Elbow and Forearm Injuries in Runners

0

Elbow and joint injuries from previous trauma or participation in other sports, can be exacerbated in runners, as running requires constant movement of the arm in a flexed position. Runners can also be prone to an elbow injury if involved in triathlons, where some of the movements and exercises stress the arm and elbow joints. Even those who do not engage in daily tennis, golf, gymnastics, or other sports requiring heavy arm maneuvers can irritate the muscles, tendons, or nerves that run from the wrist, up along the forearm, to the elbow.

 

The Elbow: Anatomy and Structure of Joints

 

The elbow is made up of bones, muscles, and ligaments that form joints. It forms the link between the brachium, or the upper arm, and the forearm. The movement of elbow joints controls the orientation of the hand and the length of reach. The humerus, the main bone in the upper arm, and the two bones in the forearm, the radius and the ulna, join muscles by way of ligaments that hold the muscles and bones together and work to prevent dislocation of the joints. The humeroulnar, or ulnohumeral joint allows for bending of the elbow and is found between the ulna and humerus and the radiocapitellar, or radiohumeral joint is made up of the radius and part of the humerus and allows for rotation of the forearm. The ulnohumeral joint resembles a hinge allowing flexion and extension.  The radiohumeral joint along with the proximal radioulnar joint allow for axial rotation, otherwise described as a pivoting motion.

Flexors, extensors, supinators, and pronators form muscle groups in the elbow. The biceps brachii, the brachioradialis, and brachialis muscles are grouped as flexors, while the extensors are the triceps. While flexors and extensors allow for the bending of and extending the arm, other muscles knows as supinators and pronators are muscles rotate the arm. 

The final component of an elbow and its joints includes innervation. The median nerve passes through the heads of the pronator teres muscle and crosses the elbow and may be a site of nerve entrapment. The ulnar nerve passes behind the medial epicondyle and can be easily compressed as it passes behind the medial epicondyle. Finally the radial nerve divides into two branches, the deep and the sensory, and can also be prone to injury.

Epidemiology and Incidence of Elbow Injuries

Elbow injuries can range from simple overuse injuries, sprains and strains, to torn ligaments, and fractures to nerve compression.

Overuse injuries are especially common in runners, although typically consist of lower extremity problems. Elbow injuries in runners may not necessarily be directly related to running, but other activities or sports the runners may engage in. Elbow injuries in runners are becoming more common as more runners participate in triathlons, as well as throwing and racket sports. In addition, runners are sometimes involved in both track and field (discus throwing) activities, making them more prone to elbow and shoulder overuse injuries.

Elbow injuries are grouped into enthesopathies (lateral and medial epicondylitis and similar conditions), stress injuries (fractures), or injuries involving nerve compression or impingement. Injuries can also be grouped by the area of the elbow in which they occur: the anterior, posterior, lateral, or medial elbow.

According to statistics reported in literature, throwers are especially prone to injury. Up to 50% of all pitchers were reported to have flexion contractures from past injuries, and 50% of pitchers also had injuries of either the shoulder or elbow that sidelined them at some point in their careers.

Mechanisms of Elbow Injury (Causes)

Elbow injuries are often a result of overuse. Overuse of the arm can lead to micro trauma caused by repetitive stress to bones, growth plates, muscles, tendons or ligaments over a period of time. Ineffective warm-ups, failure to rest the arm, and prior injuries can predispose the elbow and shoulder to overuse injuries. Pain may be only intermittent during heavy athletic activity, progress to making its presence known in light activity, like jogging, and later become constant, conclusively present at rest, and sometimes even disturbing sleep.

The muscles of the elbow that run up the forearm are attached to a point of bone outside of the elbow called the epicondyle, and the force of activity is transmitted to this attachment. This focuses the full force of an activity into one point.

Elbow movement varies with each athletic sport or activity. Because elbow injuries are most common in pitchers and  throwers, most research has focused on what goes on during the act of throwing that may potentially lead to an elbow injury.

The act of throwing can be divided into six phases which include the wind up, the stride, arm cocking, arm acceleration, arm deceleration, and the follow through. During the wind up phase the elbow is initially flexed. It quickly extends and flexes again in the stride phase, as the pitcher or thrower acquires his stance to cock the arm and accelerate a toss. These two initial phases consist of minimal muscle strain and activity.  During the cocking phase,  elbow flexors are active during the early part of the phase, while triceps activate toward the end of it inactivating flexors. During this final part of this cocking phase, a large amount of stress is placed on the elbow and heavy loads may lead to injury.

As the acceleration phase takes over, the shoulder rotates internally, and the elbow flexes a few more degrees increasing stress on the medial side of the elbow before rapid extension. It is during this phase that the olecranon may wedge against a trochlear groove of a bone leading to bone fragment deposits, or loose body formation that land in the bursae. In the final, follow through phase the elbow flexes into the resting position.

When the upper extremities transmit high loads, elbows may be prone to traction injuries. These include tears in the flexor muscle mass or medial epicondyle injuries. In racket sports like tennis, the load on the elbow is dependent on the type of stroke used. For example, the pronator teres and triceps play significant roles in the power of a serve, while ground strokes creates smaller demands on the elbow, but the repetitive motion of these may lead to micro trauma.

Types of injuries

Elbow pain and type of injury following elbow trauma can be categorized by the location of the Injury and can be divided into anterior, posterior, medial, and lateral regions.

Conditions Resulting from Trauma to the Anterior Elbow

  • Pronator Syndrome: Racket or throwing sports may lead to median nerve entrapment resulting in pronator syndrome. Median nerve entrapment can cause numbness or a tingling sensation  in the hand or forearm. The medical term for these nerve entrapment symptoms is paresthesia. Another sign of pronator syndrome is hypertrophy of the forearm muscle.
  • Biceps Tendinosis: Repetitive elbow flexion (bending) and forearm supination (rotation) may lead to this condition. The bicep tendon becomes tender and this tenderness increases with resisted flexion and supination.

Conditions Resulting from Trauma to the Posterior Elbow

  • Triceps Tendinosis: On the other side of the spectrum of biceps tendonitis is triceps tendinosis. With this condition, repetitive elbow extension results in worsening posterior elbow pain. Tenderness of the triceps tendon is mostly superior to, or above, the attachment on the olecranon.
  • Olecranon Impingement, olecranon bursitis, or stress fractures of the elbow: The act of throwing forcefully can lock the elbow in a terminal extension, and eventually lead to hypertrophy or overgrowth of the olecranon, sending loose bodies of bone into the bursae. The repetitive friction and loose bodies may cause swelling of the outer tip of the olecranon, inflammation, and the buildup of fluid.

Conditions Resulting from Trauma to the Lateral Elbow

  • Lateral Tennis Elbow. Lateral epicondylitis is the most common overuse injury of the elbow and is the result of degenerative tendinosis of a muscle called the extensor carpi radialis brevis muscle.   The extensor carpi radialis braves (ECRB) muscle helps stabilize the wrist when the elbow is straight. When this muscle is weakened, microscopic tears form in the tendon where it attaches to the bone. As the elbow bends and straightens, the muscle rubs against bone which can cause gradual wear and tear of the muscle over time.   The pain experienced in tennis elbow is typically achy in nature. It’s usually located on the outer part of the elbow, and it worsens with activity radiating down the lateral, or the outside part of the arm and the elbow. Although the pain worsens with activity, pain may develop at rest or at night in later stages of the injury. Tennis elbow is caused by motions that repeatedly stretch the muscle and surrounding tendons. Pain felt in the elbow and arm may be worsened by lifting.
  • Radial Tunnel Syndrome: This is a disorder in which the radial nerve is compressed and causes pain in the forearm. Because the nerve is involved numbness or tingling may also occur. With radial nerve involvement, rotating the arm induces pain and finger and wrist extensor weakness may be present as well.

Conditions Resulting from Trauma to the Medial Elbow

  • Golfer’s elbow, or medial epicondylitis, otherwise known as the other tennis elbow, affects the inner or medial part of the arm in the elbow area. Golfer’s elbow is not specific to golfers and can develop in tennis players and those who engage in activities where the wrist or finger muscles are overused. This includes  the repetitive motion of wrist movement and clenching of clubs or rackets with fingers.   Pain worsens with golf club or racket swings, or pitching and throwing activities.  Swinging clubs or gripping a club or a racket incorrectly or too forcefully can strain the joint, muscles, and tendons. Throwing activities like football, archery and javelin or even running with weights can lead to injury. Pain may also occur with daily activities like shaking hands or turning doorknobs, or picking up objects with the palm facing down.
  • Ulnar Collateral Ligament Sprains: Vague medial elbow pain may indicate a sprain of a ligament rather than a tear or an overuse injury. Pain worsens with activity, but is typically relieved with rest and returns with throwing activities.
  • Ulnar Nerve Entrapment: Pain in the medial elbow along with distal paresthesias (numbness and tingling) along the ulnar aspect of the forearm and into the ring and little fingers may indicate an ulnar nerve entrapment. The affected hand may not be able to grip objects as well and may fatigue more easily.

Other Injuries

Runners’ elbow: This is a term used to describe elbow pain when running with weights or when pain is reproduced with arm movements. Runners’ elbow is most likely an exacerbation of tennis or golfers elbow or nerve irritation.

Nursemaid’s elbow: Nursemaid’s elbow is not a typical athletic or runner injury and is most common in children ages 1 to 4, but can happen any time from birth up to age 6 or 7 years old. It is an elbow dislocation that occurs in growing kids if the child is forcefully pulled by the hand or dragged. Anther common name for this injury is radial head subluxation since the radiocapitellar joint is involved. What ultimately leads to injury is the partial separation of the radiocapitellar joint because of a loose annular ligament due to the fact that the child’s body is not yet fully developed. Treatment of this injury includes “reduction.” In this process, the wrist or forearm is held palm up. While putting pressure near the top of the radius bone with the thumb, the elbow is slowly bent until a faint pop or click may be heard when the joint goes back into place.

Elbow dislocation: Pulling or grabbing ropes, or monkey bar and climbing activities can lead to a dislocated elbow, especially if previous injuries have occurred in the area impacting the joint stability.

Bursitis: Bursae act like cushions between bones and soft tissues and contain small amounts of fluid. More fluid accumulates if the bursae become irritated or inflamed. The extra fluid can cause pain and limit movement of the joint. Bursitis usually develops after trauma to the elbow, prolonged pressure on the area, or following an infection.

Lateral Elbow Tendinopathy: This condition is a result of an inflamed tendon, the common extensor tendon. It usually occurs between the ages of 5 and 50 years old and symptoms are pain to touch and palpation over the lateral humeral epicondyle as well as pain with wrist movements.

Elbow Fractures: Elbow fractures directly involve bones in the arm or the olecranon and  may result from a fall on the elbow, a direct impact, or a break from twisting when spraining the joint.

Symptoms

Most symptoms of elbow injuries include pain on the inner or outer part of the elbow and weakness in the hand, wrist or arm. Tingling or hand and finger numbness are more indicative of a nerve injury. While acute sprains are worsened with activity and relieved with rest, chronic micro trauma can lead to degenerative damage that also causes pain at rest and occasionally even during sleep. Pain from tennis or golfer’s elbow, develops gradually and slowly worsens over weeks and months. There is usually no specific injury with chronic degenerative pain, but there may be an accumulated history of overuse or minor injuries.

Risk Factors

Risk Factors for elbow injuries include the type of athletic activity and the length and frequency of years played in the sport or hours practiced weekly respectively.   Sports with a high rate of elbow injuries include baseball, softball, tennis, golf, discus throwing, gymnastics. Runners are more at risk for elbow injuries than in years past due to high involvement in multiple sports as well as involvement in triathlons.

Complications of elbow injuries

Elbow stiffness or instability: Following repeat injuries the elbow may become more prone to stiffness, instability or subluxation, or dislocation. Stiffness of the joint typically results from something called heterotrophic ossification. This process is a sequelae of direct microtrauma to the elbow. Heterotrophic ossification has an incidence of 3% among those with elbow injuries, and can lead to a decrease in range of motion due to stiffness and can make athletes more prone to future injuries.

  • Joint contractures: Traumatic elbow injuries carry a risk of joint contracture that may affect range of motion. Although range of motion improves up to 1 year after injury, a failure to progress 3 months after the injury suggests a possible joint contracture.
  • Osteoarthritis of the elbow: It is similar to osteoarthritis in the knee in that it tends to occur when the cartilage in the area becomes damaged or worn due to previous injury. The good news about OA of the elbow is that it is one of the least affected joints because the ligaments in the area tend to be more stabilizing and can tolerate large forces due to the well constructed joints.

Complications of elbow trauma or injury may also result from invasive treatments. For example, those who elect to undergo surgery or arthroscopy of the elbow can sustain nerve injury.

Diagnosis

Musculoskeletal clinical testing can be done right in the doctor’s office if elbow injuries are suspected. Just the extension the arm may be a reliable way to identify an elbow injury. According to some literature, the sensitivity of the elbow extension test for identification of bone or joint injury was 97%, meaning that extending an injured elbow to elicit pain was 97% positive for an elbow injury.

The tennis elbow test is also used to make a clinical diagnosis.  The arm is held out straight to as a fist is made with the palm facing down. Attempting to tilt the hand up while holding it down with the other hand is a technique that may induce pain in the outside part of the elbow if tennis elbow is suspected.

Typically after the initial clinical diagnosis, an imaging test may be used to rule out a more serious injury.

These imaging tests include:

  • X-rays: X-rays may be done to rule out a fracture and can also show arthritis of the elbow if it is present. 
  • Magnetic resonance imaging, or MRIs: An MRI image can show details of soft tissues and also identify causes of arm pain that starts in the spinal cord. Spinal cord nerve impingement typically causes shooting pain down the arm.
  • Electromyography, or EMG: This test can be used to rule out ulnar, median, or radial nerve compression. It picks up nerve signals and can diagnose an nerve injury.

Treatment

The most conventional treatment for overuse injuries is RICE, (rest, ice, compression, and elevation) if the injury is caught early enough. Anti-inflammatory medications like NSAIDs, may help to reduce swelling. For those who wait to start conventional symptom reduction, pain medications or elbow braces may be necessary to relieve symptoms.  Conventional treatment relieves symptoms but overuse injuries will recur if arm muscles are not strengthened, so rehabilitation of the injured arm is critical to recovery.

Physiotherapy may help to improve movement and flexibility around the affected joint, but rest from the offending activity is critical to give the muscles and connective tissue time to heal and recover. Elbow rehabilitation involves strengthening the injured muscle below and above the affected joint. 

Once inflammation is reduced and range of motion has been restored, strengthening of the joint, tendons, ligaments, and muscles can be achieved by gripping exercises. These consist of  gripping a stress ball, or performing flexion and extension exercises using a dumbbell. It’s crucial to note that none of the rehabilitation exercises should cause pain outside of the normal exercise induced muscle soreness.

Physical therapy is beneficial and physical therapists can work with athletes following elbow injuries. Specific exercises involving wrist flexion, extension, external rotation of the arm and forearm pronation and supination, as well as elbow flexion and extension are physical therapy exercises that will recuperate injured elbows.

Bracing the elbow may also help relieve symptoms of tennis or golf elbow, taking pressure off the muscles and tendons. A brace should be placed about 10 cm down from the spot that appears to be most painful.  The Velcro strap should rest on the outside of the arm or on the side of the arm of the fifth finger. If the arm appears pale or a tingling sensation occurs, the straps should be loosened slightly to allow maintenance of circulation in the arm. A sling may be needed for 2 to 3 weeks while the elbow heals.

Those with recurring elbow pain may benefit from corticosteroid injections into the joint to reduce inflammation. By reducing inflammation steroids decrease pain in the affected area. Injections can be effective for three to six weeks or until recovery.

If conservative treatments are ineffective after 6 to 12 months surgery may be necessary to remove diseased muscle and reattach healthy muscle back to bone.

Elbow arthroscopy is a minimally invasive procedure where a small camera is inserted into the elbow joint and  displays pictures on a television screen. Surgeons then use the images to guide surgical instruments in the operating room in treatment of tennis elbow, removal of loose bodies (bone fragments), or release of scar tissue.

Elbow replacement is  generally reserved for severe injuries that cause significant disability. It involves placing plastic or metal implants or parts after removing the damaged joint. Each implant is attached to either the humerus, the upper arm bone, or the ulna, the forearm bone and these form a brand new hinge that stabilizes the joint.

Surgical fracture repairs are necessary when the bones of the arm are displaced or broken at an angle, and screws must be used to realign the joint appropriately. Surgery is usually needed to reposition the bone. Hardware like metal plates and screws are necessary to hold the pieces in place while they heal.

Summary of steps to recover rom an elbow injury:

  1. Start with conventional therapy like the above (RICE)
  2. Include range of motion exercises
  3. Incorporate strength and stability training that will prevent future injuries
  4. If pain is chronic or persists for over six months to a year, consider steroid injections or surgical intervention

Prevention of Repeat Elbow Injury:

Here is what you can do to prevent future elbow injuries:

Check your equipment. Stiff rackets or looser-strung ones often can reduce the stress on the forearm during the game. If you’re a tennis player, changing from an oversized racket to a smaller one may help prevent symptoms of tennis elbow from recurring.

Warm up and stretch well before exercise, games, or practice to avoid overuse injuries.

Rest in between games or practices. If the pain persists only during games or intermittently during practice, take a few days off and rest, ice, elevate the arm. 

Alternate exercises during practice: For example, in tennis, change practicing your forehand to your backhand with increased frequency. Increased frequency of changing repetitions or drills like this also can improve muscle memory.

Strength Rehabilitation Exercises for Injured Elbows

Arm exercises using 3 lb weights

  • Curls fully extending the elbow
  • Reverse curls (same as curls but the palm faces down instead of up)
  • Wrist curls with the arms at your sides, palms forward, holding the weights bend the wrist up
  • Reverse wrist curls with arms at your sides, palms facing backward, bend the wrist up
  • Hold the dumbbell of a weight by one knob, straight out at arm’s length. Rotate in a half circle.

The above can be done once or twice a day, at fifty reps and can strengthen the elbow to prevent future injury.

Arm stretching exercises

With the arm straight out, elbow locked, make a fist with palm down and try to push it down with the other arm. Repeat with palm up. Do this in five repetitions, 10 seconds each up to six times a day.

Be sure to consult a local medical professional if pain recurs with any of the strengthening exercises above.

There are times when elbow pain may be an emergency. It is time to hit the doctors office when:

  • You notice that the elbow is hot and inflamed and the inflammation is quickly spreading
  • If you develop a fever along with an inflamed elbow as above
  • If you cannot bend the joint at all because of intense pain
  • If the elbow looks deformed after trauma in any way

Conclusion

Trauma to the elbow can result in acute pain, while recurring trauma or microtrauma can lead to more chronic pain requiring rehabilitation. Following an elbow injury, stability of the elbow should be achieved followed by rehabilitation of the joint. Although conservative therapy is the best way to start, occasionally other intervention, such as surgery or steroid injections, may be necessary for a symptom-free recovery. 

Lateral or medial epicondylitis (or tennis elbow and golfer’s elbow) are overuse injuries that respond well to conservative management.  In general, 6 to 12 months of conservative, nonoperative intervention should be tried before considering surgery. Acute injuries like fractures and tendon ruptures, may be superimposed on underlying degenerative process. Acute injuries can be diagnosed clinically and confirmed with imaging.

If surgery, such as arthroscopy, or an open reduction, hardware implantation, and the resetting of the bone is necessary, postoperatively physical therapy is instituted to regain full range of motion by about six weeks. Flexion and extension exercises with a physical therapist, as well as passive pronation and supination of the forearm are encouraged. These minimize the formation of scar tissue and accelerate healing. Strengthening exercises should start after at least six weeks of focused physical therapy to improve range of motion.

Runners can typically resume activity if they are pain free when exercising, or when cleared by their physician or surgeon post operatively, but a return of symptoms should be a hint that it’s time to prolong the rest. Rest, ice, and bracing should be considered in those with symptoms. Prevention of future injuries is critical, especially after an injury has already occurred because the joint is more prone to injury all over again. Using the right equipment and paying attention to technique while playing a sport or exercising will prevent unnecessary injuries from occurring and is key to resuming activities that make the elbow susceptible to frequent  injury.

Credible sources were used in the creation of this presentation. Please consult your healthcare provider before using any of the information.

Sources

  1. Maharam, Textbook,
  2. American Academy of Orthopaedic Surgeons, Nursemaid's Elbow,
  3. Kelly et al. , Complications of elbow arthroscopy, J Bone Joint Surg Am,
  4. Cheung et al, Complications of Elbow Trauma,
  5. Ristolainen et al., Type of sport is related to injury profile: A study on cross country skiers, swimmers, long-distance runners and soccer players. A retrospective 12-month study,
  6. Docherty et al, Literature review,
  7. American Society for Injury to the Hand, Elbow Fractures,
  8. Mayo Clinic , Golfers elbow,
  9. Buchbinder et al, Acupuncture for lateral elbow pain,
  10. Chumbley et al, Evaluation of Overuse Elbow Injuries,
  11. Frostick et al, Sport Injuries of the Elbow,
  12. US National Library of Medicine , Elbow sprains,
  13. Chard et al , Rheumatology. 6th ed. Philadelphia, PA: Elsevier Mosby; 2015:chap 74,