An uncommon cause of elbow pain, cubital bursitis is being seen in clinical practice more frequently because of the increasing number of people using exercise equipment. The cubital bursa lies in the anterior aspect of the elbow and produces anterior elbow pain when inflamed. Also known as the bicipitoradial bursa, the cubital bursa may exist as a single bursal sac or in some patients may exist as a multisegmented series of sacs that may be loculated.
The cubital bursa is vulnerable to injury from acute trauma and repeated microtrauma. Acute injuries frequently take the form of direct trauma to the anterior aspect of the elbow. Repetitive movements of the elbow, including repeated biceps-strengthening exercises and throwing of javelins and baseballs, may result in inflammation and swelling of the cubital bursa. Gout or rheumatoid arthritis rarely may precipitate acute cubital bursitis. If the inflammation of the cubital bursa becomes chronic, calcification of the bursa may occur.
What are the Symptoms of cubital bursitis?
A patient with cubital bursitis frequently reports pain and swelling with any movement of the elbow. The pain is localized to the cubital area, with referred pain often noted in the forearm and hand.
Physical examination reveals point tenderness in the anterior aspect of the elbow over the cubital bursa and swelling of the bursa. Passive extension and resisted flexion of the elbow reproduce the pain, as does any pressure over the bursa.
How is cubital bursitis diagnosed?
The diagnosis of cubital bursitis usually can be made on clinical grounds and easily confirmed with ultrasound imaging. Plain radiographs of the elbow may reveal calcification of the bursa and associated structures consistent with chronic inflammation. Magnetic resonance imaging (MRI) is indicated if the patient is thought to have a joint mouse or primary pathological process of the elbow joint. Laboratory testing to rule out hyperuricemia and collagen-vascular disease also should be considered in appropriate patients.
Electromyography and nerve conduction velocity testing rule out nerve entrapment syndromes at the elbow. Injection of the cubital bursa with a local anesthetic and steroid is a diagnostic and therapeutic maneuver.
The most common causes of elbow pain are arthritis of the elbow joint, tennis elbow, golfer’s elbow, and olecranon bursitis. Arthritis of the elbow joint may mimic cubital bursitis because both painful conditions are associated with movement of the joint. The anterior point tenderness seen in cubital bursitis is absent in arthritis of the elbow, however.
Tennis elbow and golfer’s elbow are distinct clinical entities that should not be confused with cubital bursitis because the point tenderness seen in these painful conditions is identified over the lateral and medial epicondyles, rather than at the midline, as is seen with cubital bursitis.
Acute gout affecting the elbow manifests as a diffuse acute inflammatory condition that may be difficult to distinguish from infection of the joint, rather than as a localized musculoskeletal pain syndrome.
Initial treatment of the pain and functional disability associated with cubital bursitis should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold also may be beneficial.
The repetitive movements that incite the syndrome should be avoided. For patients who do not respond to these treatment modalities, injection of the cubital bursa with a local anesthetic and steroid may be a reasonable next step.
To inject the cubital bursa, the patient is placed in the supine position, with the arm fully adducted at the patient’s side, elbow extended, and the dorsum of the hand resting on a folded towel. Using a 5-mL sterile syringe, 2 mL of local anesthetic and 40 mg of methylprednisolone is drawn.
After sterile preparation of skin overlying the anterior aspect of the joint, the clinician identifies the pulsations of the brachial artery at the crease of the elbow. After preparation of the skin with antiseptic solution, a 25-gauge, 1-inch needle is inserted just lateral to the brachial artery at the crease and slowly advanced in a slightly medial and cephalad trajectory through the skin and subcutaneous tissues. If bone is encountered, the needle is withdrawn back into the subcutaneous tissue. The contents of the syringe are gently injected.
Little resistance to injection should be felt. If resistance is encountered, the needle is probably in the tendon and should be withdrawn back until the injection proceeds without significant resistance.
The needle is removed, and a sterile pressure dressing and ice pack are placed at the injection site. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.
The major complication associated with cubital diagnosis is misdiagnosis.
Failure of the clinician to recognize an acute inflammatory or infectious arthritis of the elbow may result in permanent damage to the joint and chronic pain and functional disability. Injection of the cubital bursa at the elbow is a safe block, with the major complications being inadvertent intravascular injection and persistent paresthesia secondary to needle trauma to the median nerve.
This technique can be performed safely in the presence of anticoagulation by using a 25- or 41-gauge needle, although at increased risk for hematoma, if the clinical situation dictates a favorable risk-to-benefit ratio. These complications can be decreased if manual pressure is applied to the area of the block immediately after injection. Application of cold packs for 20-minute periods after the block also decreases the amount of post-procedure pain and bleeding.
Bursae are formed from synovial sacs whose purpose is to allow easy sliding of muscles and tendons across one another at areas of repeated movement.
These synovial sacs are lined with a synovial membrane invested with a network of blood vessels that secrete synovial fluid. Inflammation of the bursa results in an increase in the production of synovial fluid with swelling of the bursal sac.
With overuse or misuse, these bursae may become inflamed, enlarged, and, rarely, infected. Coexistent tendinitis and epicondylitis also may contribute to elbow pain and may require additional treatment with more localized injection of local anesthetic and depot steroid.
This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected, in particular avoiding the median nerve by keeping the needle lateral to the brachial artery.
Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator.
The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection.
The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for elbow pain.
Vigorous exercises should be avoided because they exacerbate the patient’s symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.