Peer-review started: November 11, 2017
First decision: December 11, 2017
Revised: December 21, 2017
Accepted: March 1, 2018
Article in press: March 2, 2018
Published online: April 18, 2018
To develop practical guidelines for diagnosis and treatment of the painful snapping elbow syndrome (SE).
Clinical studies were searched in the databases PubMed and Scopus for the phrases “SE”, “snapping triceps”, “snapping ulnar nerve” and “snapping annular ligament”. A total of 36 relevant studies were identified. From these we extracted information about number of patients, diagnostic methods, patho-anatomical findings, treatments and outcomes. Practical guidelines for diagnosis and treatment of SE were developed based on analysis of the data. We present two illustrative patient cases-one with intra-articular pathology and one with extra-articular pathology.
Snapping is audible, palpable and often visible. It has a lateral (intra-articular) or medial (extra-articular) pathology. Snapping over the medial humeral epicondyle is caused by dislocation of the ulnar nerve or a part of the triceps tendon, and is demonstrated by dynamic ultrasonography. Treatment is by open surgery. Lateral snapping over the radial head has an intra-articular pathology: A synovial plica, a torn annular ligament or a meniscus-like remnant from the foetal elbow. Pathology can be visualized by conventional arthrography, magnetic resonance (MR) arthrography, high resolution magnetic resonance imaging (MRI) and arthroscopy, while conventional MRI and radiographs often turn out normal. Treatment is by arthroscopic or eventual open resection. Early surgical intervention is recommended as the snapping can damage the ulnar nerve (medial) or the intra-articular cartilage (lateral). If medial snapping only occurs during repeated or loaded extension/flexion of the elbow (in sports or work) it may be treated by reduction of these activities. Differential diagnoses are loose bodies (which can be visualized by radiographs) and postero-lateral instability (demonstrates by clinical examination). An algorithm for diagnosis and treatment is suggested.
The primary step is establishment of laterality. From this follows relevant diagnostic measures and treatment as defined in this guideline.
Core tip: Elbow snapping is medial or lateral. Medial snapping is caused by dislocation of the ulnar nerve or a part of the triceps tendon, demonstrated clinically and by dynamic ultrasonography. Treatment is transposition of the nerve and/or resection of the snapping tendon. Lateral snapping is intra-articular by a synovial plica, a torn annular ligament or a meniscus-like remnant from the foetal elbow, demonstrated by arthrography, magnetic resonance arthrography, high resolution magnetic resonance imaging or arthroscopy. Treatment is arthroscopic resection. Early surgical intervention is recommended to reduce tissue damage. Medial snapping promoted by repeated, loaded activities might be treated by activity reduction.