding is rarely visible during the period of the first 2-3 weeks when the athlete experiences symptoms.
  • Olecranon osteophytes or loose bodies in the fossa can be seen in posterior impingement syndrome.
  • Radiocapitellar chondromalacia can appear on plain films as an irregular joint space, osteophytes, or loose bodies.
  • Plain radiographs are of little help to the physician when diagnosing entrapment syndromes. Plain films may be of some help in excluding the differential diagnosis in patients who fail to respond to physical therapy (see Differentials and Other Problems to Be Considered).
• Triple-phase bone scans can be very useful in helping clinicians to diagnose olecranon stress fractures. Bone scans can show increased radionuclide uptake at the capitellum and/or radial head when an osteochondral lesion that is associated with chondromalacia of the radiocapitellar joint is present.
• Magnetic resonance imaging (MRI) is very good at delineating soft-tissue injuries. This imaging modality is also very helpful to the physician in the evaluation of chondral defects and loose bodies about the elbow.^{[5 ]}
  • Many times, the site of nerve entrapment—with the resultant edema around the nerve—can be visualized on MRI, which can be very helpful for planning the surgical release of the nerve compression.
  • Often, MRI can be used to evaluate stress fractures and the resultant bone edema at the fracture site.
  • With MRI, the extent of tendon degeneration in a tendinosis can also be evaluated, as well as ligamentous injuries, which can help in the treatment of a posterolateral rotatory instability.
  • MRI is very good at delineating the extent of the articular erosion that is present in cases of radiocapitellar chondromalacia.
• Angiograms can be performed to rule out vascular causes for nerve pain in recalcitrant cases of nerve entrapment.

Related eMedicine topic:
Stress Fracture [in the Radiology section]

Other Tests

• Electrophysiologic studies are often performed to localize the area of nerve entrapment in cases of radial tunnel syndrome and pronator syndrome.^{[3,10,15 ]}The main disadvantage to these studies is a high false-negative rate. Needle electromyography seems to be more useful than nerve conduction studies in localizing the lesions.

Procedures

• In a review by Chumbley et al, the authors described a lidocaine nerve block that may be used to diagnose radial tunnel syndrome.^{[12 ]}Injection of 1 mL of lidocaine (1%) is given 4 fingerbreadths distal to the athlete's lateral epicondyle. This injection relieves pain and causes a deep radial palsy in radial tunnel syndrome. However, when, at another time, a second injection is given more proximally in the area of the lateral epicondyle and the symptoms are not alleviated, the diagnosis of radial tunnel syndrome is confirmed.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

In general, overuse injuries are treated using protection, rest, ice, compression, elevation, medications, and modalities (PRICEMM).^{[12 ]}PRICEMM is an accepted treatment regimen for overuse syndromes of the elbow and forearm, whether these conditions are nerve entrapments, tendinoses, or instability syndromes.

Protection means the athlete needs to modify his or her activity and equipment to allow proper healing and to prevent further injury. Rest does not mean cessation of activity, which can lead to deconditioning, but rather modified activity, or relative rest, which does not aggravate the injury. Ice is used to alleviate patient's pain and help control swelling. Compression is used to prevent swelling, but this should be used with caution when dealing with nerve entrapment syndromes. Elevation is used to prevent venous stasis around the injury, which can lead to increased inflammation and pain. Medications that can be used include nonsteroidal anti-inflammatory drugs (NSAIDs) and, very rarely, corticosteroids. Modalities can include ultrasound, electrical stimulation, and friction massage. Myofascial release techniques are often very helpful in reducing the soft-tissue restrictions of motion.

Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management 
Resource Center Pain Management: Pharmacologic Approaches
CME/CE Medical Interventions Effectively Treat Overuse Injuries in Adult Endurance Athletes

Occupational Therapy

Occupational therapy is appropriate when the injury is aggravated by the patient’s vocational activity. Many times, ergonomic evaluation of the workplace is needed to help treat overuse syndromes.

Medical Issues/Complications

Cryotherapy can cause symptoms of ulnar neuropathy when this therapy is used on the medial elbow due to the close proximity of the ulnar nerve to the surface at the cubital tunnel. As previously mentioned, caution should be used when applying compression over areas of nerve entrapment (see Physical therapy in the Treatment, Acute Phase, Rehabilitation section).

Surgical Intervention

In cases of olecranon impingement syndrome, surgery is often needed early in the treatment course to remove loose bodies from the joint. Surgery is also indicated early in cases of posterolateral rotatory instability. Many times, the collateral ligaments must be repaired before rehabilitation can begin. Arthroscopy or open arthrotomy is often needed to remove loose bodies and scar tissue in radiocapitellar chondromalacia cases.

Consultations

Consultation with an orthopedic surgeon, preferably an upper-extremity specialist, is indicated for the above procedures.

Recovery Phase

Rehabilitation Program

Physical Therapy

The recovery phase begins once the patient's pain is resolved or is improved enough so that strengthening exercises can begin. Flexibility and strengthening programs are the main goals of therapy. Various modalities are used to prevent inflammation and speed the recovery from each session of therapy.
 
Take care not to proceed though this phase too quickly, as the overuse syndrome can return. The athlete may begin with simple ball squeezing and newspaper crumbling with the affected hand. This can cause gentle strengthening of the forearm muscles. The athlete then progresses to gentle wrist flexion and extension exercises. Instruct patients to start out doing the wrist flexion and extension exercises with a can of soup, which is about 7.5 ounces. Once these exercises can be accomplished with a very light weight (ie, 2-4 lb), the patient may progress to elbow flexion and extension exercises, along with wrist pronation and supination activities.

Recommend that patients also perform these exercises at home, possibly with a common household hammer. A hammer provides the athlete with a handle to grip, and the tool usually weighs between 18-26 ounces. Patients can also increase or decrease the resistance on pronation-supination activities by sliding their grip up or down the shaft of the handle.

Occupational Therapy

Strengthening and flexibility of the elbow are being recovered during this time. The goal here should be progression to full activity. Proper biomechanics in the workplace or home are stressed to the athlete to help prevent reaggravation of the original injury.

Medical Issues/Complications

During the rehabilitative phase, the athlete must take caution to not progress too rapidly. Too rapid progression can cause either the original symptoms to return or result in other overuse syndromes in the upper extremity.

Surgical Intervention

Determine if conservative care is appropriate for the nerve entrapments once the initial pain is controlled. Frequently, surgical decompression of the entrapment is necessary, the discussion of which is beyond the scope of this article. In cases of tendinosis, consider surgical debridement of the degenerative tissue near the tendon to promote healing if the patient's injury fails to progress through this phase.

Consultations

Neurology consultation can be warranted to rule out cervical or brachial plexus pathology in nerve entrapment syndromes that are not improving. Electromyography (EMG) and nerve conduction velocity (NCV) studies may be appropriate at this time to help isolate nerve entrapment sites when surgical intervention is being considered.

Related eMedicine topic:
Electrophysiology

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase of therapy is often fulfilled with a home therapy program. In the ideal setting, the athlete can perform a preventative program with an athletic trainer or a strength and conditioning coach at regular intervals. Coaches are very important during this phase, and they must emphasize proper biomechanics, so that the athlete does not create the same stresses that caused the original overuse syndrome. The occasional use of NSAIDs or cryotherapy may be needed.

Medication

Medical intervention is aimed toward the joint goals of decreasing inflammation and providing analgesia. The major concern is the effect on the gastrointestinal (GI) tract with the long-term use of certain medications. Renal function must be followed with long-term NSAID use. Long-term corticosteroid use has a myriad of side effects, which are beyond the scope of this article.

Related eMedicine topics:
Corticosteroid-Induced Myopathy
Corticosteroid Injections of Joints and Soft Tissues

Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management 
Resource Center Pain Management: Pharmacologic Approaches
CME Integrating Ongoing Research and Knowledge into the Clinical Management of Chronic Pain
CME/CE Medical Interventions Effectively Treat Overuse Injuries in Adult Endurance Athletes
CME Overcoming Barriers to Pain Relief: An Interactive Patient Case Symposium
CME/CE Turning Adverse Drug Events Into Better Patient Care

Nonsteroidal anti-inflammatory drugs

NSAIDs are used to help reduce inflammation and are used as analgesics. Numerous drugs comprise this class, and physicians should be aware of each NSAID subclass, as some patients respond better to one subclass than another subclass. A few of the medications are named below, not to belabor the wide variety of choices available.

Cyclooxygenase-2 (COX-2) inhibitors are new-generation NSAIDs that are supposed to have decreased GI side effects. Although the GI side-effect profiles of these drugs may be slightly better than the previous generation of NSAIDs, their efficacy is not any more impressive. These drugs inhibit COX-2, but they do not inhibit COX-1.

Related Medscape topics:
CME/CE GI Risks and Benefits of Traditional and COX-2-Selective NSAIDs
CME The NSAID Debate: Balancing Gastro-Protective Effects With Cardiovascular Risk
CME/CE Use of Multiple NSAIDs Reduces Arthritis Pain but May Increase Complications

Ketoprofen (Oruvail, Orudis, Actron)

Has good anti-inflammatory properties and exceptional analgesic properties. Used as a first-line medication because of the qd dosing, which helps with patient compliance.

Available in 100-mg and 150-mg doses for patients who do not tolerate the higher dose. All doses should be taken with food.

Dosing

Adult

Oruvail: 200 mg PO qd ac

Orudis: 75 mg PO tid ac or 50 mg PO qid ac

Pediatric

Not recommended

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy

Naproxen or naproxen sodium (Naprelan, Naprosyn, Aleve, Anaprox)

Available in many dosages and delivery systems. Fairly inexpensive and has a similar therapeutic profile to the other NSAIDs.

Dosing

Adult

Naproxen: 375 mg or 500 mg PO bid ac

Naproxen sodium: 275 mg PO qid or 550 mg PO bid ac

Pediatric

Oral suspension: 125 mg/5 mL at 10 mg/kg/d PO, divided bid

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; can induce asthma, rhinitis, nasal polyps

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of the drug.

Corticosteroids

Corticosteroids are some of the strongest anti-inflammatory agents available. Injectable preparations make it possible to deliver the drug directly to the joint in a concentrated dose, while greatly decreasing systemic effects.

Prednisone (Deltasone, Orasone, Meticorten, Sterapred)

Oral prednisone is used in cases when inflammation is severe and the patient has contraindications to the administration of steroidal injections. Use with great caution because of systemic effects.

Dosing

Adult

20 mg PO bid for 5-7 d; multiple doses available

Pediatric

Not recommended

Interactions

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing the maintenance dose); monitor for hypokalemia with the coadministration of diuretics.

Contraindications

Documented hypersensitivity; patients with systemic fungal infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use.

Follow-up

Return to Play

Return to play is usually appropriate when (1) the patient's symptoms are tolerable, (2) anatomic and biomechanic corrections are made, and (3) 90% of the strength of the affected side as compared with the unaffected side has returned. If the dominant side is affected, athlete's elbow and forearm should return to 100% of the strength of the nondominant side.

Complications

The major complication of overuse syndromes is the individual returning to the same poor habits that caused the original insult. Care must be taken when correcting the biomechanics of an injury, in order not to cause overuse injuries at another point in the kinetic chain. Very rarely, permanent nerve damage can result from nerve entrapment syndromes.

Prevention

The best way to prevent overuse injury is to stress to athletes and coaches the proper biomechanics with any physical activity. A frequent mistake that athletes make is increasing the intensity or duration of an activity too rapidly for the body to adapt. Runners use a 10% rule that is usually fitting: only increase the weight, distance, or duration of an exercise 10% every 10 workouts.

Related Medscape topic:
Resource Center Exercise and Sports Medicine

Prognosis

The prognosis of most overuse injuries is very good, as long as the athlete completes a thorough rehabilitation program. The correction of any training or biomechanical errors that caused the original overload is also very important.

Education

Educate athletes and coaches concerning preventive measures to help eliminate overuse injuries in their respective sports. Many times, it is important to have the athletes participate in a sound strength and conditioning program to ensure that these individuals are physically prepared for the stresses of their sport.

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

Miscellaneous

Medicolegal Pitfalls

• The only potential medicolegal issue in elbow and forearm overuse injuries is the misdiagnosis of a nerve entrapment syndrome, which allows the injury to progress to permanent nerve damage. This condition very rarely occurs if the physician initially performs a thorough history and physical examination and follows the patient closely throughout the treatment of the injury.

Related Medscape topics:
Resource Center Medical Malpractice and Legal Issues
Resource Center Trauma

Special Concerns

• Overuse injuries of the elbow are often seen in pediatric athletes. This is especially true in the throwing athletes, which is covered in a special article in this journal entitled Little League Elbow Syndrome. Take caution with these athletes to prevent permanent damage to the physis.

References

1. Mehlhoff TL, Bennett JB. Elbow injuries. In: Mellion MB, Walsh WM, Shelton GL, eds. The Team Physician's Handbook. 1997. 2^nd ed. Philadelphia, Pa: Hanley & Belfus; 461-74.

2. Reid DC. Sports Injury Assessment and Rehabilitation. New York, NY: Churchill Livingstone; 1992:999-1053.

3. Bridgeman C, Naidu S, Kothari MJ. Clinical and electrophysiological presentation of pronator syndrome. Electromyogr Clin Neurophysiol. Mar-Apr 2007;47(2):89-92. [Medline].

4. Grana WA, Boscardin JB, Schneider HJ, et al. Evaluation of elbow and shoulder problems in professional baseball pitchers. Am J Orthop. Jun 2007;36(6):308-13. [Medline].

5. Saliman JD, Beaulieu CF, McAdams TR. Ligament and tendon injury to the elbow: clinical, surgical, and imaging features. Top Magn Reson Imaging. Oct 2006;17(5):327-36. [Medline].

6. Lee ML, Rosenwasser MP. Chronic elbow instability. Orthop Clin North Am. Jan 1999;30(1):81-9. [Medline].

7. Maloney MD, Mohr KJ, el Attrache NS. Elbow injuries in the throwing athlete. Difficult diagnoses and surgical complications. Clin Sports Med. Oct 1999;18(4):795-809. [Medline].

8. Nirschl RP, Kraushaar BS. Assessment and treatment guidelines for elbow injuries. Physic Sportsmed. 1996;24(5):43-60. [Full Text].

9. Field LD, Altchek DW. Elbow injuries. Clin Sports Med. Jan 1995;14(1):59-78. [Medline].

10. Weinstein SM, Herring SA. Nerve problems and compartment syndromes in the hand, wrist, and forearm. Clin Sports Med. Jan 1992;11(1):161-88. [Medline].

11. Magra M, Caine D, Maffulli N. A review of epidemiology of paediatric elbow injuries in sports. Sports Med. 2007;37(8):717-35. [Medline].

12. Chumbley EM, O'Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. Feb 1 2000;61(3):691-700. [Medline]. [Full Text].

13. Colman WW, Strauch RJ. Physical examination of the elbow. Orthop Clin North Am. Jan 1999;30(1):15-20. [Medline].

14. O'Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. Mar 1991;73(3):440-6. [Medline]. [Full Text].

15. Gross PT, Tolomeo EA. Proximal median neuropathies. Neurol Clin. Aug 1999;17(3):425-45, v. [Medline].

16. Chiodo A, Chadd E. Ulnar neuropathy at or distal to the wrist: traumatic versus cumulative stress cases. Arch Phys Med Rehabil. Apr 2007;88(4):504-12. [Medline].

17. Kaeding CC, Whitehead R. Musculoskeletal injuries in adolescents. Prim Care. Mar 1998;25(1):211-23. [Medline].

18. Kamineni S, Hirahara H, Neale P, et al. Effectiveness of the lateral unilateral dynamic external fixator after elbow ligament injury. J Bone Joint Surg Am. Aug 2007;89(8):1802-9. [Medline].

19. Nuber GW, Assenmacher J, Bowen MK. Neurovascular problems in the forearm, wrist, and hand. Clin Sports Med. Jul 1998;17(3):585-610. [Medline].

Keywords

biceps tendinosis, biceps tendinopathy, biceps tendonitis, anterior capsule strain, pronator syndrome, median nerve compression syndrome, median nerve entrapment, radial tunnel syndrome, posterior interosseous nerve compression syndrome, triceps tendinosis, triceps tendinopathy, triceps tendinitis, olecranon impingement syndrome, posterior impingement syndrome, hyperextension valgus overload syndrome, boxer's elbow, tennis elbow, olecranon stress fractures, radiocapitellar chondromalacia, posterolateral rotatory instability, ulnar neuropathy

Contributor Information and Disclosures

Author

Vincent N Disabella, DO, FAOASM, Team Physician, Student Health Service, University of Delaware
Vincent N Disabella, DO, FAOASM is a member of the following medical societies: American College of Sports Medicine, American Medical Society for Sports Medicine, and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Joseph P Garry, MD, Director of Sports Medicine and Sports Medicine Fellowship, Associate Professor of Family Medicine and Exercise & Sport Science, Department of Family Medicine, East Carolina University Brody School of Medicine
Joseph P Garry, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Heart Association, American Medical Society for Sports Medicine, North American Primary Care Research Group, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)