Other conditions

A range of other conditions can also cause pain about the elbow in football players (and other athletes). Click on the tabs below to learn more about some of the less common causes of elbow pain.

Click on the tabs below to learn more about some of the less common causes of elbow pain.

Ulnar collateral ligament injuries (UCL)
The bone structure of the elbow provides stability when the elbow is flexed to less than 20 degrees or more than 120 degrees. Between these angles, the primary valgus stabiliser is the anterior oblique band of the UCL. In football, this injury generally happens with acute trauma, e.g. from a fall. In throwing sports, however, this is more commonly an overuse injury due to repeated valgus stress.

Athletes have pain and tenderness over the medial elbow that is worse with the late cocking and acceleration phases of throwing. It is important to test valgus stability in 30o and 70o of flexion; the UCL provides greatest stability at 70o of elbow flexion and neutral rotation. MRI and MRI arthrography are the best methods of investigating this type of injury.

In footballers and other non-throwing athletes, a conservative treatment regime is acceptable. Casting or a range-of-motion programme can be used to control pain and swelling. Generally, there are poor results in high-demand throwing athletes with anything but surgical treatment. Symptomatic non-throwing athletes with a minimum of three months of failed rehabilitation may also be candidates for surgery.

Posterior impingement
This problem, like most other elbow injuries, is most commonly reported in throwing athletes. Older patients generally have osteophyte formation within the olecranon fossa or established OA particularly in the radio-capitellar joint. Younger athletes are more likely to have synovitis.

Repeated or forced hyperextension of the elbow creates a shearing force between the olecranon and its fossa that leads to soft tissue hypertrophy, osteophyte formation, or both. The main clinical feature is a fixed flexion deformity and pain with forced elbow extension.

Treatment is with relative rest and avoidance of pain. Corticosteroid injections can be considered in some cases while an arthroscopy (to clear osteophytes from the olecranon fossa) can be helpful in refractory cases.

Olecranon bursitis
Olecranon bursitis is a relatively common cause of elbow pain and swelling. It can be caused by repetitive movements, but can occur after a single incident (like a fall onto the elbow). The patient typically has a localised fluid collection over the tip of the olecranon that can become infected in some cases.

Rest and compression can be very useful in minimising contact or blows to the olecranon. If the patient is very symptomatic, one can consider aspiration of the bursa and an injection with steroid. Aspiration is usually successful, but the condition resolves faster if the aspiration is combined with a corticosteroid injection.18 An oblique needle angle or zig-zag is suggested to prevent formation of a sinus and a lateral approach to avoid the ulnar nerve. It is essential to exclude infection particularly if considering a steroid injection. In refractory cases, the bursa can be surgically excised.

Ulnar nerve entrapment (cubital tunnel syndrome)
After carpal tunnel syndrome, this is the second most common nerve entrapment in the general population.5 Symptoms are typically the result of a subluxing ulnar nerve, an anatomical variant (bone or muscular) at the cubital tunnel, or from traction during throwing and valgus stress.

Patients present with posteromedial elbow pain that can refer into the ulnar nerve distribution (i.e. the medial forearm and the fourth and fifth fingers). Symptoms and signs are typically worse when the elbow is flexed; the length of the nerve and compression against the medial epicondyle both increase. There may be objective sensation changes or weakness in the ulnar distribution. Also for a positive Tinel’s sign at the elbow.

Imaging modalities (USS or MRI) may show a source of compression and an enlarged nerve. Local massage as well as neural stretching can be of some assistance. Surgical decompression, including subcutaneous or sub-muscular transposition of the nerve, is often needed. Surgery for a UCL deficiency is not successful unless this entrapment is also addressed.

Posterior interosseous nerve (PIN) entrapment
This condition causes lateral elbow pain that is hard to distinguish from common extensor origin tendinopathy. PIN entrapment is often associated with activities that require repetitive pronation and supination. A number of anatomical variants have been described that may contribute to this condition.

It is possible to confirm the diagnosis of PIN entrapment with nerve conduction studies. In some cases, the entrapment can be successfully treated with massage and nerve stretching; however, surgical decompression may be necessary.

Click on the images below to view some examples of the conditions discussed above.

  • Posterior impingement – sagittal MRI

    Significant joint effusion and synovitis causing posterior impingement.

  • Olecranon bursitis longitudinal view

    Olecanon bursitis is a clinical diagnosis – imaging is not generally needed.

  • MRI - ulnar neuritis axial

    Note the increased T2 signal and minor thickening at the cubital tunnel.

  • MRI - ulnar neuritis coronal

    Further image of the ulnar nerve – no evidence of a compressive lesion.