Elbow and arm pain

Introduction

Pain in the elbow and arm is a common clinical problem that affects people across all ages. It may present acutely following injury, or insidiously as a result of overuse, inflammation, nerve compression, or systemic illness. Proper evaluation is important because the elbow and arm are involved in nearly all upper-limb functions, and persistent pain can severely impact work, daily activities, and quality of life.

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Anatomy in Brief

• Bones: Humerus, radius, ulna.

• Joints: Elbow joint (humeroulnar, humeroradial, proximal radioulnar).

• Muscles: Flexor–extensor groups of forearm, biceps, triceps.

• Nerves: Median, ulnar, radial (frequent sources of pain if compressed).

• Vascular: Brachial artery and branches.

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Causes of Elbow and Arm Pain

1. Traumatic and Acute Causes

• Fractures: Humerus, radius, or ulna fractures.

• Dislocations: Elbow dislocation, radial head dislocation.

• Sprains/strains: Ligament or muscle injury from sudden movement.

• Contusions: Bruising from direct trauma.

2. Overuse and Repetitive Strain Injuries

• Lateral epicondylitis (tennis elbow): Pain at lateral epicondyle due to repetitive wrist extension.

• Medial epicondylitis (golfer’s elbow): Pain at medial epicondyle due to repetitive wrist flexion.

• Olecranon bursitis: Swelling and pain over posterior elbow.

• Biceps tendinitis: Pain in anterior elbow.

3. Nerve Compression Syndromes

• Cubital tunnel syndrome: Ulnar nerve compression at elbow.

• Radial tunnel syndrome: Radial nerve entrapment.

• Carpal tunnel syndrome (pain radiating to arm).

4. Arthritis and Inflammatory Disorders

• Osteoarthritis: Degenerative joint disease.

• Rheumatoid arthritis: Chronic autoimmune synovitis.

• Psoriatic arthritis, gout, pseudogout.

5. Referred Pain

• Cervical radiculopathy (C5–C7): Neck pathology radiating to arm.

• Cardiac pain: Angina or myocardial infarction occasionally radiates to left arm.

• Thoracic outlet syndrome: Vascular/nerve compression at shoulder.

6. Systemic Causes

• Fibromyalgia, polymyalgia rheumatica, infection, tumors (rare).

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Clinical Presentation

• Location: Localized to elbow vs. diffuse arm pain.

• Character: Sharp, dull, aching, burning.

• Duration: Acute vs. chronic.

• Exacerbating factors: Movement, lifting, gripping, night pain.

• Associated symptoms:

  • Swelling, redness, deformity (trauma, arthritis).

  • Numbness, tingling (nerve compression).

  • Systemic features (fever, weight loss → infection/malignancy).

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Diagnostic Approach

1. History

• Onset, duration, occupation, sports activity.

• Past trauma, systemic illness.

2. Physical Examination

• Inspection: swelling, redness, deformity.

• Palpation: tenderness at epicondyles, bursa, muscle belly.

• Range of motion testing.

• Neurological exam: sensation, motor, reflexes.

3. Investigations

• X-ray: Fractures, arthritis, calcifications.

• MRI/Ultrasound: Tendon, ligament, soft tissue pathology.

• Nerve conduction studies: For neuropathies.

• Blood tests: ESR, CRP, rheumatoid factor, uric acid (if inflammatory arthritis suspected).

• Cardiac enzymes and ECG: If suspect cardiac cause of referred arm pain.

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Management and Treatment

Treatment depends on the underlying cause, severity, and impact on daily function.

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A. General Measures

• Rest: Avoid aggravating activity.

• Ice/heat therapy: Ice in acute trauma, heat in chronic stiffness.

• Physiotherapy: Strengthening and stretching exercises.

• Bracing: Tennis elbow strap, wrist splints.

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B. Pharmacological Treatment

1. Analgesics and Anti-inflammatory Agents

• Paracetamol (acetaminophen): 500–1000 mg orally every 6–8 hours (max 4 g/day).

• NSAIDs (for pain, inflammation):

  • Ibuprofen: 400 mg orally every 6–8 hours.

  • Naproxen: 250–500 mg orally twice daily.

  • Diclofenac: 50 mg orally twice daily.

2. Corticosteroid Injections

• For persistent epicondylitis or bursitis.

• Triamcinolone acetonide: 10–40 mg intralesional injection, single dose, with local anesthetic.

3. Disease-Specific Medications

• Rheumatoid arthritis:

  • Methotrexate: 10–25 mg orally once weekly, with folic acid.

  • Sulfasalazine: 500 mg orally twice daily, increase as tolerated.

• Gout:

  • Colchicine: 0.5 mg orally 2–3 times daily.

  • Allopurinol: 100–300 mg orally daily (for uric acid control).

• Neuropathic pain (nerve compression):

  • Gabapentin: 300 mg orally at night, titrate to 900–1800 mg/day.

  • Pregabalin: 75 mg orally twice daily.

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C. Non-Pharmacological and Interventional Options

• Physical therapy: Ultrasound, shockwave therapy for tendinitis.

• Occupational therapy: Adaptive devices for work/sports.

• Platelet-rich plasma (PRP) injections: For chronic tendinopathy (experimental).

• Surgical options:

  • Nerve decompression (cubital tunnel, radial tunnel).

  • Tendon repair for severe tears.

  • Joint replacement in severe arthritis.

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D. Cardiac and Systemic Causes

If left arm pain is associated with chest pain, sweating, shortness of breath:

• Acute coronary syndrome (emergency):

  • Aspirin: 300 mg orally immediately.

  • Nitroglycerin: 0.4 mg sublingual every 5 min (max 3 doses).

  • Oxygen, morphine, urgent cardiology referral.

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Complications

• Chronic disability and reduced function.

• Loss of employment or athletic ability.

• Neuropathy leading to weakness and sensory loss.

• Missed diagnosis of systemic illness (e.g., cardiac disease).

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Prognosis

• Tendinitis/epicondylitis: Usually improves with rest and physiotherapy, but may recur.

• Arthritis: Chronic but manageable with medications and joint care.

• Nerve compression: Good prognosis if treated early; severe cases may require surgery.

• Referred cardiac pain: Prognosis depends on rapid recognition and treatment.

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Patient Education

• Correct posture and ergonomic adjustments at work.

• Avoid repetitive overuse without breaks.

• Weight control and exercise to strengthen supporting muscles.

• Seek urgent care if arm pain is associated with chest pain, dizziness, or breathlessness.