STUDENT’S ELBOW

Physiotherapy Management of Student's Elbow

1. STUDENT’S ELBOW ( olecranon bursitis) DR.AHMAD MERAJUL HASAN INAM

2. INTRODUCTION Olecranon bursitis is a condition in which there is an inflammation of the bursa overlying the olecranon process at the proximal aspect of the ulna.  The superficial location of the bursa, namely between the ulna and the skin is susceptible to inflammation from a variety of mechanisms, primarily either acute or repetitive trauma . It is also possible that the inflammation is due to infection, called septic bursitis. Two-thirds of the cases are bursitis without an infection or nonseptic bursitis.  [3]  Nevertheless this type of bursitis is less common . However the olecranon bursa normally provides a mechanism with which the skin can glide freely over the olecranon process, consequently the bursa prevents tissue tears.

3. EPIDEMIOLOGY/ ETIOLOGY Although the overall incidence is not known, it typically affects men between the ages of 30 and 60 years. Two-thirds of cases are nonseptic ( ie , without infection) and usually occur when trauma or repeated small injuries lead to bleeding into the bursa or release of inflammatory mediators . No predisposition for race or sex. Long-term hemodialysis treatment , uremia or a mechanical factor (like resting the posterior elbow during a hemodialysis treatment) can be a cause of inflammation.   This condition can be caused by acute injuries (trauma) during sports activities because they can include any action that involves direct trauma to the posterior elbow. For example falling onto a hard floor ETC.

4. CONT… R epetitive microtrauma , like rubbing constantly the elbow against a table during writing .   People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows. Finally inflammation may be due to a systematic inflammatory process, like rheumatoid arthritis, or a crysal deposition disease, like gout and pseudogout .

5. SIGNS AND SYMPTOMS Patients usually remark a focal swelling at the posterior elbow the swelling is sometimes painless. Pressure, like leaning on the elbow or rubbing against a table while writing with the ipsilateral hand, are factors which can often exacerbate the pain. Chronic recurrent swelling is usually not tender. A typical symptom of olecranon bursitis is the frequent bumping of the swollen elbow, because it protrudes further than it usually would. It is possible that the patient reports a history of isolated trauma or repetitive microtrauma . The start may be sudden, when it is secondary to infection or acute trauma. When olecranon bursitis is secondary to chronic irritation, the onset will be more gradual.

6. CLINICAL PRESENTATION Patient history may include following findings: Bursal inflammation’s most classic finding is a swelling, at the posterior elbow. This swelling is clearly marked off by its appearance as a goose egg over the olecranon process . There may be a tenderness for palpation at the affected site. Cases in which infection is present may show a warm and red affected area . Patient may report a history of isolated trauma or repetitive micro trauma such as constant rubbing of the elbow against a table while writing. If the trauma has recently occurred, the inspection of the skin may reveal abrasion or contusion. Generally a patient with advanced infection, can have fever.

7. CONT…. The Range of motion (ROM) of the affected elbow is usually normal but now and then it is possible that the end-range of elbow flexion is slightly limited due to pain . Patients suffering from systematic inflammatory processes (like rheumatoid arthritis) or crystal – deposition disease (like gout or pseudo gout ) may reveal evidence of focal inflammation at other sites. When you exam a patient who has rheumatoid arthritis, it is possible that you can see rheumatoid nodules during inspection of the elbow. If the patient reports elbow pain during active or passive ROM and if a history of trauma exists, this may increase the clinical suspicion of an olecranon process fracture.

8. DIAGNOSTIC PROCEDURES Laboratory tests are essential to differentiate septic from non-septic bursitis when doubt remains after clinical examination, so the aspirate should be sent for microscopy and culture. Blood tests are not usually helpful . If there is any doubt about the diagnosis then treatment should be given as for a septic case until culture results are available.

9. Physical T herapy Assessment SUBJECTIVE FINDINGS On-set - Gradual in nature following overuse Sudden following truma Age-between 30-60 years Duration- Chronic in nature,with a history at least 2-3 months and othen longer

10. Frequency- one ongoing episode that appears to be intermittent Area of sympotoms - Posterolateral aspects of the elbow Type of Symptoms- Sharp pain over the posterior side of the elbow while resting on table Pain subside anything from a few minutes to 1 or 2 hr

11. OBJECTIVE FNDINGS Observation - Swelling may or may not be observable On rare occasions redness of the skin AROM- PROM- Resisted Movement- Palpation

12. DIFFERENTIAL DIAGNOSIS Rheumatoid arthritis Elbow and forearm overuse injuries Gout and pseudogout Olecranon fractures Triceps tendon avulsion

13. MANAGEMENT During the first 24 to 48 hours following diagnosis: Apply light compression by wrapping the elbow a specific way, using a compressive wrap. Rest the area by avoiding any activity that causes pressure or pain on the elbow. Apply ice packs to the area for 15 to 20 minutes every 2 hours .

14. Reduce Pain and Swelling.  If repetitive activities have caused the elbow bursitis, avoid or modify the activities, to allow healing to begin. Use electrotherapeutic modalities (TENS, US, etc ) for reduction of pain and swelling. Improve Motion.  Begins with passive movements and then gradually progresses to active movements, if needed joint mobilization. Improve Flexibility. stretch the muscles that are tight.

15. CONT… Improve Strength.  If any muscles are weak start with resisted training of muscles for improvement of its strength. Improve Endurance.  Restoring arm's muscular endurance is important after an injury . Learn a Home Program . physical therapist will teach strengthening and stretching exercises to perform at home.

16. PRECUATIONS/ RESTRICTIONS To help prevent a recurrence of the injury, physical therapist may advise to: Avoid leaning on your elbow as much as possible. Use a wrist guard/pad on your desk to cushion your elbow when you do lean on it. Use a proper typing arm position that does not involve leaning on the elbows.

17. CONT… Avoid hard hits or prolonged pressure to the tip of the elbow. Use elbow pads during sports or other physically challenging activities to protect your elbow. Follow a consistent flexibility and strengthening exercise program, especially for the elbow muscles, to maintain good physical conditioning, even in a sport's off-season. Always warm up before starting a sport or heavy physical activity. Gradually increase any athletic activity, rather than suddenly increasing the activity amount or intensity.

18. When the patient shows no response to conservative treatment and his condition deteriorates, then surgery may be indicated. When a patient undergoes a bursal excision ( bursectomy ), there might be a recommendation for physical therapy after the operation for regaining or maintaining the ROM and strength of the elbow.

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