An elbow that hurts at the end of extension, that locks from time to time, in a man of fifty whose job has long forced his arms: the picture is stereotyped, the condition is little known, and its name is almost always mangled. This article covers primary osteoarthritis of the elbow, from its vocabulary to its rehabilitation, saying at each stage what the literature supports and what it does not.

A synthesis written from primary sources verified one by one on PubMed. Every figure carries its reference at the point where it is written; the full bibliography, with PMIDs, appears at the end of the article.

Clinical summary

Why do people say “omarthrosis” when it is the elbow?

An error of vocabulary is a detail only for as long as it does not change what you do. This one changes the word the patient types into their search engine, the page they open, and sometimes the joint they are told about.

“Omarthrosis” comes from the Greek ômos, the shoulder. The term means glenohumeral osteoarthritis and nothing else. The check is easy to make yourself: two German-language papers entitled literally Omarthrose and Omarthrose – Pathogenese, Klassifikation, Diagnostik und Therapie are indexed in PubMed under the English headings “Omarthrosis” and “Shoulder Osteoarthritis”12. Both deal with the glenohumeral joint; neither deals with the elbow. Using that word for an elbow is naming one joint while meaning another.

The correct name is ulnohumeral osteoarthritis, or humeroulnar, after the compartment the disease affects first. It is in fact the term used by the English-language literature, where the reference operation is called ulnohumeral arthroplasty3 and where the series speak of humeroulnar4 involvement. You also meet “cubital osteoarthritis”, vocabulary from before the revision of the anatomical nomenclature, when the ulna was called the cubitus: it is the same bone and the same joint.

Three compartments coexist at the elbow, and the disease affects them neither at the same time nor in the same way:

• the humeroulnar joint: the humeral trochlea against the trochlear notch of the ulna, this is the flexion-extension hinge and the main seat of the disease;
• the humeroradial joint: the capitellum against the radial head, involved almost constantly on radiographs;
• the proximal radioulnar joint: the one for pronation and supination, most often spared functionally.

In the series by Doherty and Preston, the first to describe the primary form properly, radiographic involvement was present in the humeroradial compartment in 100 % of elbows, humeroulnar in 96 % and radioulnar in 85 %4. The disease is therefore pan-articular on imaging, whereas the complaint is almost always that of a hinge that jams.

Naming it correctly is not fussiness: a patient who comes in for “omarthrosis of the elbow” has already read, before seeing you, pages that were about their shoulder.

What is ulnohumeral osteoarthritis and who does it affect?

An osteoarthritis like no other: it makes bone rather than destroying cartilage, it stays silent in most of those who carry it, and it strikes an identifiable occupational profile.

A hypertrophic osteoarthritis with a preserved joint space

The feature that defines primary osteoarthritis of the elbow is that it is hypertrophic : the bony response dominates by far over cartilage loss. Osteophytes develop at the points of impingement, the tip of the olecranon, the coronoid process, the radial head, and the olecranon and coronoid fossae fill in, sometimes by a genuine thickening of the membrane lining them. Meanwhile, the joint space remains largely preserved5.

This feature is not incidental, it is what governs the whole strategy. Where advanced knee osteoarthritis requires the surfaces to be replaced, elbow osteoarthritis can often be treated by removing what blocks : osteophytes, loose bodies, contracted capsule. The relatively spared cartilage explains the good results of conservative procedures and also explains why prosthetic arthroplasty remains, in this indication, a last resort5.

Dalal's case-control radiographic series quantified exactly what the images show, comparing 50 osteoarthritic elbows with 50 elbows matched for age and sex. Olecranon osteophytes were present in 96 % of patients, coronoid osteophytes in 90 %, radial head osteophytes in 86 %, and osteophytes of the coronoid and radial fossae in 64 %. Thickening of the membrane of the olecranon fossa concerned 68 % of cases. Joint space narrowing, for its part, predominated in the radiocapitellar compartment (58 %) and remained rare in the humeroulnar one (16 %). In the controls, only the coronoid osteophyte was frequent (36 %); the other signs were rare6.

Frequent on radiographs, rare in the clinic

The epidemiology of this disease remained unknown for a long time, for want of a general population study. It was established in 2022 by a Japanese survey conducted on a random draw from a municipality's resident registry: 415 residents over 50 sampled, 318 retained after excluding every cause of secondary osteoarthritis, all radiographed in two views7.

Radiographic prevalence was 25.2 % (27.3 % in men, 23.2 % in women) for a Kellgren-Lawrence grade of 2 or more. The prevalence of symptomatic forms, for its part, fell to 0.9 %. In other words, one adult over 50 in four carries radiographic osteoarthritis of the elbow, and barely one in a hundred suffers from it. The progression with age is steady and rapid7.

Two practical lessons come out of these figures. The first: finding osteoarthritis on an elbow radiograph does not prove that it explains the pain. At 75, the probability that any given elbow carries osteoarthritic signs approaches one in three, and nine times out of ten those signs are silent. The second: this osteoarthritis is, in the authors' own words, a disease that most people “accommodate” by themselves7. It is the rarity of the symptom, and not the rarity of the lesion, that makes it seldom seen.

The profile of the patient who consults

The surgical series draw a very consistent portrait. In Antuña, 46 operated elbows: 44 men to one woman, mean age 483. In Doherty, 16 patients: 14 men, 2 women, mean age 61, with involvement of the dominant elbow in 14 of them4. The review by Gramstad and Galatz sums up the classic background: a middle-aged man doing intense manual work5.

The Japanese survey adds factors that were measured rather than assumed. Age and body mass index were independently associated with the presence of grade 2 or higher osteoarthritis. The use of vibrating tools emerged as a factor specifically associated with the most advanced forms, those of grade 47. That last point deserves to be remembered in the clinic: jackhammer, grinder, chipping hammer, hammer drill, but also chainsaw and brushcutter in grounds maintenance workers.

One detail of Doherty's series often goes unnoticed and is nevertheless useful: these patients frequently had osteoarthritis elsewhere: the second and third metacarpophalangeal joints in 62 % of them, knees in 38 %, hips in 31 %4. Faced with isolated elbow osteoarthritis in a young person, it is therefore worth looking at the hands: associated metacarpophalangeal involvement points towards a more general arthropathy, and notably towards a search for haemochromatosis or chondrocalcinosis, two diagnoses the picture can borrow.

The same authors also established a point that tradition contradicts: the role of trauma is hard to support in the primary form4. Post-traumatic osteoarthritis exists, it is frequent and well documented, but it is another entity: it follows a radial head fracture, a complex dislocation or a fracture of the distal humerus, and it has neither the same profile nor the same prognosis.

How do you recognise elbow osteoarthritis on examination?

There is no validated clinical test for this condition: no published sensitivity, specificity or predictive value. The diagnosis therefore rests entirely on a body of arguments, and it is as well to know which ones carry weight.

The three complaints that should raise it

Pain at terminal extension. This is the cardinal symptom, and the word “terminal” counts: the pain does not appear in the middle range but in the very last degrees, when the tip of the olecranon comes up against a filled fossa. In Antuña's series, all 46 operated elbows complained of terminal extension pain3. Patients rarely describe it in those terms; they say they can no longer “straighten the arm fully”, or that it catches when they push a heavy door or carry a shopping bag with the arm extended.

Locking. It reflects the presence of intra-articular loose bodies, found on 69 % of the radiographs in Doherty's series4 and present in 36 of the 46 elbows operated on by Antuña3. Fourteen of those 46 patients reported frank locking. It is a useful sign because it is specific and because it points straight away to a simple surgical procedure, removal of the loose body, often very rewarding.

The ulnar nerve signs. Twelve of Antuña's 46 patients complained of them before the operation3. This chapter is important enough to have its own section below; for now, remember that not looking for them means missing the commonest and most disabling complication of this osteoarthritis.

What, by contrast, is not the picture: constant pain at rest, prolonged morning stiffness, hot swelling, bilateral involvement from the outset in a young person. These features should prompt a search for something else.

What the examination measures: the ranges, and above all their functional threshold

Loss of range starts with extension and then progresses to flexion. The flexion contracture sets in insidiously, and the patient compensates for it so well with the shoulder that they do not notice it. Pronation and supination stay normal for a long time, which distinguishes this osteoarthritis from post-traumatic radioulnar involvement.

The classic “functional arc” marker comes from an experimental study of 1995: one hundred healthy upper limbs, a brace progressively limiting the range, twelve activities of daily living to perform at each setting. Forty-nine of the fifty subjects completed all the tasks with a range restricted to 75-120° of flexion8. That is the figure the surgical literature has used ever since to judge the need for a procedure.

That marker has aged, however, and it must be said to the patient. A three-dimensional kinematic study of 2011 measured the ranges actually required by contemporary tasks: the flexion arc needed rose to 130° ± 7 to use a telephone, with a maximum of 142° ± 3; pronation reached 65° ± 8 to type on a keyboard and supination 77° ± 13 to open a door9. The authors conclude explicitly that the functional range of the elbow is probably wider than was thought.

The physical examination, step by step

• Comparative bilateral goniometry, active then passive, flexion-extension and pronation-supination with the elbow at the side. Note the flexion contracture as an absolute value, not as “slight” or “moderate”: it is the only figure that will make it possible to say in six months whether anything has been gained.
• End-feel. A hard, abrupt, bony stop is the most telling argument in favour of osteophytic impingement. A soft, springy stop points rather to capsular contracture, and does not have the same prognosis under conservative treatment.
• Reproduction of the pain in forced passive hyperextension, then in hyperflexion. Posterior impingement pain in extension and anterior pain at maximum flexion mark out the two conflict zones.
• Palpation. Para-olecranon gutters, lateral epicondyle, medial epicondyle, radiocapitellar joint line, ulnar groove. Posterior thickening and a widened olecranon are frequent.
• Look for an effusion in the lateral soft spot. A frank, recurrent effusion is not very compatible with simple osteoarthritis and should raise an inflammatory or crystal cause.
• Systematic ulnar neurological examination : Tinel's test in the groove, flexion-compression test, sensation in the last two fingers, strength of the dorsal interosseous and Froment's sign. See the dedicated section.
• Isometric testing of the common extensor and common flexor tendons, so as not to confuse them or in order to detect associated involvement.

What it gets confused with, and how to decide

What imaging should you request and how do you read the report?

Two films are enough for the diagnosis. The rest of the imaging does not serve to confirm, it serves to prepare a procedure or to rule out something else, and the classifications the report uses are not all equally reliable.

The plain radiograph, and nothing else first line

Two views, AP and a strict lateral, are enough to make the diagnosis. On them you look for exactly what Dalal's series quantified: osteophytes of the olecranon, the coronoid process and the radial head, filling of the olecranon and coronoid fossae, loose bodies, and a joint space whose relative preservation is an argument in favour and not against6.

The strict lateral is the one that counts: it shows the filling of the fossae and the impinging osteophytes, that is, precisely what explains the extension pain. An AP view alone can massively underestimate the disease.

The reading trap comes down to one sentence: the coronoid osteophyte exists in 36 % of control subjects of the same age6. It is the only sign that normal ageing produces often enough to be misleading. The others (olecranon osteophyte, filling of the fossae, thickening of the membrane) are discriminating.

The classifications, and which to believe

Three systems circulate in reports and publications. A reliability study published in Osteoarthritis and Cartilage compared them on 81 cases, having each file rated by four orthopaedic surgeons, twice11. The results deserve to be known before basing a decision on a stage.

The practical consequence is direct: a radiographic stage is not solid data, and the difference in severity between two successive reports may be nothing more than a difference between two readers. If a surgical decision turns on the stage, it is CT that decides, and it is also CT that, in that study, correlates best with what the patient feels.

When to request something else

• CT scan (with reconstructions). Before any surgical procedure, to map the osteophytes, locate the loose bodies and measure the filling of the fossae. It is also what allows the osteophyte volume inside the cubital tunnel to be assessed, information directly useful when ulnar involvement is associated12.
• MRI. Of little use for the osteoarthritis itself. Indicated for a differential diagnosis: osteochondritis of the capitellum, thickened radiocapitellar plica, ligament lesion, deep tendon involvement.
• Ultrasound. Useful for effusion, synovitis, and above all for the dynamic study of the ulnar nerve in the groove: dislocation, fusiform thickening, flattening.
• Electroneuromyography. For ulnar signs, to locate the level of compression and grade the involvement. Note, however: in a randomised series of mild to moderate cubital tunnel syndromes, 76 % of patients with typical symptoms had a normal electrophysiological examination, and 75 % of those whose examination was abnormal improved without surgery13. A normal study therefore does not rule the diagnosis out.
• Blood tests. For an effusion, early bilateral involvement or a young person: inflammatory markers, iron studies looking for haemochromatosis, uric acid, calcium.

Why is the ulnar nerve so often involved?

This is the subgroup that on its own justifies a chapter: elbow osteoarthritis is the leading identified cause of surgically treated ulnar neuropathy, and it is also the variable that decides the surgical timetable.

A figure that changes the consultation

A Japanese multicentre series reviewed the records of 413 elbows operated on for ulnar neuropathy at the elbow, diagnosed on the clinical and electrophysiological criteria of the American Association of Electrodiagnostic Medicine. An elbow lesion was present in 75.1 % of cases, and the commonest of all was primary elbow osteoarthritis, found in 54.5 % of the elbows. Next came the medial ganglion (8.5 %) and cubitus valgus (6.5 %), themselves most often associated with osteoarthritis14.

More worrying: the severity. McGowan grade III involvement (that is, with motor deficit and wasting), concerned 50.8 % of osteoarthritic elbows against 35.0 % of elbows with no associated lesion14. In other words, when osteoarthritis is the cause, the nerve is on average more damaged by the time it is operated on. The slow onset of bony compression lets the patient get used to it, and the diagnosis comes late.

Faced with an osteoarthritic elbow, the question is not “should the ulnar nerve be examined?” but “how fast is it deteriorating?”.

What compresses: the osteophyte, not the tunnel

For a long time compression was explained by narrowing of the cubital tunnel in flexion. A dynamic CT study measured the thing in vivo, scanning 13 osteoarthritic elbows with cubital tunnel syndrome and 25 osteoarthritic elbows without, in three positions: full extension, 90° of flexion, full flexion12.

The result reverses the classic explanation. The area of the humeral osteophytes and their proportion inside the tunnel increased markedly with flexion: 24.7 mm² and 49.9 % in full flexion in symptomatic patients, against 9.0 mm² and 31.3 % in extension. And those values were significantly higher in symptomatic patients than in the others. The authors conclude that it is the effect of the medial osteophytes, humeral above all, on the nerve, and not narrowing of the tunnel, that explains the compression12.

The practical consequence is immediate and worth explaining to the patient: it is prolonged flexion that makes things worse, because it brings the osteophyte against the nerve. Sleeping with the arm bent, long phone calls, driving with the elbow bent resting on the door, working at a keyboard with the elbows tightly flexed: those are the positions to correct, and that correction is the first therapeutic step for the associated neuropathy.

What physiotherapy can do for this nerve, and what it cannot

There is one randomised trial, on cubital tunnel syndrome in general, not specifically on osteoarthritic forms. Seventy patients with mild or moderate symptoms were allocated to three groups: night splint, nerve gliding, or a control group. All received information on the cause of the symptoms and on the positions to avoid. At six months, 51 of the 57 patients followed up (89.5 %) had improved, and there was no difference between the three groups on any of the variables measured: not the Canadian Occupational Performance Measure, not the pain scales, not strength, not electrophysiology13.

The honest reading of that trial is not that physiotherapy is useless: it is that information and avoidance of provocative positions do most of the work, and that neither the night splint nor nerve gliding adds anything measurable in mild to moderate forms. That is good news for the patient, and it is an argument for investing the first session in explanation rather than in a technique.

What that trial does not say, on the other hand: nothing about severe forms, nothing about osteoarthritic forms specifically, and nothing about McGowan grade III, which, as we have seen, accounts for half the osteoarthritic elbows operated on. Faced with an established or progressing motor deficit, the timetable is no longer that of rehabilitation.

What can physiotherapy really do in elbow osteoarthritis?

This chapter begins with an admission, because leaving it out would amount to manufacturing a certainty: there is, to this day, no controlled trial of physiotherapy in primary elbow osteoarthritis. What follows is therefore reasoned transposition, and each proposal carries the level of evidence that really belongs to it.

The state of the evidence, without embellishment

The search was conducted for this article on PubMed, crossing elbow osteoarthritis with exercise, rehabilitation, corticosteroid injections, hyaluronic acid and platelet-rich plasma: no relevant randomised controlled trial exists at this site. The reference reviews confirm it by omission: the one by Del Core and Koehler recommends starting with “activity modification, anti-inflammatories, hand therapy and corticosteroids”15, without being able to underpin that sequence with anything other than customary consensus.

So you have to tell the patient where what you are proposing comes from. Two indirect sources are legitimate and a third is not:

• Legitimate. The OARSI 2019 guidelines for knee, hip and polyarticular osteoarthritis, whose core treatments are education about the disease and a structured land-based exercise programme16. Those guidelines do not cover the elbow, and that has to be said: it is an extrapolation.
• Legitimate. Lindenhovius's randomised trial on post-traumatic elbow stiffness, which documents what can be hoped for from patient, prolonged range-of-motion work17. The stiffness mechanism there is capsular and not osteophytic, but the recovery timetable is instructive.
• Not legitimate. Transposing the strengthening protocols for epicondylar tendinopathies. The target tissue is not the same, nor is the objective, and a bony block does not respond to progressive loading the way a tendon does.

What rehabilitation actually aims at

Objective 1: preserve the useful arc. Loss of extension is the first to set in and the hardest to recover. Daily maintenance work, through range, without forcing against a hard stop, aims to delay the establishment of the flexion contracture. The marker to give the patient is not “you must straighten the arm completely” but the functional arc: 75 to 120° of flexion allows almost all everyday activities8, while knowing that contemporary activities, the telephone first among them, demand more9.

Objective 2: protect the ulnar nerve. Correct prolonged flexion positions, at night as at work, on the basis of the mechanism demonstrated on dynamic CT12. It is probably the measure with the best benefit-to-effort ratio in the whole arsenal.

Objective 3: reduce the impingement load. Analyse the occupational and sporting movements that take the elbow into terminal extension under load, and change them: carry close to the body rather than with the arm extended, bring loads nearer the trunk, break up the use of vibrating tools, adjust the height of the work surface.

Objective 4: maintain strength without provoking. Strengthening is done in the pain-free range, avoiding the ends of range. Triceps work in terminal extension against resistance is precisely what to avoid at the start, since it compresses the posterior impingement.

The table of modalities, with the level of evidence actually available

The ranking below applies the GRADE principles (nature of the study design, directness of the evidence, precision, risk of bias), to the precise question of primary elbow osteoarthritis. This is an editorial appraisal: no formal GRADE assessment has been published for this site, and no learned society has issued a guideline covering it.

When does surgery become necessary and what do you rehabilitate afterwards?

The physiotherapist does not set the indication for surgery, but is almost always the one who sees the patient long enough to spot the moment when it becomes reasonable, and the one to whom the aftermath is entrusted.

An unusual hierarchy: you remove before you replace

The relative preservation of the cartilage changes everything. The surgical reviews agree on a gradation that has no equivalent at the knee or the hip: debridement and osteocapsular arthroplasty are enough in most symptomatic elbow osteoarthritis, distraction arthroplasty has its place in the young person at an advanced stage, and total replacement is reserved for end-stage forms in the older, low-demand person19.

In practice, what the surgeon removes is what blocks: osteophytes of the olecranon and the coronoid, loose bodies, contracted capsule, with, in the technique known as Outerbridge-Kashiwagi, a fenestration of the olecranon fossa that restores the travel of the olecranon. Open or arthroscopic, the principle is the same.

What surgery delivers, in figures

The reference series is Antuña's: 46 elbows operated on with ulnohumeral arthroplasty between 1986 and 1996, reviewed at a mean of 80 months. The flexion-extension arc went from 79° to 101° ; at final follow-up, 35 elbows out of 46 (76 %) were painless or only slightly painful. The Mayo score was excellent for 26 elbows, good for 8, fair for 4 and poor for 83.

The British series by Phillips, with a mean follow-up of 75 months on 20 ulnohumeral arthroplasties, gives convergent results: 85 % good or excellent results on the DASH, 65 % on the Mayo score, a flexion contracture reduced by 10° on average and 20° of flexion gained. Of the 16 patients who were working at the time of the operation, 12 (75 %) returned to the same job20.

These gains in range, some twenty degrees, may seem modest. Set against the functional arc, they are not: going from 79° to 101° of arc means crossing the threshold that separates a hand that no longer reaches the face from a hand that gets back to it.

Open or arthroscopic: what the comparison shows

A systematic review of 18 papers totalling 625 patients and 634 elbows compared the two approaches. Both improve pain, the flexion-extension arc and functional scores. The open approach gains more in flexion; arthroscopy gives more consistent results. The price differs: complications 5.1 % open against 2.0 % arthroscopic, revisions 9.5 % against 5.6 %21.

An earlier controlled, non-randomised trial pointed the same way with a useful nuance: arthroscopic debridement relieved pain better, the Outerbridge-Kashiwagi technique improved flexion better22. The choice is therefore made on the patient's dominant complaint as much as on the surgeon's habit.

The particular risk of elbow arthroscopy deserves to be known and passed on, because it is specific to this joint: a systematic review of 52 papers reports 1.5 % to 11 % total complications and 1.26 % to 7.5 % nerve injuries, with obesity, age over 65, previous surgery and perioperative corticosteroid injections as risk factors18. No level I or II study exists on the subject.

Why total replacement remains the last card

A systematic review of 49 studies and 1,995 total elbow replacements measured what the operation gives depending on the indication. For rheumatoid arthritis and fractures, long-term survival is satisfactory. For osteoarthritis, the rates reported are 50 % complications and 11 % revisions23. Conversely, survival free of conversion to a replacement after simple debridement reaches 98 % at ten years24.

The arithmetic is quickly done for a man of fifty who works with his arms: you do not put a total elbow replacement in a patient who is going to ask it to carry loads. The review by Gramstad and Galatz puts it bluntly: prosthetic arthroplasty is rarely indicated in primary osteoarthritis and must be reserved for older, low-demand people in whom the other options have failed5.

Postoperative rehabilitation, and its one solid figure

No trial has compared rehabilitation protocols after debridement of the osteoarthritic elbow. What can be tied to evidence concerns stiffness: in Lindenhovius's randomised trial of 66 patients, the flexion arc improved by 29° at three months, 40° at six months and 47° at twelve months, with no difference between dynamic splinting and static progressive splinting17. The message the authors draw from it is explicitly this: patience is justified.

Two points of vigilance specific to this surgery should guide the first weeks:

• The ulnar nerve. Twenty-nine per cent of Antuña's patients reported ulnar symptoms after the operation, and six had to be reoperated on to decompress it. The authors identify the patients at risk: a preoperative loss of extension of more than 60°, flexion of less than 100°, and manipulation under anaesthesia in the early postoperative period, in whom they recommend preventive decompression3. A rapid gain in range puts the nerve under tension: watch for paraesthesiae at every session in the first fortnight, and raise the alarm without waiting.
• Manipulation under anaesthesia appears in that same series among the risk factors for ulnar dysfunction3. It is one more argument for favouring active, early and progressive work rather than the forced conquest of range.

What do concrete clinical cases teach us?

Three documented situations, taken as they were published. None is reconstructed for the sake of the example: the first two are series data, the third a case report with its identifier.

How do you apply all this from Monday morning?

A condition that is rare in the clinic, with no therapeutic trial and no guideline, calls for an approach written down in advance: otherwise every practitioner reinvents their own.

The first session, in six points

1. Name it. Tell the patient that this is ulnohumeral osteoarthritis, and that the word “omarthrosis” they may have read means the shoulder. The right vocabulary saves weeks of reading beside the point.
2. Measure. Bilateral goniometry, flexion-extension and pronation-supination, recorded in degrees. It is the reference against which everything else will be judged.
3. Qualify the end-feel. Hard stop or soft stop: the answer changes the session, the promise made to the patient and the prognosis.
4. Examine the ulnar nerve. Tinel, flexion-compression test, sensation in the last two fingers, pinch strength, Froment's sign, bulk of the first web space. Record it, so as to be able to compare.
5. Analyse the load. Occupation, vibrating tools, movements in terminal extension under load, position of the elbow at night and at the workstation.
6. Explain the natural history. That 85 % of the elbows in the original series ran a favourable course without surgery4, that the disease fluctuates over years, and that the physiotherapist's role is to maintain the arc and protect the nerve rather than to “make the osteoarthritis go away”.

What you follow, and at what interval

Who to refer to, and when

• A hand and upper limb surgeon, for repeated locking, a loss of arc that gets in the way of everyday activities, or above all ulnar signs that are progressing. Do not wait for conservative treatment to fail completely when the nerve is at stake: half the osteoarthritic elbows operated on for a neuropathy were at McGowan stage III14.
• A rheumatologist, for a recurrent effusion, early bilateral involvement, a young person, associated metacarpophalangeal osteoarthritis, or a doubt about a crystal or inflammatory arthropathy.
• An occupational physician, as soon as vibrating tools or repeated load carrying are involved. See the box below: this osteoarthritis appears in the schedule of occupational diseases.
• An occupational therapist, for adapting the workstation, the tools and everyday activities, particularly in the patient whose ulnar nerve is affected.

Frequently asked questions

Can elbow osteoarthritis go away?

No: the bony lesions do not regress. But the patient's question is really about the symptoms, and there the answer is more encouraging. In Doherty's series, 22 of the 26 affected elbows had a favourable clinical course without surgery4. And at population level, the disease is radiographically present in one adult over 50 in four while fewer than one in a hundred suffers from it7.

Do I have to stop sport or manual work?

Rarely stop it, often adapt it. What provokes is end of range under load and prolonged flexion. Break up the use of vibrating tools, bring loads nearer the body, avoid pushing with the arm extended and positions with the elbow bent and supported. The use of vibrating tools is the only occupational factor formally associated with advanced forms in the general population study7.

Why does my elbow wake me at night with pins and needles in my fingers?

Because sleeping with the arm bent brings the medial osteophytes against the ulnar nerve. Dynamic CT has shown it: their area inside the cubital tunnel goes from 9.0 mm² in extension to 24.7 mm² in full flexion12. Correcting the night-time position is the first treatment, and in mild to moderate forms, information alone proved as effective as a night splint in a randomised trial13.

Can an injection help me?

It is cited as an option by the reference reviews15, but no trial has evaluated it in elbow osteoarthritis. It must therefore be announced for what it is: an individual therapeutic trial, with no efficacy data specific to this site. Note also that perioperative corticosteroid injections are among the risk factors for complications of elbow arthroscopy18.

How long does it take to regain range?

Months, not weeks. The most informative randomised trial on elbow stiffness (post-traumatic, therefore with a capsular component) shows an arc gain of 29° at three months, 40° at six months and 47° at twelve months17. The authors conclude explicitly that patience is justified. In osteoarthritis, where part of the obstacle is bony, you have to be more cautious still in what you promise.

Am I going to be given a replacement?

It is very unlikely. At the elbow, the surgical strategy is first to remove the osteophytes and the loose bodies, and survival free of conversion to a replacement reaches 98 % at ten years after simple debridement24. Total replacement remains reserved for end-stage forms in the older, low-demand person: put in for osteoarthritis, it shows 50 % complications and 11 % revisions in the reference systematic review23.

My radiologist wrote “elbow osteoarthritis” when I have no pain: should I worry?

No. That is in fact the commonest situation: 25.2 % radiographic prevalence after 50 against 0.9 % symptomatic forms7. And an isolated coronoid process osteophyte is found in 36 % of control subjects of the same age6. An image is not a disease.

Can the physiotherapist really do anything, since there is no study?

Yes, provided they are clear about what is demonstrated and what is not. Two things rest on randomised trials: information and correction of provocative positions for the ulnar nerve13, and prolonged range-of-motion work on stiffness with a capsular component17. The rest (maintaining the arc, strengthening outside the ends of range, load management) is a matter of coherent clinical reasoning, which the patient has a right to know as such.

Bibliography

Every reference has been checked individually in PubMed: existence of the identifier, accuracy of the journal and the year, and reading of the abstract to check that the source does establish what is attributed to it.

1. Wülker N. Omarthrose. Orthopade 2000;29(10):909-916. Original German title “Omarthrose”, translated and indexed by PubMed under “[Omarthrosis]”, attached to shoulder osteoarthritis. PMID 11142910
2. Tauber M, Martetschläger F. Omarthrose – Pathogenese, Klassifikation, Diagnostik und Therapie. Orthopade 2019;48(9):795-808. Translated and indexed by PubMed under “[Shoulder Osteoarthritis — pathogenesis, classification, diagnostics and treatment]”. DOI 10.1007/s00132-019-03792-9 — PMID 31432200
3. Antuña SA, Morrey BF, Adams RA, O'Driscoll SW. Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications. J Bone Joint Surg Am 2002;84(12):2168-2173. DOI 10.2106/00004623-200212000-00007 — PMID 12473704
4. Doherty M, Preston B. Primary osteoarthritis of the elbow. Ann Rheum Dis 1989;48(9):743-747. DOI 10.1136/ard.48.9.743 — PMID 2802795
5. Gramstad GD, Galatz LM. Management of elbow osteoarthritis. J Bone Joint Surg Am 2006;88(2):421-430. DOI 10.2106/JBJS.E.00568 — PMID 16452758
6. Dalal S, Bull M, Stanley D. Radiographic changes at the elbow in primary osteoarthritis: a comparison with normal aging of the elbow joint. J Shoulder Elbow Surg 2007;16(3):358-361. DOI 10.1016/j.jse.2006.08.005 — PMID 17188910
7. Nakayama K, Kato H, Ikegami S et al. Prevalence and associated factors of primary elbow osteoarthritis in the Japanese general elderly population: a Japanese cohort survey randomly sampled from a basic resident registry. J Shoulder Elbow Surg 2022;31(1):123-132. DOI 10.1016/j.jse.2021.07.015 — PMID 34454037
8. Vasen AP, Lacey SH, Keith MW, Shaffer JW. Functional range of motion of the elbow. J Hand Surg Am 1995;20(2):288-292. DOI 10.1016/S0363-5023(05)80028-0 — PMID 7775772
9. Sardelli M, Tashjian RZ, MacWilliams BA. Functional elbow range of motion for contemporary tasks. J Bone Joint Surg Am 2011;93(5):471-477. DOI 10.2106/JBJS.I.01633 — PMID 21368079
10. Lee HI, Koh KH, Kim JP et al. Prominent synovial plicae in radiocapitellar joints as a potential cause of lateral elbow pain: clinico-radiologic correlation. J Shoulder Elbow Surg 2018;27(8):1349-1356. DOI 10.1016/j.jse.2018.04.024 — PMID 30016689
11. Kwak JM, Kholinne E, Sun Y et al. Intraobserver and interobserver reliability of the computed tomography-based radiographic classification of primary elbow osteoarthritis: comparison with plain radiograph-based classification and clinical assessment. Osteoarthritis Cartilage 2019;27(7):1057-1063. DOI 10.1016/j.joca.2019.03.004 — PMID 30922981
12. Kawanishi Y, Miyake J, Omori S et al. The association between cubital tunnel morphology and ulnar neuropathy in patients with elbow osteoarthritis. J Shoulder Elbow Surg 2014;23(7):938-945. DOI 10.1016/j.jse.2014.01.047 — PMID 24739797
13. Svernlöv B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Eur Vol 2009;34(2):201-207. DOI 10.1177/1753193408098480 — PMID 19282413
14. Sato N, Okita G, Uchiyama S et al. Ulnar neuropathy at the elbow in 413 Japanese patients: an assessment of pathological elbow lesions and neurological severity. J Orthop Sci 2020;25(2):235-240. DOI 10.1016/j.jos.2019.03.018 — PMID 31005383
15. Del Core MA, Koehler D. Elbow Arthritis. J Hand Surg Am 2023;48(6):603-611. DOI 10.1016/j.jhsa.2022.12.014 — PMID 36759236
16. Bannuru RR, Osani MC, Vaysbrot EE et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage 2019;27(11):1578-1589. DOI 10.1016/j.joca.2019.06.011 — PMID 31278997. These guidelines do not cover the elbow.
17. Lindenhovius AL, Doornberg JN, Brouwer KM et al. A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. J Bone Joint Surg Am 2012;94(8):694-700. DOI 10.2106/JBJS.J.01761 — PMID 22517385
18. Tsenkov T, Dimitrov N. A systematic review of elbow arthroscopy complications: complications, risk factors, and safety tips. Int Orthop 2022;46(5):1073-1083. DOI 10.1007/s00264-022-05320-5 — PMID 35106672
19. Kwak JM, Jeon IH. Surgical management for primary osteoarthritis of the elbow. J Orthop Surg (Hong Kong) 2021;29(1):2309499020988174. DOI 10.1177/2309499020988174 — PMID 33570019
20. Phillips NJ, Ali A, Stanley D. Treatment of primary degenerative arthritis of the elbow by ulnohumeral arthroplasty: a long-term follow-up. J Bone Joint Surg Br 2003;85(3):347-350. DOI 10.1302/0301-620x.85b3.13201 — PMID 12729106
21. Kim DM, Han M, Jeon IH et al. Range-of-motion improvement and complication rate in open and arthroscopic osteocapsular arthroplasty for primary osteoarthritis of the elbow: a systematic review. Int Orthop 2020;44(2):329-339. DOI 10.1007/s00264-019-04458-z — PMID 31834444
22. Cohen AP, Redden JF, Stanley D. Treatment of osteoarthritis of the elbow: a comparison of open and arthroscopic debridement. Arthroscopy 2000;16(7):701-706. DOI 10.1053/jars.2000.8952 — PMID 11027753
23. Samdanis V, Manoharan G, Jordan RW et al. Indications and outcome in total elbow arthroplasty: a systematic review. Shoulder Elbow 2020;12(5):353-361. DOI 10.1177/1758573219873001 — PMID 33093874
24. Tat J, Vicente M, Hall J. Long-term survivorship of open débridement and débridement arthroplasty for elbow arthritis: a retrospective chart review. J Shoulder Elbow Surg 2022;31(8):1571-1580. DOI 10.1016/j.jse.2022.01.138 — PMID 35189372
25. Institut national de recherche et de sécurité (INRS). Schedule No. 69 of the general scheme: conditions caused by vibration and shock transmitted by certain machine tools, tools and objects and by repeated impacts of the heel of the hand on fixed elements. Database of occupational disease schedules. Consult the schedule
26. Spalkit S, Sinha A, Prakash M, Tripathy S. Primary elbow osteoarthritis presenting as ulnar nerve palsy with claw hand. BMJ Case Rep 2021;14(5):e242773. DOI 10.1136/bcr-2021-242773 — PMID 33958369