Important Information About Four Elbow Conditions

Elbow problems getting you down? Wondering what to do? There are many choices including steroid injections, platelet-rich plasma (blood therapy), physical therapy and even surgery. Perhaps giving the problem some time (the old wait-and-do-nothing approach) might be best.

The information in this review article may be helpful. Two orthopedic surgeons from the Hospital for Special Surgery in New York City bring us up-to-date on four elbow conditions: 1) lateral epicondylitis (tennis elbow), 2) medial epicondylitis (golfer's elbow), 3) biceps tendon rupture, and 4) triceps tendon rupture.

And there's one "double whammy" condition of interest to some: biceps or triceps tendon rupture on top of a tendinopathy. Tendinopathy describes a chronic condition present with epicondylitis -- there is no active inflammation going on. Microscopic studies have shown us that the area has poorly organized collagen fibers. There is scar tissue and an area where acute inflammation was present in the beginning but just never healed right. Tendinopathy is more of a degenerative condition than one of inflammation.

Causes, natural history (what happens over time), treatment, and outcomes are discussed for each problem. The first thing patients must understand is that these problems take some time to heal (up to a year or more). There's no quick, easy fix but conservative (nonoperative care) is effective. Time, patience, and consistency are the keys to recovery.

Let's start with lateral epicondylitis known more commonly as tennis elbow. Repetitive overuse of wrist extension is the most likely cause -- and it affects many people, not just tennis players. Men and women are affected equally. Adults between the ages of 35 and 54 who smoke and/or who are obese are at greatest risk for this type of elbow problem.

Once the diagnosis is made (based on patient history and clinical examination and sometimes imaging studies), then treatment can begin. Treatment ranges anywhere from "benign neglect" (just watch and wait) and activity modification to shock therapy. When all else fails, surgery may be done to remove the diseased tissue followed by splinting and postoperative rehab with a physical therapist. Studies are ongoing to find out what works best.

Medial epicondylitis (remember: golfer's elbow) occurs in anyone who uses wrist flexion over and over. This does include golfers but also anyone in the work force who is required to use this type of repetitive motion. Just like lateral epicondylitis, medial epicondylitis is evaluated and treated in a similar fashion.

In both conditions, steroid injections are known to provide short-term (immediate) pain relief but there's no long-term benefit. In other words, patients with the same condition who don't have the injection(s) have the same results three to six months later compared with patients who do have the steroid injection.

Surgery is a bit more problematic with medial epicondylitis because of the potential for nerve damage. Patients with chronic medial epicondylitis may not be able to return to the sport that contributed to the problem in the first place. In fact, studies show that as many as 20 per cent of the adults with medial epicondylitis are unable to return to the recreational sporting activity of their choice.

Now, what about tendon ruptures (either partial or complete) affecting the biceps or triceps? These conditions are much more uncommon when compared with how often epicondylitis develops. Here's what we know. Anyone who has ever had this type of tendon rupture is at increased risk for the same injury a second time.

Men engaged in lifting activities (sports or occupational) develop tendon ruptures much more often than women. Tobacco use really ups the risk of tendon ruptures. Smokers have 75 times greater risk of tendon rupture than nonsmokers.

Unlike tendinitis that seems to come on more slowly over time, tendon ruptures occur with trauma and load and create immediate symptoms. Patients report a sudden, sharp, painful episode often with a "pop" at the time of the rupture. Weakness, loss of motion, bruising, and a bulge or lump signal tendon injury. An MRI will show the damage clearly and allow the surgeon to evaluate more accurately whether it is a partial or complete rupture.

In cases of tendon rupture (biceps or triceps), surgery is often required to restore full strength and motion. Some patients can get by without surgery, especially if it is a partial tear. Conservative care can always be tried (for partial and complete tears). But the earlier surgery is done, the better the results with less scarring and easier return of the tendon to the place where it belongs.

The biggest challenge in surgical repair is deciding how to reattach the tendon to the bone. Special sutures and surgical buttons have been used with varying results. Triceps ruptures are more likely to require elbow replacement. Most of these injuries occur as a result of acute trauma, which is linked with early development of osteoarthritis and the eventual need for joint replacement.

In summary, whether from acute injuries or overuse, elbow tendinopathy affects many adults. The condition causes chronic pain, loss of motion, and decreased function potentially leading to disability. Finding ways to treat these conditions in the most effective way possible remains the focus of orthopedic surgeons, sports physicians, and physical therapists.

Keeping up-to-date with a review of causes, pathophysiology, evaluation, and treatment such as these authors provide is essential in helping patients accept a realistic view of what to expect. There's no quick fix to these injuries. But with a careful examination and implementation of the appropriate plan-of-care, most people are able to recover in six to 12 months' time.

References: Samuel A. Taylor, MD, and Jo A. Hannafin, MD, PhD. Evaluation and Management of Elbow Tendinopathy. In Sports Health. September/October 2012. Vol. 4. No. 5. Pp. 384-393.