How to treat inflammation of the elbow joint (bursitis)

Our joints are in constant motion. Due to this, they live: it is known that the friction of the articular surfaces against each other provides nourishment to the cartilage. If the joint is something wrong, it very quickly becomes noticeable. Joint pain is a very common problem, according to statistics, the world's first reason for the frequency of help-seeking behavior and the main reason for use of analgesics. So doctors often have to break your head: what caused the "failure" of a joint?

The Joint design is not very complicated, but the causes of pain in it enough: may cause damage to the articular surface, the soft tissue around can hurt your muscles or bones. Can become inflamed and cause suffering and also joint bag, which the doctors called a Bursa. Bag surrounds the joint, insulates it from the surrounding tissue and creates a cavity in which circulates synovial fluid – lubricant for smooth sliding of the surfaces against each other. Inflammation of this anatomical formation is called bursitis.

Bursitis most characteristic of large, highly loaded joints with a large range of motion – shoulder, knee, elbow. For each of the joints is known to a range of situations, encourage the development of bursitis. In the ICD-10 code has bursitis 70-71.

Elbow joint in humans is very popular. This is due to the active use of the upper limbs in daily life, work. Elbow joint – second after the shoulder on the scope of the load (if it is upper limb).

Causes

Of Course, to assume that bursitis of the olecranon will occur more often in those people, the joint of which is overloaded to a greater degree. Indeed, this kind of disease is more common in people in certain occupations or a specific occupation. These include:

• professional athletes (mostly tennis players, boxers, gymnasts, judokas, wrestlers, spear throwers, and weightlifters, as well as representatives of various schools of martial arts)
• people whose professional activity is connected with increased stress on the elbow joint: the operators of pneumatic hammers, locksmiths, gardeners, steel workers. In the past this disease was often struck by the bakers (the need to lay the bread into the oven on the shovel with the long handle-lever, loading the elbow), students and clerks (manually rewriting large amounts of text). Now, when computer typesetting replaced hand, this problem may occur in the operators PC, programmers. As a rule, in such case, both the affected and wrist joints, are also exposed to strong exertion;
• other segments of the population most often disease of the joints found in people of older age groups. Tennis elbow is no exception: the frequency of appealability of this condition increases significantly after 50 years.

The Most common causes of bursitis of the elbow joint (table 1)

Reason	Clinical case
Acute injury of the joint and periarticular bags	intra-Articular fractures, blows to the elbow joint (especially with the occurrence of hematoma)
Repeated trauma and stretching of the joint and periarticular bags	Professional sport, work with high load on the joint
metabolic Disorders	Gout
Autoimmune diseases	Rheumatoid arthritis, ulcerative colitis, Crohn's disease, systemic lupus erythematosus, scleroderma, psoriasis,
Infectious lesions of joints	Tuberculosis, rheumatism, gonorrhea, secondary post-traumatic arthritis, sepsis
arthritis and arthritis	Poisoning, hypothermia, age-related changes in joints, deforming arthrosis

the Anatomical features of the elbow joint

The complexity of the structure of the elbow joint is that it is a structure that can be described as "three in one". Essentially this is three different joints enclosed in a single capsule:

• preselective joint – between humerus and ulna bones;
• brachioradialis joint – between humerus and radius bones;
• radioulnar joint is between the radius and ulna.

Thanksthe device in the articulation of possible such movements, which provide higher mobility of the underlying parts of the upper limb: forearm and hand.

The Capsule of the elbow joint consists of two layers, or leaflets, as doctors say. The inner layer provides moisture for the production of articulation, the outer – capsule gives strength. The capsule covers all three joints, forming a kind of closed bag.

Also Has the value and the fact that in the cavity of the joint capsule forms folds that partition, with the result that he has a complex compartmental structure. For example, the front and rear parts of the joint cavity are communicated with each other only through a narrow aperture is a gap between the radius and ulna. This feature is important when carrying out the puncture of a joint: for complete removal of fluid or blood, it is necessary to carry out the puncture in two places – front and back.

Capsule and ligaments at the elbow joint is very strong: for example, the most powerful of the ligament is internal, can withstand tensile stress up to 230 kg, the other to have the strength of 130-160 kg per gap.

Of all the joints of the elbow, perhaps, has the highest reactivity in response to minor damage. Because of the peculiarities of its blood supply and innervation. The fact that the main artery of the joint, creates three developed vascular network in capsules: two in the inner layer and one outer. In the same folds of the joint capsule vessels can form loops. This structure nature intended for better drainage of blood from the joint, which normally happens. But at the slightest trauma to the joint capsule occurs the reduction of its capacity for blood flow and the joint swells very quickly.

Moreover, the mass of nerve endings embedded in all layers of the joint capsule. The pain that accompanies any injury or inflammation, the body is perceived as a danger signal, and the muscles surrounding the elbow, immediately spazmiruyutsya – there is immobilization of the elbow. When this spasm is pronounced and also prevents outflow of blood, a swelling develops over a very short period of time.

Symptoms

To be precise, in the elbow joint there is not one, but three bags. And although in essence they still form a single seamless design, anatomic and clinical point of view they are better treated separately. These include:

• subcutaneous bag: envelops the joint on the perimeter
• localekey: covers the radial head and ulna;
• ulnar interosseous: is need all three bones of the joint.

depending on what kind of bags becomes inflamed, bursitis of the elbow joint can manifest different symptoms. But later, as a rule, the pathological process spreads on all three Bursa, and differences in initial clinic simply erased.

While bursitis can occur following symptoms and syndromes:

1. Swelling usually occurs earlier than other symptoms and bothers the patient most. Microtrauma, autoimmune diseases swelling begins gradually and can be the only manifestation of bursitis. If untreated, it progresses: the joint increases in size, the motion in it are violated, there are other signs of illness.
2. For bursitis is characterized by bent and forced position of the hands. Outside of its joint capsule protrudes. The olecranon is the most protruding part of the joint is much increased joint bag, resembling the size of a plum (in the unbent condition of the limb).
3. Redness of the skin occurs not always and not only indicates the violation of the outflow of synovial fluid, but also about the current active inflammation – microbial, autoimmune.
4. the Pain always accompanies inflammation, so bursitis at the various options – from discomfort to severe pain, leading to the impossibility of motion in the elbow. The intensity of the pain depends on the severity of inflammation;
5. Common symptoms of inflammation – fever, intoxication – little characteristic for an isolated bursitis, unless infection has occurred the joint capsule.

All these features are typical not only for the bursitis and can occur in other rheumatic and traumatological diseases – arthritis, epicondylitis, fractures and sprains, etc. So for proper diagnosis of bursitis great importance to provide additional methods of research, as well as properly collected history.

The Final idea of the process helps to make the classification used in clinical practice. Bursitis (code 70-71 ICD-10) differ from each other according to the following criteria:

• the nature of the exudate: serous, purulent, hemorrhagic;
• type of current: acute, subacute, recurrent and chronic.

Methods of diagnosis

Sometimes for the diagnosis of "tennis elbow" is not enough clinical data. Need to collect more information about the affected joint. In such cases, can be used (at the discretion of the physician) the following diagnosticprocedures:

x-ray

This is the gold standard in orthopedics, rheumatology and traumatology, which allows to evaluate the structure, contours of bones, the presence or absence of fractures. On the radiograph it is impossible to see the soft structures – muscles, ligaments, the skin, but when bursitis this method is extremely important because it allows us to see the absence of the other, gross pathology, and thereby to make the correct diagnosis.

Professional athletes on the radiograph will be visible changes in the bones, which were formed over a long period of time in response to increased load: a thickening of bone, closing of growth zones ahead of time. In the attachment of ligament to bone can be used to detect multiple spikes (osteophytes) and the joint cavity – articular body, in the home referred to as "articular mice".

The Most characteristic symptom of "joint athlete" is the detection of spurs on the inside of the joint. This spur can reach large sizes and can sometimes even break. In this case, bursitis of the elbow joint is very long, responds poorly to treatment and requires surgical intervention.

If the bursitis appeared on the background of rheumatic diseases, he is always accompanied by a loss of cartilage. On the radiograph that is manifested by the graininess of the articular surface (uzuratsiya).

If symptoms are not caused by the bursitis, and fractures, the latter is easily identified on the x-ray image.

x-ray contrast study

Allows you to see in the joint cavity foreign bodies which are invisible on conventional radiographs. The method represents a radiography after injection into the joint of a special contrast medium together with air or without him. The photo also allows to obtain information about the status of the articular surfaces, to determine the optimal spot for puncture of joint (if required), to trace the contours of ligaments and joint capsules.

Radionuclide method

The Study is widely used in traumatology and rheumatology, allowing with high accuracy to identify tumors, to evaluate mineral metabolism and the degree of maturity of bone outgrowths – spikes. Chronic and recurrent bursitis of the elbow joint is the most common indication for radionuclide diagnostics, it allows you to determine the cause of such a prolonged course of the disease and to choose correct tactics of treatment. But with the advent of simpler and less informative methods indications for use of this research is currently restricted.

ultrasound of the joints

Ultrasonography is one of the most important non-traumatic methods of research, allowing you to see the contents of the joint capsule and soft tissues around the joint. This is its main value, since ultrasound is very bad "shows the" state of the cartilage and bone surfaces.

Currently, there are five accesses, one of which can be inspected joint. In addition, there are five pathological conditions that can be detected by ultrasound examination. These include:

• thickening of the tendon;
• inflammation of the tendons (tendonitis)
• thickening of tendon sheath (paratenon);
• intra-muscular hematoma;
• elbow bursitis.

Thus, the role of ultrasound of the joints is greatly increased when the need for differential diagnosis between these conditions. This is a very urgent task for sports medicine, as well as in the treatment of occupational diseases of the joints.

tomography and magnetic resonance imaging

In some cases, patients found recurrent swelling and limitation of movement in the elbow joint, discomfort or pain in it, however, to identify the cause of these symptoms oznaczonymi methods cannot. In such situations shows a CT or MRI. These methods are not equivalent: computed tomography allows you to monitor the status of hard tissues – bone, cartilage, and magnetic resonance – soft: cartilage, bursae and ligaments.

CT scan and MRI can help in resolving the most difficult diagnostic situations. The need in their application typically occurs when a chronic or recurrent course of disease and allows to identify the effects of bursitis of the elbow joint.

Arthroscopy of elbow joint

The Method is unique: on the one hand, it allows to inspect the joint cavity and immediately to conduct medical manipulation, if in the course of the study they had a need. In fact arthroscopy – surgical operation.

Indications for arthroscopy:

• pain in the joint after minor injuries;
• symptoms of recurrent bursitis;
• restriction of joint movement
• bursitis of unknown etiology.

Contraindications to arthroscopy:

• the presence of General or local infection;
• deforming arthrosis III or IV degree;
• significant joint space narrowing detected on radiographs;
• severe contractures of the elbow joints;
• significant reduction in volume of the articular cavity.

The Technique of arthroscopynext: after the preliminary layout (see figure) is carried out under local anaesthesia the area of the puncture and then the puncture. In connection with the above-described anatomical features to carry out a full examination of the oral cavity of the elbow joint, you must enter it from three different approaches. The inspection of the articular surface and joint capsule, and then determine the pathology that was the cause of the bursitis, and proceed to the second part of the procedure is therapeutic action. Arthroscopy allows you to take the following steps:

• washing the joint cavity and the removal of foreign bodies;
• artrosis (separation of adhesions in the cavity of the articulation and joint capsule);
• removal of osteophytes (outgrowths);
• removal of part of the articular capsule;
• removal of foci of necrosis.

Differential diagnosis of certain diseases of the elbow joint

There are a number of diseases, which are very similar to tennis elbow – arthritis, epicondylitis and osteoarthritis.

1. Arthritis is an inflammation of the cartilage surface of the joint. Is also a consequence of many factors – infectious, autoimmune, traumatic. Bursitis in one degree or another always accompanies any arthritis because the inflammation from the head joint very quickly spreads to periarticular bag.
2. Epicondylitis – an inflammation that occurs at the site of attachment of tendons to the bones. Causes of epicondylitis – a long period of repeated stress on the forearm muscles (computer work, professional sports, music, etc.), trauma. When also always epicondylitis is inflammation of the Bursa located around the ligament.
3. Osteoarthritis – changes in the joint associated with prolonged malnutrition of the cartilage. Osteoarthritis is also accompanied by pain, swelling and sometimes inflammation of periarticular bags.

Despite clinical similarity, all of these States have fundamental differences in tactics of treatment. The table shows the number of signs, allowing to differentiate diseases from each other.

Symptom	Bursitis	Arthritis	Epicondylitis	Osteoarthritis
Causal disease	Occupational hazards, sports	Trauma, systemic disease	Occupational hazards, sports	Age, old injury.
the course	Acute or chronic with clear exacerbations	Sharp	Chronic	Chronic
Pain	Moderate or weak, and rarely strong (with the development of complications)	Strong or moderate, less weak	Mild to moderate	Mild to moderate
Edema	Leading symptom very pronounced	Expressed	Not defined	Not defined
Redness, increased local temperature	Rare, only the presence of complications	Expressed	No	No
Fever, intoxication	Rare, only the presence of complications	Moderate to severe	No	No
Movement in the joint	Reduced	Drastically reduced	Slow	Reduced
the Speed of development of symptoms	moderate to high	High	Slow	From a few months to several years

Treatment

Treated for bursitis of the elbow differently, depending on its causes. However, there are General principles of care for this pathology:

1. Immobilization of the joint. Is fixation of the elbow joint using a bandage or orthesis that provides rest to the body, reduces unpleasant sensations that occur when driving, helps to resolve edema.
2. as a emergency care in acute bursitis, you can use a cold compress. In chronic bursitis use compresses with honey, aloe, burdock, St. John's wort or yarrow. In folk medicine, the use of compresses of fresh vegetables – cucumber, potato, leaves of cabbage.
3. anti-Inflammatory drugs – the so-called NSAIDs. The baseline group for the treatment of bursitis and all rheumatologic diseases. Fundamentally can be applied in three dosage forms: topically, orally and intramuscularly/intravenously.

Topically applied anti-inflammatory agent in the absence of large amounts of fluid in the joint, weak pain syndrome. Dosage form is a gel or ointment ("Diclofenac", "Dolobene", "Indometacin", "Voltaren").

In the acute stage is contraindicated ointment that increases the blood flow to the joint, Vishnevsky ointment", "Finalgon", "Fastum gel", etc., because they significantly increase the swelling.

NSAID tablets used for any severity of bursitis. If you want to get a quick effect or has disease of the stomach, which pillsnot prescribe ampouled media. Drugs from this group there is a great variety, but the greatest effect have those that have a predominantly anti-inflammatory effect. These include:

• Analgin
• Indometacin
• Diclofenac
• Ibuprofen
• Ketoprofen
• mefenamic acid
• Nimesulide.

Significantly inferior in terms of efficacy of paracetamol, coxib, dexketoprofen, Ketorolac, aspirin, xefocam. Any NSAIDs cannot be used for a long time.

Antibiotics in most cases is contraindicated in bursitis.

4. the Exception is purulent bursitis, in which synovial fluid becomes infected with bacteria. Acute purulent bursitis is manifested by the following symptoms:

• pronounced swelling and tenderness;
• fever, high body temperature;
• signs of lymphadenitis in the axillary and cubital areas;
• obtaining pus with puncture of the joint.

In this case, use antibiotics from group of penicillins or the cephalosporins, at least – the drugs of other groups ("Ampicillin", "Amoxiclav", "Augmentin", "vil'prafena", "Sumamed", "Ceftriaxone, Ceftazidime, Cefoperazone, Cefepime," etc.).

5. Physiotherapy on the joint area as shown in the acute phase and during remission of bursitis. In the second case, use mud therapy, massage, physiotherapy, acupuncture. During exacerbation of the process you can use magnetic therapy, UHF. There is evidence of the effectiveness of hirudotherapy (leech therapy) in acute and chronic bursitis. A warm compress is the simplest type of physiotherapy that can be used during the chronic bursitis. Such a compress can be provided at home.
6. arthrocentesis is performed with pronounced swelling that hinder the movement, the absence of a positive effect of basic therapy, in the diagnosis of purulent bursitis. This technique, although simple, is very effective and quickly removes the excess fluid in the joint. After puncture of the joint, you can leave the drainage, providing a slow outflow of the inflammatory content.
7. Surgical treatment (operation) and arthroscopy are performed when it is impossible to treat bursitis conservatively in patients with recurrent or chronic bursitis. In addition to the removal of foreign bodies, can surgically remove part of the synovial membrane, to resect bony growths to get rid of the reasons that support the circulation of synovial fluid.

What specialist treats bursitis

In the event of a sports injury support is provided by a sports doctor, and in his absence – the doctor-the traumatologist. Surgeon engaged in complicated forms of bursitis, namely purulent. In large cities for the treatment of complicated forms infectious lesions of the joints, there are specialized departments – purulent orthopedics, tuberculosis of bones and joints, etc. If bursitis has arisen on the background of rheumatic diseases, it should be treated by a rheumatologist. The emergency doctor must conduct emergency activities when expressed pain syndrome. Complicated to treat bursitis need only in a hospital.
Summarizing, we can say that tennis elbow is a heterogeneous concept. Sometimes bursitis is an independent disease, sometimes it can be a symptom of another disease. A clear understanding of the mechanisms of origin of bursitis – the main condition for successful treatment. Given the diversity of causes, its causes, conduct diagnostic search when bursitis is the prerogative of a podiatrist or physician-rheumatologist.

Sources:

1. Rheumatology. National leadership. M.: 2013
2. Mironov S. P. Injuries of the elbow joint during sports activities. M.: 2000