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.

4. 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.

5. CONT…
 Repetitive 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. Physical Therapy 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

11.  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

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

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

14. 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.

15.  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.

16. 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.

17. 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.

18. 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.

19.  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.

20. THANK YOU