Musculo Casestudy 11

Musculoskeletal Case Study 11 – Elbow Paul Jones is a 37 year old joiner who has been diagnosed with olecranon bursitis by his GP and referred to physiotherapy. He began with sharp pain over the posterior aspect of the left elbow whilst working for a local building firm. The symptoms came on gradually 6 weeks ago and were initially intermittent. He has been unable to avoid aggravating activities such as sawing and hammering and the pain has increased in intensity and now spreads down the posterior arm to the wrist. Paul is currently off sick, spending his time helping care for his six month old daughter. He is otherwise fit and well with no previous musculoskeletal problems.

Anatomy of the Elbow •

The elbow joint occurs at the junction of three bones, the Humerus (upper arm bone), Ulna (larger of the two forearm bones) and Radius. The Humerus forms the upper part of the joint and widens near the end to form the Medial and Lateral Epicondyles which are the two bony processes you can feel either side of the elbow joint.

What is the olecranon bursa? •

The olecranon is the top part of the ulna bone. It is the bony part of the back of the elbow - the bit that you lean on. A bursa is a small sac that contains a small amount of fluid. The fluid is similar to the fluid in joints (synovial fluid). There are several bursae in the body including one just over the olecranon. Bursae help to make movement smooth between bones which 'stick out' and the overlying skin.

What is olecranon bursitis? •

Bursitis means inflammation of a bursa. The bursa at the back of the elbow over the olecranon is the commonest bursa to become inflamed. Inflammation causes swelling and extra fluid to be made.

What causes olecronon bursitis? •

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Mild but repeated injury is thought to be the common cause. For example, people who lean on their elbows a lot cause friction and repeated mild injury over the olecranon. (Fancy names have been given to this condition when the cause is clear. For example 'students elbow' when it occurs in people who study with their elbows leaning on a desk. Other names include 'miners elbow', 'plumbers elbow', etc, when the job involves crawling a lot using elbows.) One-off injury such as a blow to the back of the elbow may set off inflammation. Arthritis. One or more bursae may become inflamed as part of a generalised arthritis. (Note: most cases of olecranon bursitis are not associated with arthritis.) Infection of a bursa. This may occur if there is a cut in the skin over a bursa which allows in bacteria. Unknown (idiopathic). Many cases occur for no apparent reason. However, it is possible that some of these are due to a mild injury that has been forgotten.

What are the symptoms of olecranon bursitis? •

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You cannot normally feel or see a bursa. If the olecranon bursa is inflamed then it causes a thickness and swelling over the back of the elbow directrly over the boney prominence of the tip of the elbow. The bursa may also fill with fluid and it then looks like a small soft ball - a bit like a cyst. Most cases (those not infected or associated with arthritis) are painless, or are only mildly painful. The movement of the elbow joint maybe slightly limited. If the bursa is infected ('septic' olecranon bursitis) then you will usually develop pain, redness and tenderness behind the elbow. A bursitis associated with arthritis may not be painful itself, but you will have other symptoms related to the arthritis such as joint pains. There are other conditions that can cause elbow pain and swelling, and these should also be considered as a possible diagnosis. Your doctor can usually diagnose elbow bursitis on examination, but an x-ray will often be done to ensure the elbow joint itself appears normal. A MRI is not necessary to diagnose elbow bursitis, and will only be done if there is uncertainty about the diagnosis.

What are the signs of infected elbow bursitis? • • • •

Fevers Chills or sweats Significant redness around the back of the elbow Breaks in the skin (scrapes/cuts) around the swollen area

What is the treatment for olecronon bursitis? •

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No treatment may be needed. A small painless thickening or swelling is common. It often clears by itself. If a small amount of fluid remains once the inflammation has gone then this can be left alone. However, a large collection of fluid may be unsightly. Anti-inflammatory medication (such as ibuprofen, naproxen, diclofenac, etc) may be prescribed to reduce inflammation and swelling. A steroid injection into the bursa may cure the problem. Steroids are good at reducing inflammation. Aspiration (draining the fluid) can be done with a needle and syringe if a lot of fluid builds up. However, the fluid tends to build up again after being drained. Therefore, you may be advised to wear a tight pressure bandage for a while after the fluid is drained to prevent it building up again. Surgery to remove the bursa is an option if the above do not work. Antibiotics are needed if the cause of the bursitis is an infection. If you protect the elbow from excessive friction and rubbing it may prevent further bouts of bursitis. This may mean using elbow pads if you need to lean on you elbows whilst working.