PHYSICAL THERAPY MANAGEMENT OF TUBERCULOUS ARTHRITIS OF

THE ELBOW

Amit Murli Patel BPT, MPT-Orthopaedics*

ABSTRACT
BACKGROUND AND PURPOSE: Tuberculous arthritis is not commonly seen by physical therapists in India.
The purpose of this case report is to describe a case of tuberculous arthritis of the elbow. CASE
DESCRIPTION: The patient was a 35-year-old man referred for physical therapy evaluation and intervention
for chronic elbow pain. After an evaluation and a trial of physical therapy, the patient was referred back to a
primary care provider for additional tests to rule out systemic pathology. An open debridement of the synovium
and a biopsy of the capitellum and radial head was positive for acid-fast bacilli, which was later identified as
Mycobacterium tuberculosis. OUTCOMES: The patient was placed on a 4-drug antituberculosis regimen that
resolved all patient complaints and restored full elbow function. DISCUSSION: Tuberculous arthritis has
characteristic findings during examination and in diagnostic tests. Although tuberculous arthritis is uncommon, it
should be considered when patients have chronic or vague musculoskeletal complaints.

KEYWORDS: Tuberculous arthritis, Elbow arthritis, Knee effusion, Physical therapy managemet.

INTRODUCTION of the bones or joints of the body but is usually

Tuberculous arthritis occurs in approximately confined to one location, with 10% of tuberculous
5
1% to 5% of all patients with TB. It can involve any arthritis in the upper extremity6 and up to 8% in the

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 Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013
elbow.7 The sites most frequently affected are the
spine, sacroiliac, hip, and knee.8 Because weight-
bearing joints are the most frequently involved,
some authors5 suspect that trauma plays a role in the
pathogenesis of bone and joint TB.
Tuberculous arthritis is usually secondary to
hematogenous dissemination of tubercle bacilli from
1,8
a primary pulmonary lesion. Less commonly, it
can occur by spreading through the lymphatic
8
system or into adjacent tissue. Joints can become
infected by activation of dormant lymphatic or blood
stream areas of morbidity.9 In the long bones, TB
originates in the epiphysis in response to
mycobacteria and causes tubercle formation in the
marrow, with secondary infection of the trabeculae.8
The joint synovium responds to the
mycobacteria by developing an inflammatory
reaction, followed by formation of granulation
tissue. The pannus of granulation tissue formed then
begins to erode and destroy cartilage and eventually
5
bone, leading to demineralization. Because TB is
not a pyogenic infection, proteolytic enzymes, which
destroy peripheral cartilage, are not produced. The
joint space, therefore, is preserved for a considerable
time. If allowed to progress without treatment,
however, abscesses may develop in the surrounding
5
tissue.
Asaka et al10 described an abscess around the
elbow joint and between the biceps brachii and
brachioradialis muscles in a patient with tuberculous
arthritis.
In India, the most common early symptoms of
tuberculous arthritis are insidious onset of local pain
and swelling around the joint. In advanced cases,
which occur primarily in countries where TB is more
common and often is allowed to progress, sinuses
17
and joint deformities may develop.8 The
granulomatous process eventually imparts a “boggy”
or “doughy” feeling to the joint and periarticular
structures.9 Localized pain may precede other
symptoms of inflammation or radiograph changes by
weeks or even months.9 Other symptoms include
joint stiffness, reduced range of motion, fever, night
sweats, or weight loss.8,11 Because of the rarity of
tubercular infections of joints and because the usual
signs of inflammation (eg, erythema, heat) do not
occur, diagnosis of tuberculous arthritis affecting
peripheral joints is often delayed.8,11 When diagnosis
is not timely, joint contractures and limited
functional improvement after treatment are more
likely to occur, especially if bone and articular
cartilage are destroyed.12 Authors have reported
diagnoses of olecranon bursitis,13,14 tennis elbow,15
and pyogenic arthritis, osteomyelitis, neopathic
articular disease, and neoplasm before an eventual
diagnosis of tuberculous arthritis.
The purpose of this case report is to describe a
case of tuberculous arthritis of the elbow. The
patient described in this report had numerous
previous diagnoses for chronic elbow pain and was
ultimately referred for physical therapy evaluation
and intervention.
CASE DESCRIPTION
Patient: The patient was a 35-year-old, Athlete,
right-hand–dominant man who reported
experiencing intermittent sharp pain with insidious
onset and swelling in his left elbow 10 months
previously. He reported that his symptoms were
aggravated with movements of the elbow and eased
with rest. There was no known history of left elbow
or arm injury. The patient did not report any recent
 ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

fever or weight loss, and he said that he was healthy

except for the elbow pain. He stated that he had been
an intravenous (IV) drug user for 5 years, during
which he used his left arm for injections, but he said
he had not used any IV drugs for 2 years prior to the
physical therapist examination and evaluation. The
patient was not working at the time of the
examination His goal was to play Tennis pain-free.
The patient had a 10-month history of evaluations
for left elbow pain, swelling, and decreased range of
motion. The patient had been diagnosed with lateral
epicondylitis, degenerative joint disease, synovitis,
and tenosynovitis by 3 different physicians at 3 Figure 1. Anteroposterior radiograph of elbow
different facilities, and he had been treated with showing cyst-like structures (arrows).
nonsteroidal anti-inflammatory drugs. After 10
months, an orthopedic surgeon examined the patient.
The physician referred the patient to the physical
therapist for examination, evaluation, and
intervention for chronic elbow pain and ordered
electromyography (EMG) and nerve conduction
studies (NCS).
Three series of elbow radiographs were taken
prior to the physical therapy evaluation. Each of the
Figure 2. Lateral radiograph of elbow showing a
3 series of elbow radiographs was taken at a posterior fat-pad sign (arrows)
different facility
The third radiographic series 4 months before
The first series, taken 10 months previously,
the physical therapy evaluation revealed a posterior
showed no noticeable abnormalities. Two months
fat-pad sign, which the radiologist suggested may
later, a second series was negative for fracture, but
have been created by joint effusion or an occult
there were cyst-like structures and mild exostotic
fracture (Fig. 2). Normally, the posterior fat pad,
bone formation in the region of the lateral
which lies deep in the olecranon fossa, is not visible
epicondyle, and there was another cyst-like structure
on the lateral view. It can be displaced out of the
in the proximal shaft of the ulna (Fig. 1). The lateral
fossa by blood or synovial fluid within the joint, thus
view showed exostotic bone formation at the
becoming visible.17 The radiologist who interpreted
anterior distal humerus, which the radiologist stated
the third series recommended further evaluation if
may have been indicative of an old injury.
the patient’s complaints continued.

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 Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013
Nerve conduction studies of motor and sensory
components of the left median, ulnar, and radial
nerves completed just prior to the physical therapy
evaluation were within normal limits.
Electromyograms of the middle deltoid, biceps
brachii, brachioradialis, pronator teres, abductor
pollicis brevis, and first dorsal interosseus muscles
also were within normal limits. The patient had
positive purified protein derivative (PPD) tests since
the previous year. A standard posteroanterior chest
radiograph for patients with a positive PPD test was
normal. A normal chest radiograph shows no
pleurisy with effusion.
Pleurisy with effusion results when the pleural
space is seeded with Mycobacterium tuberculosis.18
EXAMINATION
The patient held his left elbow in a flexed
position and apparently was guarding the elbow
against his body. He had diffuse left elbow effusion,
with the left elbow joint girth 1.5 cm greater than the
right elbow joint girth measured at the elbow flexion
crease. There was no ecchymosis at the time of
examination, but wasting of the biceps and triceps
muscles was noticeable. The patient had elbow
active and passive range of motion of 30 to 110
degrees, with pain at both flexion and extension end
ranges. Wrist range of motion was normal, but the
patient did have a sharp pain at the lateral and
medial condyles during end ranges of pronation and
19
supination, respectively. The shoulder was cleared
for pathology using overpressure during active
flexion, abduction, and while the patient was
reaching behind his back. The therapist performed
overpressure by applying a force to the patient’s end
range at the point where his active range of motion
19
stopped. The wrist was cleared when overpressure
was performed during active flexion and extension.
Because both procedures failed to reproduce the
patient’s elbow pain, the therapist considered the
shoulder and wrist cleared as the source of his
pathology. The therapist tested light touch sensation
by moving the index fingers along the patient’s C4-
T2 dermatomes and upper-extremity nerve fields
bilaterally. Sensation was recorded as intact and
symmetrical. Muscle stretch reflexes were not tested.
Manual muscle tests of the upper-extremity
musculature were performed during the examination
as described by Kendall and McCreary.19 The
trapezius, middle deltoid, wrist flexor, dorsal and
palmar interosseus, and extensor pollicis longus
muscles were painless and rated normal bilaterally.
The patient said that he was unable to hold the left
biceps brachii, triceps brachii, and wrist extensor
muscles in the test position against resistance
because he said that it reproduced his pain. Because
pain limited the patient’s effort during these muscle
tests, grading was not done.
Palpation revealed a mild increase in warmth
around the left elbow compared with the right
elbow. Palpation at the olecranon and both lateral
and medial epicondyles caused a sharp pain that did
not radiate. Palpation of the patient’s entire anterior
forearm also reproduced his elbow pain.
EVALUATION
A posterior fat-pad sign has been reported to be
a possible sign of interarticular fracture or
swelling.17 Due to local tenderness, swelling, and a
documented fat-pad sign on this patient’s
radiographic report, the therapist chose to rule out
systemic pathology or a fracture before initiating
 ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

aggressive stretching or joint immobilization During the week 4 follow-up evaluation, the
intervention. The patient began a light physical patient reported increased pain in the area of the
therapy regimen of active range of motion exercises medial and lateral epicondyles. Examination of
for 10 to 15 minutes 3 times a week on an upper- elbow girth, active and passive ranges of motion,
body cycle to maintain his present range of motion, and palpation revealed no other changes. Based on
followed by ice massage for 10 minutes. The patient the patient’s continued pain and swelling, the
was instructed to use ice bags for 10 to 15 minutes physician and Therapist agreed that a magnetic
on his own throughout the day. He was also resonance image (MRI) could be informational. At
instructed to stop playing tennis. The therapist the same time, the physician referred the patient
discussed the case with a physician, who back to the orthopedic surgeon for re-evaluation
subsequently ordered follow-up radiographs, following the MRI. Physical therapy was
including an oblique view to rule out an discontinued until the MRI and orthopedic
interarticular fracture as was originally advised in evaluations were completed. The MRI showed a
the most recent radiologist’s report. large joint effusion and increased marrow signal
within the radial neck (Fig. 3).
RE-EVALUATION AND INTERVENTION
The new radiographs showed a smaller
posterior fat-pad sign but no fractures or evidence of
other pathologies in osseous structures. Therefore,
the patient continued his physical therapy program
and was re-evaluated 2 weeks after the initial
evaluation. During the week 2 follow-up, the patient
reported that the pain had lessened and that his
elbow was tender to palpation only at the olecranon.
Both active and passive ranges of motion were
unchanged, as was the elbow flexion crease girth.
Resistive exercises were added because the patient
expressed concern about the atrophy in his biceps
Figure 3. T2 weighted sagittal view of the elbow.
and triceps muscles. Because he was reporting less Note the increased marrow signal within the
elbow pain with palpation and range of motion end radial neck (arrows).
ranges, the therapist decided to allow the patient to
Signal intensity refers to the strength of the
perform seated biceps muscle curls and supine
radiowave that a tissue emits following excitation.
triceps muscle extension exercises in a pain-free
The strength of the radio wave determines the degree
range. The patient performed 3 sets of 10 repetitions,
of brightness of the imaged structures. A bright
3 times a week, in the clinic under the therapist’s
(white) area in any image is said to demonstrate a
supervision.

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 Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013
high signal intensity, and a dark (black) area
demonstrates a decreased intensity.17 Hematopoietic
marrow normally displays a low to intermediate
signal intensity, whereas fluid displays a higher
signal intensity on T2 weighted MRI.17 The
radiologist suspected infection and recommended
aspiration of synovial fluid and a biopsy. During the
second orthopedic evaluation, 2 months after the
MRI, the surgeon aspirated the elbow and ordered a
bone scan. A culture of the aspirated fluid was
negative for growth, but the bone scan image was
consistent with possible septic arthritis
osteomyelitis.
At the orthopedic follow-up 3 months later, the
surgeon ordered an open debridement and biopsy
based on the bone scan reports and performed an
arthrotomy of the left elbow with open debridement
of synovium and biopsy of the capitellum and radial
head the next day. The culture was positive for acid-
fast bacilli, which was later identified
Mycobacteria tuberculosis. Following identification
of TB, a physician specializing in infectious diseases
evaluated the patient. The bacterium was sensitive to
ethambutol, pyrazinamide, isoniazid, and rifampin,
and the patient began a 4-drug anti-TB regimen for
no less than 1 year.
OUTCOMES
Four months after initiating the drug regimen,
the patient reported that he was pain-free, and he
was discharged from the orthopedic surgeon’s care.
The therapist attended a weekly orthopedic clinic
during which patient was evaluated by an orthopedic
surgeon.
At 12 months after the diagnosis of TB, the
patient had recovered normal elbow range of motion,
and manual muscle tests of the biceps brachii,
triceps brachii, and wrist extensor muscles were
normal and painless.19 He said that he was working
and playing Tennis without pain. The patient
performed janitorial work, which consisted of Room
cleaning, walls, and bathroom fixtures.
DISCUSSION
Tuberculous arthritis usually occurs in an
insidious manner, with pain and swelling of the
and affected joint. It is rare among people born in the
India and is more often found in people born in other
countries or those with a compromised immune
system. The patient in this case report had chronic
elbow pain and swelling without signs of infection.
Lack of signs of infections is consistent with other
cases of tuberculous arthritis described.15,16 He also
reported a history of IV drug use, which, along with
direct joint trauma, interarticular steroid injections,
as
and systemic illness, has been found to be a
predisposing factor for tuberculous arthritis.16 These
factors and this patient’s history suggest an onset of
TB that is consistent with reports of other patients
who developed tuberculous arthritis.
Joint effusion, such as that seen in this patient,
often occurs with tuberculous arthritis and has been
shown to affect muscles and nerves around the
elbow.20,21 Chen and Eng20 noted compression of the
posterior interosseous nerve at the region of the
arcade of Frohse. Prem et al21 noted wasting of
muscles around the upper limbs and shoulder girdle
along with obliteration of bony landmarks due to
swelling around an elbow infected with tuberculous
arthritis. Yao and Sartoris1 also stated that weakness
and muscle wasting could be present around
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 ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji
involved joints. The patient in this case report did
not have sensory deficits, but he did have noticeable
wasting of his biceps and triceps muscles. Persistent
effusion in the knee affects afferent activity of
intracapsular receptors and can cause reflex
22–24
inhibition of the quadriceps femoris muscle.
similar mechanism may have occurred in this
patient, causing wasting of the biceps and triceps
muscles due to capsular distention and intracapsular
pressures. An alternative hypothesis might also
attribute the muscle wasting to disuse secondary to
pain during elbow motion.
Radiographs can be powerful diagnostic tools,
but they are not always beneficial during evaluation
of a patient with tuberculous arthritis. Some authors
have described normal chest radiographs in patients
with tuberculous arthritis20,25 and old or active
pulmonary disease evident in only 50% of chest
8,16
radiographs in patients with tuberculous arthritis.
Elbow radiographs can also be negative, even when
the disease is present.15 Unlike pyogenic organisms
that produce rapid destruction of bone, TB has a
26
gradual progression of symptoms. It has been
reported to begin in the distal end of the humerus,
olecranon, or synovium of the elbow joint.13,25 The
first radiograph report of the patient’s elbow was
normal.
The second series of radiographs identified a
cyst-like structure and mild exostotic bone formation
that was not identified on the first and final
radiographs. Munk and Lee26 contended that a
normal appearance on imaging is the rule with TB
infections because the underlying bone reacts (by
forming cysts and producing sclerotic borders at the
margins of the infected lesion) in an attempt to wall
off the infectious process. Thus, a cyst-like
appearance in the involved bone is not uncommon.
The third set of radiographs revealed no
abnormalities in bone or joint space, with the
exception of a positive fat-pad sign. Greenspan17
reported that a positive fat-pad sign could be
A indicative of interarticular swelling or a fracture. The
fourth set of radiographs eliminated the possibility
of a fracture that had not been diagnosed, but they
revealed a smaller fat-pad sign, which most likely
appeared because of interarticular swelling. When
radiographs are normal, an MRI may be beneficial
by revealing early changes such as edema that are
not visible on radiographs.27 The patient’s MRI
identified the complex effusion in his elbow, but a
biopsy that was needed for the definitive diagnosis.
Biopsy is the most definitive test for
tuberculous arthritis. 6,9,13,15
Some authors have
reported that synovial fluid or tissue cultures
establish a diagnosis in 90% of the cases of
tuberculous arthritis.11 Material for the culture may
be obtained from aspiration of joint fluid, but this
may be inconclusive, as it was in this patient’s case.
Laboratory tests such as sedimentation rate,
granulocyte count, and lymphocyte count are not
thought to be helpful.7 This patient’s prior tuberculin
skin tests were positive, which is consistent with
researchers’ findings for patients with tuberculous
arthritis.6,10,20,25 However, as was described in cases
involving a 66-year-old woman15 and a 76-year-old
man16 with tuberculous arthritis of the elbow, a
negative TB skin test does not exclude diagnosis of
tuberculous arthritis. Repeated negative tuberculin
tests, however, practically eliminate TB as a possible
etiology.7 Before the advent of anti-TB
chemotherapy, the classic treatment in adults
consisted of excision or arthrodesis of the elbow
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 Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013
joint.28 The disadvantage of arthrodesis was loss of
motion, and the risk of excision was an unstable
elbow.28 Anti-TB agents are effective in halting the
destructive process and treating the infection.
However, they cannot repair the anatomical defects
8
that can occur in later stages. During these stages,
fibrous tissue can result in ankylosis of the joint.
Similarly, the untreated cases can evolve to bony
ankylosis.16 The literature provides few specifics for
the physical therapist management
29
Investigators have reported using prolonged
immobilization for an average of 18 months. With
the introduction of TB drugs, this is no longer
12 6,28
necessary. Some authors
immobilizing the elbow for 1 to 2 months at 90
degrees to relieve pain and, in the event of fusion, to
achieve a functional position. After removing the
cast, rehabilitation proceeded daily for 3 to 6
months, with a back splint used between therapy
sessions to prevent extension deformity and help the
6
elbow flexors regain power.
descriptions of the splint or interventions were
reported.
Surgery may be necessary in certain cases when
the disease does not respond to drugs or to correct
deformities or improve joint function. Vohra and
Kang25 treated 6 cases of elbow TB, ranging from
the disease being restricted to within the synovial
membrane to extensive articular
involvement. Patients were treated with 3 to 6 weeks
of immobilization after surgery followed by
encouraging active movements and using night
splints for 2 to 5 months. No other intervention
30
specifics were given. Other authors
using a hinged long arm brace for a month after
surgically removing granulation tissue returned the
patient’s elbow to being pain-free with full range of
motion. Chen et al12 reported that a continuous
passive movement (CPM) device improved
functional results after synovectomy and intra-
articular debridement. Following surgery, the arc of
movement was set at 30 to 90 degrees and then
increased to a level that the patients were able to
tolerate. Patients used the CPM device for 2 to 4
weeks until movement exceeded 120 degrees. The
of TB. average flexion deformity in a group of 8 patients
who used the CPM device was 24 degrees versus 34
degrees in a group of 8 patients who were treated
with active and passive movement. Active and
advocated passive movement was not defined.
The patient in this report responded well to
antibiotics and regained full elbow function without
immobilization or surgery. This improvement could
have been due, in part, to the location of the disease
in the joint. Vohra and Kang25 stated that prognosis
is excellent in synovial and extra-articular lesions,
No specific whereas involvement of articular cartilage reduces
the chances of maintaining good range of motion. In
addition, this patient’s improvement could have been
due to diagnosing tuberculous arthritis early and
administering anti-TB treatment before severe
8
destruction occurred. Chen et al12 noted that joints
with severe intra- and extra-articular destruction
usually become stiff with fibrosis and adhesions.
cartilage Martini and Gottesman28 hypothesized that, unlike
the lower-limb joints, the elbow is non–weight
bearing and therefore more able to recover a normal,
painless range of motion, as this patient was able to
do.
reported that
CONCLUSION
Patients with tuberculous arthritis are not often
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examined or treated by physical therapists in India
due to the relative rarity of TB infections of joints.
Because of its often slow progression,
tuberculous arthritis is a frequently misdiagnosed
condition, which delays treatment and can lead
deformities and functional deficits.
This patient’s disease was identified as a result
of diagnostic tests and communication between a
physical therapist and other health care providers.
Physical therapists and other health care providers
can learn from this case to consider tuberculous
arthritis in the differential diagnosis of unexplained
musculoskeletal complaints, especially in patients
with compromised immunity or from an area where
TB is endemic.

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CORRESPONDING AUTHOR:

* Amit Murli Patel BPT, MPT-Orthopaedics, Assistant Professor & Vice Principal, College Of Physiotherapy,
Ahmedabad E-Mail : patelmpt@Yahoo.Com

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