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Weightlifter with Elbow Pain

Jones, Nathaniel S. MD1; Raasch, William B. MD2

doi: 10.1249/JSR.0b013e31822d404f
Case Report

1Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI; and 2Department of Orthopedics, Medical College of Wisconsin, Milwaukee, WI

Address for correspondence: Nathaniel S. Jones, MD, Froedtert & The Medical College of Wisconsin, Sports Medicine Center, 8700 Watertown Plank Road, Wauwatosa, WI 53226 (E-mail:

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Case Presentation

A 50-yr-old, right-handed, male recreational weightlifter presented to the sports medicine clinic for evaluation of left elbow pain. The pain was gradual at onset, beginning approximately 2 years ago. Although he could not recall any history of specific injury, at the time of onset, he had an episode of elbow swelling that required drainage. Medical history of the elbow included intermittent discomfort secondary to tendinitis but no history of dislocation. His pain was generalized around the whole elbow joint, especially at the ends of the range of motion, with occasional intense pain located more posteriorly. With the onset of pain, he reported a diminishing range of motion in both extension and flexion of his elbow, with occasional episodes of locking. As an avid competitive weightlifter, he noted worsening pain especially after a workout or a competition. He was unable to do some weightlifting maneuvers because he could not lock out his elbow in full extension. This interfered with his 3- to 4-h·d−1 training regimen. Also, this progressive decrease in range of motion was affecting his activities of daily living, in that he had difficulty buttoning his shirt. He denied any buckling, swelling, numbness, or tingling. He had not attempted any treatment at that time. He mentioned also that symptoms were beginning to manifest in his right elbow.

On examination, he was a pleasant, muscular, middle-aged gentleman in no acute distress. General examination of his neck and left shoulder did not reveal any abnormality. Examination of his left elbow revealed no swelling or ecchymosis. He had no tenderness over the medial and lateral epicondyles. He had diffuse joint tenderness laterally to palpation, which was exacerbated by radiocapitellar compression. He lacked 20 degrees of extension, and flexion reached only 90 degrees. Supination and pronation were symmetric to those of his contralateral side. He had 5 out of 5 strength with extension, flexion, pronation, supination, wrist extension, and flexion, all without pain. Results of the examination of his ligament were normal, with good stability under varus and valgus stress.

Initial radiographs of his left elbow showed dystrophic calcifications anterior and posterior to the joint, with normal alignment of the radial head and capitellum and of the olecranon and the trochlea (Fig. 1). It also showed ossific fragments adjacent to the radial head and to the olecranon. A subsequent magnetic resonance image (MRI) without contrast of the left elbow showed a tricompartmental degenerative disease of the elbow, with prominent osteophytes at both the olecranon and the coronoid, including a large ossification at the insertion of the triceps (Fig. 2). It also showed a joint effusion with multiple intra-articular fragments. The patient was diagnosed with elbow arthritis, with osteophytes inhibiting the range of motion and causing pain in addition to loose body fragments causing intermittent mechanical locking symptoms.

Figure 1

Figure 1

Figure 2

Figure 2

The patient was given various treatment options, including the option of living with his current pain and range of motion but with significant activity modification. Also, surgery was discussed with the patient as an option to improve range of motion and pain, with the understanding that he may have more joint laxity postoperatively. This, in turn, if he continued weightlifting, would lead to a possible increase in pain. The patient's main goal was to regain range of motion so he could perform more functional activities again, i.e., be able to button the top of his shirt.

The patient elected to proceed with surgery and underwent left elbow arthroscopy with debridement of the posterior olecranon and coronoid spurs with chondroplasty of the articular surface. Physical therapy was begun at 1 wk after surgery. By 3 months he lacked only 10 degrees of extension with flexion to 100 degrees and was able to button his top shirt button. His left elbow was placed in a Dynasplint to help him achieve the last few degrees of its extension. Overall, he was pleased with both the improved range of motion and decreased pain.

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The elbow joint is composed of three articulations: ulnotrochlear, radiocapitellar, and proximal radioulnar joints. The articulation between the ulna and the humerus provides most of the joint's stability, with flexion-extension occurring at the ulnotrochlear joint and pronation-supination occurring through the radiocapitellar joints and proximal/distal radioulnar joints (7).

The etiology of elbow arthritis can be traced to sequelae of joint infection, crystalline arthropathy, hemophilia, primary osteoarthritis (OA), rheumatoid arthritis, and trauma to the elbow, which is the most common (4).

Primary OA of the elbow is uncommon in the general population, affecting less than 2% of individuals. When it occurs, it is seen more commonly on the dominant side of middle-aged men with a history of heavy use in sport or on those who engage in strenuous manual activities (1,3,10). In weightlifters, elbow arthritis is more prevalent because of the increased stress and use of the joint. OA of the elbow differs from that of other joints in that the joint space usually is preserved. Early on, it is characterized by osteophyte formation, capsular contracture, and, frequently, loose bodies (3). Although it is considered to be a non-weight-bearing joint, it does bear load. In fact, dynamic loading, seen with throwing or heavy pounding, produces forces more than six times the body weight (2). When elbow OA does develop, it usually begins laterally, with early degeneration of the radiocapitellar joint, followed by the ulnohumeral joint (5).

Overall, the presentation of a patient with elbow OA varies depending on the etiology of the arthritis and the stage of disease. Generally, in primary OA, a patient's primary presenting symptom is pain, especially at the end of range of motion accompanied with stiffness or restriction of motion. There is loss of terminal elbow extension and flexion with impingement-type pain. Joint space still is maintained, with osteophyte formation at the olecranon fossa and proximal portion of the olecranon causing discomfort in maximal extension. Osteophytes also form in the trochlea or in the coronoid process, causing impingement pain in extreme flexion (7). Then, the elbow progresses to a greater degree of restriction and pain throughout the arc of motion in the later stages (1).

Initial radiographic evaluation is done with standard anteroposterior and lateral radiographs, which usually reveal anterior and medial osteophytes involving the coronoid process and a posteromedial osteophyte on the olecranon process (3). Extensive narrowing of the joint space, without osteophytes, is more indicative of an inflammatory process (3). Although additional imaging studies usually are not necessary for preoperative planning, magnetic resonance imaging or computed tomography can help delineate substantial bony deformities or intra-articular loose bodies (4). This is especially important, because up to 30% of loose bodies are not detected on plain radiographs (6,9).

A conservative nonsurgical treatment of primary OA includes rest, nonsteroidal anti-inflammatory medications, and long-term activity modification (3). Intra-articular corticosteroid injections can provide some relief of symptoms. Physical therapy with range-of-motion exercises to maintain mobility and strength has been recommended, with or without dynamic hinged and static progressive splinting (1,4). However, one must remember that primary elbow OA is a disease affecting the bone, and that physical therapy is aimed at muscle and soft tissue. Moreover, viscosupplementation has been studied, and it was found to provide minimal pain relief at 3 months, with no lasting benefit at 6 months (8).

When conservative measures do fail, the patient's primary complaint should be the main consideration in surgical planning. Patients with restriction of motion or with pain at extremes of motion as their primary complaint likely would benefit from open or arthroscopic debridement and possible capsular release. This is in contrast to patients with evidence of late-stage disease who have pain throughout the arc of motion and diffuse narrowing of the joint space. They are likely to benefit from distraction interposition arthroplasty, total elbow arthroplasty, or elbow arthrodesis (10). Among these three more aggressive approaches, distraction interposition arthroplasty, which is reserved for those younger than 65 years, has the least postoperative activity restrictions, although it is done rarely, while arthroplasty or arthrodesis is for those aged 65 years and older who are willing to live with low levels of activity (1).

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The authors have no funding disclosures.

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