Rheumatoid arthritis is an autoimmune disorder that affects the synovial membranes and cartilage around the joints. Although rheumatoid arthritis more commonly affects small joints, it also affects some major joints and can cause a lot of discomfort. Rheumatoid arthritis of the elbow can be noticed quite frequently in clinical practice. Elbow rheumatoid arthritis can be painful and can cause significant disturbances in performing daily activities. Elbow rheumatoid arthritis is usually seen affecting both elbows.
Rheumatoid arthritis is chronic inflammatory condition that affects the joints causing joint pain, swelling and difficulty in movement of the affected joints. Elbow rheumatoid arthritis may be associated with swelling and pain in other joints as well. While many tissues are affected in rheumatoid arthritis, joints are commonly involved. Elbow rheumatoid arthritis is common, probably because elbow joints is one the most used joints of the hand. It being a hinge joint, it is involved in performing repetitive and weight bearing functions of hands.
Causes of Elbow Rheumatoid Arthritis
People who are more susceptible, or those who have certain types of genes are usually exposed to some triggers like infection, injury or some environmental factors that can trigger the autoimmune process of rheumatoid arthritis. In such cases, due to the triggers, the body gets into a protective mode and an inflammatory process begins.
While the inflammation is aimed to protect the body, in persons prone to autoimmune conditions and rheumatoid arthritis, the inflammation also begins to attack healthy cells and joints of the body. This is when certain joints may get affected and the elbow joint is one of them. Elbow rheumatoid arthritis is usually a result of such inflammatory process and may also affect other joints. It leads to pain, swelling and sometimes redness of the elbow joint.
Risk Factors of Elbow Rheumatoid Arthritis
While the exact cause is not clearly understood, certain factors have been identified as risk factors for elbow rheumatoid arthritis. These include,
- People with certain types of genes, like specific variants of human leucocyte antigen (HLA) may be more susceptible to rheumatoid arthritis than those with other variants of genes. Genes may not cause but can influence the risk of a person. Although, some people with certain genes known to increase the risk of elbow rheumatoid arthritis never develop the condition at all.
- Women in general are believed to be more susceptible to elbow rheumatoid arthritis. Gender plays an important role and being a woman increases the risk of elbow rheumatoid arthritis by almost three times.
- Usually middle aged people, those involved in manual labor involving the hands or repetitive movements of the hands and having factors and disposition towards elbow rheumatoid arthritis, can be at increased risk of damage to the joints.
- Certain studies have shown an association of low vitamin D levels with rheumatoid arthritis. Vitamin D may be related to disease activity in elbow rheumatoid arthritis, levels of inflammatory proteins and loss of bone in people with rheumatoid arthritis. Research studies suggests that vitamin D plays an important role in regulating immune system, although more clarity is required on the same.
- Elbow rheumatoid arthritis is more common in smokers than non-smokers. The risk of elbow rheumatoid arthritis can increase by three times in people having a history of smoking. It is also believed that elbow rheumatoid arthritis may be more severe, when it occurs, in case of smokers.
- Persons who are more prone to inflammatory conditions, some susceptible people who have been exposed to inflammatory process or after some viral fevers. Certain infections affecting the gut flora are also sometimes believed to trigger initiation or worsening of symptoms of elbow rheumatoid arthritis. However, this factor may need more research.
- Stress is also found to be an associated factor that can influence elbow rheumatoid arthritis. Inflammation in elbow rheumatoid arthritis can be due to many trigger factors that influence the release of certain proteins and stress is one such factors that can cause release of those inflammatory proteins. Situations that increase stress are also known to cause increase in the pain in elbow rheumatoid arthritis.
Symptoms of Elbow Rheumatoid Arthritis
Symptoms of elbow rheumatoid arthritis can be annoying, disturbing and very debilitating at times. Some of the common symptoms experienced by people with elbow rheumatoid arthritis include,
Elbow joint pain is the commonest symptom and complaint among people suffering from elbow rheumatoid arthritis. While, elbow rheumatoid arthritis is a chronic condition, when it begins, in the initial stages, the symptoms of pain in the elbow joint can be mild to moderate and may be bearable with slight periods of discomfort. The pain in hands and elbows gradually increases. As the disease progresses and becomes chronic in nature, the symptoms of pain also worsens and may become more severe, constant and cause more discomfort in performing activities. Pain may be better at rest and usually worsens with activities. Pain symptoms of elbow rheumatoid arthritis is usually more in the morning, associated with stiffness and the initial movements are more painful, but later it is better. However, over doing activities, overwork and repetitive movements of the elbows and hands again worsens the pain.
In elbow rheumatoid arthritis, the muscles around the elbow joint are often painful, stiff and tensed. Symptoms of muscle spasm make it more difficult to move the joint and tensed muscles also make it difficult to perform activities of the hand. Symptoms of weakness of the hands can also result due to tensed muscles of the elbow and hand, which can make it painful and difficult to hold objects, manipulate things in the hands and work with weights. Usually rest allows the muscles to relax and may provide some comfort, however, muscle cramps can occur even when the joint is at rest.
Joint stiffness is a common symptom in elbow rheumatoid arthritis. Stiffness is more common in the morning and may last for more than an hour unlike the other forms of arthritis, in which it settles down faster. Symptoms of stiffness in the elbow joint can make it difficult and painful to move, bend and extend. Muscles spasm is often associated with it and restricted movements due to pain add to the stiffness of the joint.
The elbow joint affected with rheumatoid arthritis is often swollen and stiff. It may also appear red and may be warm to touch. Joint complaints are often present on both sides affecting both left and right elbow or may affect the joint alternately one after the other.
Joint movements may be restricted and elbow movements may be painful. Bending or fully extending the hand, which requires folding at the elbow joint is very painful and hence restricted. Lifting weights in the hands may cause more discomfort. While rheumatoid arthritis affects other joints of the hands and can cause deformities of the fingers, tenderness and swelling at wrists, it can cause pain and deformities at the elbow in elbow rheumatoid arthritis.
Flexibility of the elbow joint is affected, which makes movements difficult. When this continues it can affect the functioning of the elbow joint and also affect the surrounding muscles in the longer run.
Rheumatoid Nodule Symptoms of Elbow Rheumatoid Arthritis
In progressive conditions, nodules, bunions and lumps may develop around the elbow. The elbow joint may get deformed and contractures may develop. In chronic cases, with greater degrees of deformities, swan neck deformities of the fingers develop, which make is difficult to use the fingers and hands.
In many cases of elbow rheumatoid arthritis, a nerve passing through the hand can get compressed, causing more symptoms. In elbow rheumatoid arthritis, the nerve passing through the arms can also get affected and cause numbness, tingling sensation in the hand. It can sometimes even affect the performance and functioning of the hands, making it feel weak with lack of co-ordination.
Rheumatoid arthritis being a chronic systemic illness, it can also affect other joints and organs of the body. This can include inflammation in the white part of the eyes causing vision problems, the lungs causing dry cough and breathlessness, enlarged spleen or sometimes dryness of eyes, mouth and other mucus membranes.
Other Symptoms of Elbow Rheumatoid Arthritis
Other symptoms associated with elbow rheumatoid arthritis include mild fever coming off and on, feeling of warmth in the body or a chilly feeling, decreased appetite, fatigue or lack of energy, malaise and a general feeling of being unwell. A tired feeling, inability to move, particularly the affected joint, in this, the elbow joint and generalized weakness may be noted. Weakness may also be noted because of anemia, which is due to low hemoglobin counts.
Diagnosis of Elbow Rheumatoid Arthritis
Rheumatoid arthritis is diagnosed with the help of proper history taking, clinical examination and certain investigations. History is taken to find the age, type of occupation, any history of injuries or trauma, family history of the patient and to assess other predisposing factors. Presence of other medical illnesses, any medications that are being taken, history of fevers, infections, surgeries, presence of morning stiffness, joint pain and other medical details are noted.
Clinical examination of the elbow joint and that of the hand can reveal signs of inflamed joints. Your physician may look for signs of swelling, redness, warmth in the elbow joints. Elbows on both sides are examined for any signs of inflammation, joint function and presence of nodules. Examination may reveal painful movement of the elbow joint, inability to fully extend or bend the elbow as in joint contractures, presence of nodules or lumps under the skin over the joint and joint deformities.
Elbow rheumatoid arthritis can be diagnosed when certain points as laid down in the criteria of diagnosis are met. Some investigations that may be performed to confirm the diagnosis of Elbow Rheumatoid Arthritis include:
Blood Tests to Diagnose Elbow Rheumatoid Arthritis
Blood investigations include detecting the presence of inflammation with Erythrocyte Sedimentation Rate (ESR) and C - reactive protein (CRP) test. Complete Blood Count (CBC) is done to find the blood picture, detect anemia and rule out any findings related to infection.
Rheumatoid specific tests include
- Rheumatoid Factor (RF) – it is done to detect the antibodies present in some people with elbow rheumatoid arthritis. However, it is shown positive only in 70 to 90 per cent of the affected individuals and may also show positive in people who may never have rheumatoid arthritis. Hence it is considered as a non-specific test but may help in understanding the severity of the disease and its progression. People with symptoms of elbow rheumatoid arthritis testing negative in RF test may have less severe symptoms.
- Anti-CCP – This test is specific and helps to detect the presence of antibodies in almost all cases of elbow rheumatoid arthritis, even if RF test has been negative. It also helps to detect subclinical cases of elbow rheumatoid arthritis and gives an idea of the severity of the disease progression.
- ANA – This is antinuclear antibody test, which is done to detect the presence of antibodies, which tests positive in autoimmune disorders.
X-ray to Diagnose Elbow Rheumatoid Arthritis
X-rays of the elbow joint and those of the other affected joints are helpful in detecting the bony changes caused to the joint due to rheumatoid arthritis. Joint space is often narrowed, which suggest deterioration of the joint, while the joint space may be widened if there is excess accumulation of the synovial fluid. Joint may show damage and erosive changes.
MRI for Elbow Rheumatoid Arthritis
MRI helps to detect the changes in soft tissues surrounding the elbow joint and nearby structures, injuries, vascular changes or any damage to the nerves. Elbow rheumatoid arthritis may show damage to the articulating cartilage, excess accumulation of synovial fluid in the joint space and thickening of synovial membrane may be noted.
Elbow Joint Fluid Analysis
Joint aspiration, also known as arthrocentesis, is a procedure done when there is excessive accumulation of synovial fluid in the elbow joint, which is evident from the joint swelling. Joint aspiration of the swollen elbow joint helps to drain excess fluid, which releases pressure and relieves pain in the joint, thus improving the joint movement.
The fluid aspirated is sent for laboratory analysis which helps to detect the presence of certain factors, which can support the diagnosis. Fluid analysis helps to rule out a condition called gout, in which uric acid crystals are found to be present in the synovial fluid; pseudo gout, in which calcium pyrophosphate crystals are found; tuberculosis in which the specific bacteria are found; septic arthritis, in which bacteria and pus cells are found and injury, in which red blood cells may be found in the synovial fluid.
Joint aspiration is also used as a part of the treatment for elbow rheumatoid arthritis to reduce pain and swelling.
Elbow Joint Arthroscopy to Diagnose Elbow Rheumatoid Arthritis
Arthroscopy is a procedure performed for diagnostic and therapeutic purposes. A thin tube with a camera is inserted into the elbow joint through small incisions made around the joint area. It enables visualizing of the elbow joint and its structures; cartilages, tendons, ligaments, muscles and synovial membrane can be viewed to assess the damage. It helps in analyzing the condition of the tissues and helps in diagnosing rheumatoid arthritis condition and also guides in surgical treatment procedure.
Treatment of Elbow Rheumatoid Arthritis
Treatment of elbow rheumatoid arthritis primarily includes non-surgical treatment and medical management along with rehabilitation.
Non-Surgical Treatment of Elbow Rheumatoid Arthritis:
Medical Management of Elbow Rheumatoid Arthritis-
Medications to reduce elbow pain and swelling are given for managing elbow rheumatoid arthritis. Non-steroidal anti-inflammatory medicines help to control joint inflammation, reduce pain and swelling, thus improving joint movements. Muscle relaxants may be given to reduce muscle spasms and pain. Oral steroid medications may be considered for chronic elbow pain in elbow rheumatoid arthritis.
- Drugs that help to modify the disease and control its progression, known as DMARDs (Disease Modifying Anti-Rheumatoid Drugs) are considered by the treating physician.
- Immunosuppressant drugs that can help to control the overactive immune system may be given, as appropriate.
- Rheumatoid arthritis is known to cause an increased secretion of Tumor Necrosis Factor, which triggers inflammation in the elbow joint. Medications that control this secretion and limit the inflammation, pain and swelling in the elbow joint may be considered.
- Nutritional and dietary supplements like vitamin D, calcium, vitamin B12 may be considered, if found appropriate.
Patients with elbow rheumatoid arthritis are advised to avoid activities that trigger elbow pain. Lifting heavy weights, repeated hand activities or sports may be restricted for some time. Sports, particularly racquet sports, those involving forceful use of hands, bending of elbows and contact sports need to be avoided. Adequate rest between periods of activities is important.
Patients may be advised to modify certain activities involving the use of elbow and hands to ensure less strain on the elbow joint. Use of supports, modified chairs, tables and desktops to suit the needs of the individual can help in reducing the elbow pain in patients with elbow rheumatoid arthritis.
Physical Therapy to Treat Elbow Rheumatoid Arthritis:
Physical therapy treatment for elbow rheumatoid arthritis can help to reduce pain, improve joint function and range of movements. It also aims at strengthening muscles to maintain joint stability and effective elbow functioning, preventing further joint damage and injuries.
Cold compresses or ice packs can be applied to the elbow joint in case of acute inflammation, swelling and pain in elbow. Hot compresses may be applied to the elbow joint area when muscles are tensed or alternate hot and cold compresses can also be applied.
Braces that help to support the elbow joint, compression bandages for limited periods and elbow joint supports can be worn as appropriate to ease activities while the joint remains supported.
Exercises for Elbow Rheumatoid Arthritis:
Elbow rheumatoid arthritis is a progressive condition, which can be managed by limiting activities that bother the elbow joint and preparing the supporting muscles to function optimally. Range of motion exercises that enable bending and extending the elbow joint to its maximum capacity without causing pain should be performed as simple movement exercises. Light weight training can help to build stronger muscles that can support the elbow joint better.
Interventional Treatment for Elbow Rheumatoid Arthritis
Interventional treatment for elbow rheumatoid arthritis includes:
- Injection of corticosteroids into the elbow joint to reduce inflammation in the joint and tissues.
- Nerve block may be considered useful for elbow rheumatoid arthritis in cases that do not respond to medical treatment. Sometimes it may be used as a diagnostic procedure, as an adjuvant to physical therapy and help to improve joint function.
Surgical Treatment for Elbow Rheumatoid Arthritis
Surgical treatment for elbow rheumatoid arthritis includes:
- Arthroscopic surgery for elbow rheumatoid arthritis may be performed as a diagnostic as well as treatment modality. In this, a tiny camera with surgical instruments is inserted into the elbow joint. It allows visualization of the joint structures and any treatment required can also be performed during this procedure.
- Elbow joint replacement surgery may be considered in some cases. In this, the elbow is replaced with an artificial joint similar to the hinge joint of the elbow, which can perform similar functions. This surgery is often followed by physical therapy for rehabilitation.
Disease Course of Elbow Rheumatoid Arthritis
Elbow rheumatoid arthritis is presented differently in different individuals and will mostly run a variable course depending on the severity of the disease. Elbow rheumatoid arthritis may show up symptoms for some time, go into remission, again show up as flare-ups and again subside. For some it may steadily continue, depending on early diagnosis and treatment while in some it may steadily worsen until there are bony deformities and significant changes in the appearance.
Long term consequences of elbow rheumatoid arthritis include damage to the joints and cartilage from persistent or repeated inflammation. The elbow joint and other affected joints can get damaged or deformed, which is irreversible after a longer period.
Treatment for Elbow rheumatoid arthritis plays a significant role in managing the symptoms and controlling progression of the disease or joint damage. With proper diagnosis and early treatment with disease modifying drugs, the disability due to Elbow rheumatoid arthritis can be minimized. Treatment choices for Elbow rheumatoid arthritis may vary depending on the person and other existing medical illnesses or other treatments they are undergoing. Some treatment options may also involve surgical correction or elbow joint replacement. Physical therapy and weight management almost always helps in all the cases of Elbow rheumatoid arthritis.
Pregnant ladies may see a period of remission during their pregnancy but within few months of childbirth there are chances of flare-ups of elbow rheumatoid arthritis.