I am in my 50’s and have dislocated my elbow on multiple occasions.  I have tried everything from physical therapy to bracing to avoiding the activities that I love.  Is there a better solution out there for me?

Depending on the direction and type of elbow dislocation that is occurring, there is a good chance that you would benefit from a radial head arthroplasty, or replacement.  There are several types of implants available and decent research to show good to excellent outcomes in most cases. However, this is typically a specialty area so you will need to discuss this with your physician for his further referral.

I have significant elbow arthritis and my surgeon wants to give me a new elbow. What will the recovery be like?

While every surgeon has their particulars about your recovery following an elbow replacement, generally speaking you will be in a splint for a little over a week followed by specific instructions regarding how far to bend and straighten your elbow. You will be able to rotate your forearm at a 90 degree angle.  After six weeks if you lack range of motion or have any significant weakness you will attend physical therapy.

I recently underwent a surgical repair for a fractured ulna and dislocated elbow. What should I expect with long term recovery and using my elbow again?

There are several factors that influence the outcome of an ulnar fracture with dislocation. Firtst, time from injury to treatment will effect outcomes. Patients treated within two weeks of injury have significantly better outcomes than those treated more than two weeks after injury when assessing range of motion, pain, and outcome measures. Type or extent of instability will also effect outcomes. Most acute simple dislocations are stable once the joint has been concentrically reduced, the ligaments will heal and function with early controlled motion. A nonacute simple dislocation, persisting beyond two weeks, can still be successfully treated with concentric reduction and early motion, however longer standing dislocations can also require surgical repair as the LCL is not successfully healing to the lateral epicondyle. These instabilities result in less favorable functional outcomes.

There is no consensus on what the optimal solution is for assuring stability of an elbow that has dislocated or subluxed. Temporary immobilization with either cross pinning or external fixation is most commonly used to help maintain elbow congruency while healing. An external fixator, however is difficult to apply, cumbersome to wear, can sometimes still allow the elbow to dislocate and can cause pin-site infection, pin breakage and/or radial nerve injury. Cross pinning of the joint is better at maintaining reduction, but the arm must be casted and there are risks of pin breakage and septic arthritis.

I am having difficulty regaining my range of motion after repair of an ulnar fracture and dislocated elbow. What can be done to help regain my range of motion?

There are many side-effects to the treatment of ulnar fracture with dislocation or subluxation, Contracture and stiffness, particularly with weeks of immobilization, can co-exist with instability and heterotropic ossification, and can impede concentric reduction. Methods available to treat excessive contracture or stiffness include an open capsular release and excision of heterotropic ossification with or without radiation. One must be careful with these procedures as the contracture or ossification may be masking latent instability. There are also braces available to force increased range of motion over time. You should consult with your surgeon and physical therapist to determine the best option for you in regaining range of motion.

I recently dislocated my elbow and had to wear a splint for ten days. I am now out of the splint and my elbow is very stiff. My doctor recommended a dynamic turnbuckle splint to help regain my range of motion. What is this and are there other options?

A dynamic turnbuckle splint has a hinge at the elbow and a mechanism that allows some movement of the elbow while being stretched the rest of the time. These splints are worn for anywhere from six to 24 hours a day as they work by applying a low load prolonged stretch to help elongate soft tissue and gain range of motion at the elbow. These splints typically cause little discomfort to the patient. The turnbuckle feature allows the hand to pronate and supinate, or twist up and down. Another option would be a static splint which allows less freedom of movement and stretches more aggressively for shorter periods of time. You can discuss with your physician which splint would be best for you. Regardless of the choice in splinting, it is important to allow the stretch and not overprotect. The greatest gains in range of motion are made in the first three months and can continue for up to a year.

I have been wearing a static progressive splint on my elbow for three months and have only gained 25 degrees range of motion. I would like to gain at least 20 degrees more range but am discouraged as in the past two weeks my progress has been very slow. Is it possible to gain more range at this point?

Yes, it is possible to gain range of motion for up to a year after the injury. The largest gains will be seen in the first three months, but with proper use of your splint and a well-guided stretching program supervised by a physical or occupational therapist, you will continue to progress. You can discuss with your physician or therapist the best protocol to use at this point in your rehabilitation. There are many choices that vary in the length of time you wear your splint and the extent of the stretch force applied.

My nephew is a young 40-something but already in need of an elbow replacement. Besides pitching ball for years, he has done construction for the last 20 years. Sounds like overuse and injuries has ruined the joint. My question is more of a worry/wonder because I had an elbow replacement about 10 years ago (I was considerably older than 40) and I can’t say it was a very good result. Not sure I would have done it if I had it to do over again. Should I say anything to him?

Joint replacement of hip, knee, and shoulder are commonplace now. Right behind those joints come ankle and elbow. Elbow implants have been around for 30 years. They were first designed for adults with rheumatoid arthritis. But over the years, as the implant materials and technology have changed and improved, younger, more active adults with elbow arthritis following trauma, failed surgery to fix an elbow fracture, or after removal of tumors have become acceptable candidates as well.

Surgeons now have different pathology-specific implant options. In other words, they can choose the implant design that best suits the patient’s problem. For example, younger patients who placed high-demand on their elbows (like your nephew) might do best with a distal humeral hemiarthroplasty (DHH) with unicompartmental radiocapitellar arthroplasty. This implant is also the one of choice for acute traumatic conditions.

Distal humeral refers to the bottom part of the upper arm (which forms the upper part of the elbow) and unicompartmental tells us only one-side of the bottom portion of the elbow is replaced (radial head). Radiocapitellar refers to the place where the radius (one of the two bones of the forearm) meets the bottom of the humerus.

The goals of elbow replacement haven’t changed much and include: pain relief, improved elbow motion, and improved function. But elbow replacement is still a challenging surgery to perform. The surgeon must position the implant correctly to restore the normal axis of motion and avoid overloading or wearing out the component parts. The use of computers to assist in accurate implant placement may help improve results.

The key area in need of improvement now is reducing complications associated with TEA. This is an area where your concerns may be very realistic. There is still a considerable amount of wear on the polyethylene (plastic) portion of the implant. Other complications and problems that can develop include loosening of the implant from osteolysis (bone cells dissolve), infection, bone fracture around the implant, and weakness of the triceps muscle, which is cut in order to put the implant in place.

Less severe but more common complications include wounds that don’t heal and damage during the surgery to the local nerves and blood vessels. Overall, studies show a complication rate as high as 43 per cent with a minimum of 27 per cent. Almost one-third of patients have a second (revision or reoperation) surgery.

The hope for future implants is a more stable joint with a lower failure rate and fewer problems and complications. Studies with long-term results are not yet available (but eventually will be!) based on implants in current use to give us an idea of what is possible for these individuals. Today’s patients will still benefit and the likelihood of a better result than even 10 years ago is very real.

Most likely the surgeon will review what your nephew can expect (including potential problems that can develop). He may receive a different type of replacement implant than you did, but it might not hurt to share your experiences. This would give him a point-of-reference for asking questions and raising concerns with his surgeon.

I have a fracture at the bottom of my humerus that hasn’t healed in six-months and likely isn’t going to heal. The surgeon calls this a “nonunion” fracture. I am being encouraged to consider having an elbow replacement. The other option is surgery to pin or wire the broken bones together in hopes that might help with healing. What do you recommend?

There was a recent article in a prominent orthopedic journal that focused on the past, present, and future of total elbow arthroplasty (TEA) or elbow replacement. The surgeons who wrote the article (from the Department of Orthopaedic Surgery at Thomas Jefferson University in Philadelphia had some information to offer that might be helpful to you.

First of all, it is important to know that elbow implants have been around for 30 years. They were first designed for adults with rheumatoid arthritis. But over the years, as the implant materials and technology have changed and improved, younger, more active adults with elbow arthritis following trauma, failed surgery to fix an elbow fracture, or after removal of tumors have become acceptable candidates as well.

Surgeons now have different pathology-specific implant options. In other words, they can choose the implant design that best suits the patient’s problem. The goals of elbow replacement include: pain relief, improved elbow motion, and improved function. Total elbow arthroplasty (TEA) is also an option in cases where fractures have failed (as in your case) to heal or healed poorly resulting in malunion and deformity.

The authors suggest that the use of total elbow arthroplasty (TEA) instead of internal fixation (pinning, screwing, or wiring the pieces together) is a good idea for some patients. The patients experience immediate improvement in motion and function. But studies show a high rate of complications (43 per cent) and reoperations (35 per cent).

Early on there can be loosening of the implant from osteolysis (bone cells dissolve), infection, bone fracture around the implant, and weakness of the triceps muscle, which is cut in order to put the implant in place. Less severe but more common complications include wounds that don’t heal and damage during the surgery to the local nerves and blood vessels.
Later on, wear on the polyethylene (plastic) portion of the implant can lead to problems.

Present-day implants can provide major improvements in pain, motion, and function. Some studies have already shown a benefit for TEA over fixation with hardware. The hope for future implants is a more stable joint with a lower failure rate and fewer problems and complications. Studies with long-term results are not yet available (but eventually will be!) based on implants in current use to give us an idea of what is possible for individuals like yourself.

I was very lucky to be able to watch my own surgery and listen to the two surgeons discuss my case. I had a rupture of the biceps tendon that pulled some of the cartilage around my shoulder socket away from the bone. They were able to reattach the tissue and hold it in place with what they called anchors. The thing that I was most surprised by was how long it took them to decide what to do once they saw all the details of my anatomy. I guess there were a few surprises that everything wasn’t exactly “normal” or expected. Does this happen very often or am I truly so unique?

Clearly, we have not come to the end of all that can be known about human anatomy. One example of new discoveries involves the very area you described: the biceps muscle of the upper arm. This particular muscle has two parts to its tendon: a long and short head. They have different insertion points on the humerus (upper arm bone). The long head of the biceps becomes part of the labrum, a rim of fibrous cartilage around the shoulder socket (glenoid). The labrum helps give the shallow glenoid greater depth.

Cadaver studies, arthroscopic examinations, and MRIs have helped identify the presence of distinct anatomic variations in these structures (i.e., the tendon insertion points, labral attachments). For example, sometimes the long head of the biceps begins along the posterior (back) aspect of the labrum. In some people, the pattern of origination of the long head of the biceps is more toward the middle (anterior/posterior) of the labrum. And in others, it can be seen entirely along the anterior (front) labrum.

Likewise, there can be anatomic variations of the glenoid labrum. These are seen as a hole (referred to as a sublabral foramen). Instead of a continuous ring of tissue around the glenoid, there is a space where the labrum is absent. The foramen or hole also varies in size and shape. At some point (further along on the edge of the shoulder socket), the fibrous cartilage continues.

It appears that these anatomic differences affect slightly more than 10 per cent of the general population (based on a study of 100 cadavers). The changes are likely formed during embryologic development (as the body was formed in the uterus). Such differences may lead to rotator cuff injuries because they allow the arm to more into internal rotation more than is normal.

Injuries that affect the labrum (e.g., superior labrum anterior and posterior or SLAP tears) can also involve the long head of the biceps if the labral tear occurs at the insertion point of the tendon. But the presence of the sublabral foramen can be misleading when the surgeon is trying to make a diagnosis. The patient with this anatomic variation looks like he or she has a labral tear when, in fact, none is present.

There are other anatomic differences from person to person affecting the biceps tendon. These include: (1) shape and depth of the bicipital groove (indentation where the tendon rests along the front of the humerus), (2) presence and strength of connective tissue that holds the tendon in the groove (called the vinculum), (3) changes in the bone (e.g., bone spurs) that can affect the tendon as it moves up and down over the bone during repetitive motions.

Each of these individual anatomic variations must be taken into consideration when deciding what surgical procedure to choose. During surgery, the placement and number of anchors to reattach the labrum and the biceps may depend on the severity of the tear as well as the patient’s individual anatomic differences. It sounds like you were able to hear some of the discussion in the operating room around these decisions.

I had endoscopic surgery to release pressure on my elbow that was causing elbow pain and an electric shock sensation down my arm. The pain is better and the shocking is gone but it still hurts, especially when I bend my arm. If I sleep with my elbow bent at night, I wake up in the morning and can hardly function for an hour or two. Is there anything else that can be done?

Let’s review this condition first to better understand what is going on and what can be done about it. Cubital tunnel syndrome is a condition that affects the ulnar nerve at the elbow. The ulnar nerve passes through the cubital tunnel just behind the inside edge of the elbow. The tunnel is formed by muscle, ligament, and bone. You may be able to feel it if you straighten your arm out and rub the groove on the inside edge of your elbow.

Cubital tunnel syndrome has several possible causes. Part of the problem may lie in the way the elbow works. The ulnar nerve actually stretches several millimeters when the elbow is bent. Sometimes the nerve will shift or even snap over the bony medial epicondyle. (The medial epicondyle is the bony point on the inside edge of the elbow.) Over time, this can cause irritation.

What is actually happening to cause this condition? Experts think it’s a combination of compression (pressure) and traction (pull or stretch) on the nerve. Elbow flexion (bending the elbow) increases these effects. Frequent bending of the elbow, such as pulling levers, reaching, or lifting may contribute to the problem. Constant direct pressure on the elbow over time may also lead to cubital tunnel syndrome. The nerve can be irritated from leaning on the elbow while you sit at a desk or from using the elbow rest during a long drive or while running machinery. The ulnar nerve can also be damaged from a blow to the cubital tunnel.

As you described, the symptoms are very similar to the pain or electric shock sensation that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Treatment begins with conservative (nonoperative) care, which often resolves the symptoms. Symptoms that are made worse with sleeping position may be eliminated by the use of a night splint. If you have not tried this approach, it may be worth asking your surgeon about it. Usually, a hand therapist measures and fits you for this type of device.

But when symptoms persist and do not respond to splinting or stretching activities, then surgery may be needed. The surgeon has several choices when deciding how to do the surgery. The first is a local (called in situ) release of the structures pressing on the nerve. You may have had this procedure done.

If symptoms are improved but not eliminated after the first surgery, there are other procedures that might help. For example, the surgeon can move (transpose) the nerve to a new location (away from the structures pressing on it). Another option is to perform a medial epicondylectomy (removal of the bone along the inside of the elbow).

There is also a procedure known as the Hoffmann technique. The Hoffmann technique is an endoscopic approach from 10 centimeters (about four inches) below the elbow, releasing the nerve all the way up to 10 centimeters above the elbow. The advantage of this surgical approach is that it enables the surgeon to release other areas where the fascial bands (connective tissue) underneath the muscles are compressing or entrapping the nerve. These fascial bands may have been missed with the first procedure.

I’m supposed to have surgery for my elbow pain and hand numbness. The diagnosis is cubital tunnel syndrome. They are going to stick a needle into the area that has a tiny TV attached to it so the surgeon can see what’s going on in there. The plan is to cut any bands of tissue that might be pressing on or wrapped around the nerve. This poking around inside my body scares me. What do you think of it?

As you have probably been told, cubital tunnel syndrome is a condition that affects the ulnar nerve at the elbow. The ulnar nerve passes through the cubital tunnel just behind the inside edge of the elbow. The tunnel is formed by muscle, ligament, and bone.

The symptoms are very similar to the pain or electric shock sensation that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Treatment usually begins with conservative (nonoperative) care, which resolves the symptoms for many patients. But when symptoms persist and do not respond to splinting or stretching activities, then surgery may be needed. It sounds like this is where you are in your treatment. The surgeon has several choices when deciding how to do the surgery. The first is a local (called in situ) release of the structures pressing on the nerve. From your description, it’s likely this is the surgeon’s first intended step.

Surgery is much less invasive now that endoscopic techniques are available. With a very small incision, the surgeon can slip the scope in through the skin and soft tissues and find the nerve. It is possible to examine the position and condition of the nerve and assess any damage that may have occurred causing your symptoms. It’s a simple matter to then snip away any bands of fibrous, scar, or connective tissue that may be compressing the nerve.

Some surgeons are using a surgical approach to accomplish this type of decompression called the Hoffmann technique. The Hoffmann technique is an endoscopic approach from 10 centimeters (about four inches) below the elbow, releasing the nerve all the way up to 10 centimeters above the elbow.

The advantages of this surgical approach are that it enables the surgeon to look down on the nerve (and the soft tissues around it). Using the endoscope inserted into the forearm through the skin, the surgeon can have direct vision of the nerve. The ligament most often pressing on the nerve (arcuate or Osborne’s) is cut much like the in situ release. But the surgeon is also able to release other areas where the fascial bands (connective tissue) underneath the muscles are compressing or entrapping the nerve.

Not everyone is a good candidate for this surgical technique. But the Hoffmann technique can be considered for most patients who have not responded well to conservative care. No matter what method your surgeon has planned for you, if you are uncomfortable with what you’ve been told, take the time to visit with your surgeon and ask any questions you may have. This is an important step no matter what type of surgery patients are facing.

I see many movie stars who have BOTOX done on their faces. My doctor has recommended this as a treatment for my chronic tennis elbow. I thought BOTOX was to smooth out wrinkles and puff up lips. How does it help with tennis elbow?

Tennis elbow (also known as lateral epicondylitis) is a fairly common work- or recreational-related problem caused by repetitive motions (e.g., gripping, bending wrist back into extension). Sometimes the elbow feels stiff and won’t straighten out completely. Men and women are just as likely to develop symptoms of tenderness and pain that starts on the outside bump of the elbow, the lateral epicondyle.

The most common first-line of treatment is usually conservative (nonoperative) care. This can involve a form of treatment known as “benign neglect” or “watchful waiting.” Other treatment approaches include physical therapy, the use of nonsteroidal antiinflammatory drugs or NSAIDs, injection therapy, and sometimes surgery.

Injection treatment for lateral epicondylitis (tennis elbow) is usually with glucocorticoid (a steroid medication). Glucocorticoid has been around since the 1950s and has been studied the longest. Other types of injection therapies (including Botulinum toxin or BOTOX) are still fairly new (developed in the last 10 years or so).

In the few, small studies reported so far using BOTOX to treat chronic tennis elbow, there have been no serious side effects in any of the trials. As with any injection treatment, pain is felt at the time of injection and for a short time after injection. Botulinum toxin (BOTOX) causes temporary paralysis of the finger extensor tendons.

But that’s how BOTOX works – it is a paralyzing agent designed to give the tendons/muscles a rest. This effect is gone two to three months later. Hopefully that is enough rest for those overused tendons that have experienced microtearing and progressive degeneration of the common extensor tendon at the elbow.

I work in a fish factory in Alaska. Half the women on my shift are out at least once or twice every week due to “tennis elbow.” How is this possible? No one plays tennis up here…we are too busy working! I think they are faking it to get a day off. What do you think?

Tennis elbow (also known as lateral epicondylitis) is a fairly common work- or recreational-related problem caused by repetitive motions (e.g., gripping, bending wrist back into extension).

Overuse of the muscles and tendons of the forearm and elbow is the most common reason people develop tennis elbow. Repeating some types of activities over and over again can put too much strain on the elbow tendons. These activities are not necessarily tennis or other recreational or high-level sports competition. Hammering nails, picking up heavy buckets, or pruning shrubs can all cause the pain of tennis elbow. No doubt, there is some aspect of the repetitive factory work you do processing fish that can result in what is commonly called tennis elbow.

Men and women are just as likely to develop symptoms of tenderness and pain that starts on the outside bump of the elbow, the lateral epicondyle. Sometimes the elbow feels stiff and won’t straighten out completely. Rest is important in the treatment of this condition but a single day off once a week (or even two days off) is not likely to turn the problem around.

Degenerative changes at the site where the extensor tendon attaches to the lateral condyle (bone along outside of elbow) from repeated movements need time to recover. Sometimes complete immobilization in a splint or cast is advised. Nonsteroidal antiinflammatory drugs (NSAIDs) are often prescribed but in chronic cases, it’s unlikely there is still an active inflammatory process going on.

Most cases of chronic tennis elbow deal with this problem for six months up to two years. The average person with tennis elbow lasting more than six weeks seems to recover within a year’s time. Treatment may help alleviate the painful symptoms for a time but the condition seems to have its own course and must go through its phases before complete resolution.

I am wondering if you can help me with something I don’t really understand. I’m having some pain, weakness, and numbness in the left forearm and hand. The surgeon says it’s either pronator syndrome or interosseous syndrome. More tests are being ordered. Should I have all these tests? Does it really make a difference?

There are several ways to look at this dilemma. On the one hand, because the treatment isn’t all that different for the two problems, a clear and accurate diagnosis may not be necessary. On the other hand, it’s always a good idea to know exactly what you are dealing with — especially if the first phase of treatment (usually conservative, nonoperative care) isn’t successful and surgery is considered.

Both conditions involve impairment of the median nerve somewhere from the elbow down to the wrist. In the case of pronator syndrome (PS), there are multiple different sites where pressure from some of the soft tissues can compress the nerve causing your symptoms. With anterior interroseous nerve (AIN) syndrome, it’s more likely a case of neuritis (inflammation) of the nerve.

The neuritis could be coming from a viral illness, immunizations, strenuous exercise, or pregnancy. The result of AIN syndrome is a motor paralysis or “palsy” of some or all of the muscles innervated by the median nerve. This is a transient neuritis, which means “temporary” — given enough time, the nerve will usually recover.

Both of these conditions are fairly rare, so the information we have on them is limited. The diagnosis requires a careful patient history, physical examination, and electrodiagnostic and imaging studies. Once the diagnosis is made, then the next step is developing an appropriate plan-of-care. Conservative (nonoperative) care is recommended for both conditions. Rest, muscle stretching exercises, activity modification, and antiinflammatory medications are tried for at least six months.

Surgery is only advised when nonsurgical intervention is unsuccessful after many, many months (up to a year or more). The exact surgical approach to take remains a point of considerable debate and discussion for both of these conditions. Although there is no formal evidence-based protocol, most surgeons release the median nerve along its entire course in the forearm for both conditions. Any places of restriction or obstruction are removed.

You may want to direct your question to the surgeon handling your case. There may be specific reasons why additional tests are being recommended. Having an understanding of the whys and wherefores may be important to you whereas other patients don’t really care — they just want the problem gone. Your surgeon will understand your interest and probably appreciate an interested audience!

Please give me a realistic understanding of what I might expect with a diagnosis of pronator syndrome. Will I get better? If so, how long will this likely take?

The median nerve innervates or supplies muscles of the forearm with messages needed for sensation and movement. Compression on the nerve can cause this condition known as pronator teres syndrome. The affected individual experiences mild to moderately painful symptoms along with numbness. Hand function may be impaired but disability from this problem is rare.

Pronator syndrome can occur if and when the nerve is compressed in any of several places (e.g., most often between the two heads of the pronator teres muscle, but also at the proximal arch of the flexor digitorum surperficialis, at the ligament of Struthers, at the aponeurosis, or at the head of the flexor pollicis longus). Though you may not be familiar with those specific soft tissues, it gives you an idea of how the nerve comes in contact with many and various structures that could put pressure on it.

This condition is fairly rare. So the diagnosis requires a careful patient history, physical examination, and electrodiagnostic and imaging studies. Specific tests that can be done to make the diagnosis and distinguish this problem from other similar conditions affecting the median nerve. But there are no tests to really confirm the diagnosis.

Electrodiagnostic tests are typically used to confirm other nerve compression problems. The test provides positive proof when there’s a problem. But with pronator syndrome, stimulating the nerve with an electrical impulse shows there’s a problem in nerve conduction for only one out of every 10 patients with symptoms of pronator syndrome.

Women in their 40s are the ones most likely to be seen with this condition. And because there are no objective measures and because surgery to decompress the nerve isn’t always successful, there is a belief that this isn’t a disease, but rather an illness.

Conservative (nonoperative) care is recommended first. Rest, muscle stretching exercises, activity modification, and antiinflammatory medications are tried for at least six months. Studies show that surgery is unsuccessful more often than not.

Surgery is only advised when nonsurgical intervention is unsuccessful after many, many months (up to a year or more). The exact surgical approach to take remains a point of considerable debate and discussion. Although there is no formal evidence-based protocol, most surgeons release the median nerve along its entire course in the forearm for both conditions. Any places of restriction or obstruction are removed.

When surgery does relieve the problem, it could be a placebo effect. So determining disease (true pathologic anatomy or physiology) from illness (physical symptoms caused by emotional or psychologic distress) can’t be cleared up by successful treatment.

Until the concept of pronator syndrome can be fully explored and explained, treatment will likely remain nonsurgical. Antiinflammatory medications and a few sessions with a hand therapist may be all that’s needed.

The therapist will teach the patient how to modify activities to avoid contracting the pronator muscle and thereby keep pressure off the nerve. Exercises to stretch the nerve and manual therapy to release fibrous tissue around the nerve may help. Any postural effects will be addressed. The therapist may conduct a review of the patient’s home and/or office work areas for possible contributing or aggravating factors.

My husband is a construction worker with a good paying job and no other skills. So his job is vital to our family support. He has been off for three months now due to a torn biceps tendon. After surgery, he’s been in physical therapy to regain his strength needed for the job. The question I have is this — X-rays show he has some bone forming inside the muscle where they reattached the tendon to the bone. Will this add or subtract to his strength? I guess I’m worried that this will cause further problems.

Ruptures of the biceps tendon at the elbow can be very disabling and often require surgical repair or reconstruction. Studies over the last 30 years (since the mid-1980s) have given us enough data to see long-term results of both conservative (nonoperative) care and surgical management. And over those 30 years many improvements have been made in surgical techniques to reduce complications following surgery and to improve strength of the repair (referred to as tendon-to-bone fixation).

We know now that many patients heal with additional bone forming in the soft tissue. This effect called intrasubstance heterotopic bone or heterotopic ossification. This complication does not seem to adversely affect final outcomes. Patients appear to do just as well as those individuals who do not form the additional bone. Pain and function (motion and strength) are unaffected by the bone formation.

Whether or not the added bone increases actual strength has not been tested. Some patients observe increased stiffness but this is not consistent among all patients and may not be directly linked with the ossification. A rehab program that is designed to prepare your husband to return-to-work is likely the best way to ensure adequate strength, flexibility, and motion for the job tasks.

I am an anatomy instructor in my first teaching year looking for any information you may have on biceps tendon tears. My hope is to provide a lecture that covers both the anatomy with some information on what happens during and after tendon injuries. What can you recommend?

There is a recent review of distal biceps tendon ruptures that may be of interest to you.

In this article, hand surgeons from the University of Pittsburg Department of Upper Extremity Reconstructive Surgery provide an update on this problem. The “new news” about distal biceps tendon injuries has come about for three reasons:

1) Technology has made it possible to discover new understanding about the biceps tendon anatomic form and function.

2) Thirty years of improvements have been made on surgical techniques to reduce complications following surgery and to improve strength of the repair (referred to as tendon-to-bone fixation).

3) Studies over the last 30 years (since the mid-1980s) have given us enough data to see long-term results of both conservative (nonoperative) care and surgical management.

As you will appreciate, a discussion of form and function (mentioned in number one above) can be the topic of just one lecture alone. In this topic, the authors include the structure of the biceps tendon, “footprint” (where and how it attaches to the bone), and biomechanics (how it contracts and relaxes to create movement). Data mentioned in number three above has been collected on both acute and chronic injuries as well as partial and complete tears of the distal biceps tendon.

Through a series of illustrations, photos, and imaging studies (MRIs, X-rays), the authors will bring you up-to-date on the basic science of biceps tendon, repair biology (how it heals), and the diagnosis of partial versus complete tears. The same approach is used to describe current methods of treatment. Here are a few highlights of new findings that may be of interest to you:

  • The distal biceps tendon is two unique and separate units. This understanding replaces the former belief that there were two units that blended together to form one at the insertion point to the bone.
  • Accurate surgical reattachment of the two tendon subunits to the bone must be done carefully. Anterior placement (forward of the original footprint) is no longer preferred. To gain the best results, the tendon must be reattached at its original anatomic site.
  • A posterior surgical approach is recommended. This technique gives the surgeon access to the footprint and allows for placement of the anchor or button (a fixation device used to hold the tendon in place) in an anatomic position.
  • Many patients heal with additional bone forming in the soft tissue. This effect called intrasubstance heterotopic bone does not seem to adversely affect final outcomes.
  • Partial tears are still treated conservatively at first; surgical repair can be saved for later if the nonoperative approach fails to give the desired results. Patients can expect some loss of strength and motion of the forearm/elbow with conservative care.
  • Chronically torn distal biceps tendons should be repaired with the elbow fully flexed (bent); this technique has been shown to decrease the need for a tendon graft.

    In addition to the details listed above, you will find information in this article about complications, complication rates, advice regarding surgical techniques, and pros and cons of conservative care versus surgical intervention. Summaries of treatment results from past studies on this topic of distal biceps tendon injuries and treatment are also provided. This should give you plenty of ammunition for your lecture!

  • I am a wrestling coach at a mid-sized high school (graduating class of 300 seniors). Every year it seems one or two of my players dislocates his elbow. The football coach says this is two too many and I must be doing something wrong in my coaching. It’s light-hearted teasing but it does make me wonder. Is this typical? What are other wrestling coaches telling you?

    A recent study of acute sport-related elbow dislocations may offer some information useful to you. Hand surgeons from the hospital for Special Surgery in New York City reviewed 62 You Tube videos posted of this type of injury.

    They were able to analyze the videos and identify patterns and mechanisms of elbow dislocation.

    They found that most acute elbow dislocations occur when the elbow is extended (relatively straight). More than two-thirds (68 per cent) of cases, the athlete’s forearm was pronated (palm down) with shoulder abduction (arm away from the side). That makes sense because the person is usually reaching the arm out to brace from a fall.

    The body is rotated inwardly with the palm planted on the floor or ground. The result is external rotation of the forearm (a common position in wrestling). The arm is also usually forward with load and impact translated from the hand through the wrist and forearm to the elbow. Of course, the force must be enough to overcome stabilizing structures like ligaments (e.g., medial collateral ligament).

    Dislocation events filmed and available on You Tube were seen most often during wrestling. Other common sporting events associated with elbow dislocation included skateboarding, martial arts, football, basketball, and weightlifting. Less often, elbow dislocations associated with rugby, gymnastics, and rollerblading were presented. After analysis of all the videos, there were four distinct patterns of elbow dislocation based on shoulder position, elbow position, and direction of the force.

    The most common pattern (half of all acute elbow dislocations) is as described above: shoulder flexed and abducted (arm forward and out to the side) with the elbow pronated and extended (palm down and straight). The pattern is one of axial force (up through the forearm) and from the outside of the elbow inward toward the body (called a valgus force). Valgus and axial forces are enough in this pattern to tear the medial collateral ligament on the inside of the elbow (side next to the body). Wrestlers and football players had this pattern of elbow dislocation.

    One-third of the cases were with shoulder extension and abduction and forearm supination (palm up) and extension. Once again, the loading forces were axial and valgus (through the forearm and across the elbow). This pattern was most often seen in inline skaters. Other much less common patterns (usually in weightlifters) were variations and combinations of these two patterns.

    As this collection of You Tube videos showed, the key differences are not only sports-specific position of the arm but also (and most especially) biomechanical stability of the anterior portion of the medial collateral ligament.

    They suggest further study to prove whether the presence of medial collateral ligament instability before the dislocation injury may be a contributing factor. It is possible that ligamentous instability is part of the cause and effect rather than just a result of deforming forces from the fall. Whether this type of ligamentous instability is more common in wrestlers compared with football players (perhaps as a result of previous strains) is another area where further research is needed.

    I was recently diagnosed with rheumatoid arthritis. It seems to have settled in my right elbow. The doctor wants me to start what she calls “aggressive” therapy taking new medications. The meds are called DMARD. I don’t really want to take drugs. Isn’t there a more natural way to deal with this problem?

    Rheumatoid arthritis (RA) is a chronic, or long-term, inflammatory form of arthritis. RA is considered an autoimmune disease, in which your immune system attacks the tissues of your own body. In RA, the immune system mostly attacks tissues in the joints, but it can also affect other organs of your body.

    This is one reason why early and aggressive therapy is now recommended for this problem. Another reason for early treatment with disease modifying anti-rheumatic drugs or DMARDs is that RA can get worse over time leading to the destruction of joints. At that point, RA can greatly affect your ability to move and to do even normal daily activities.

    Studies show that in some patients, symptoms associated with RA (pain, swelling, stiffness, loss of motion) can be completely corrected with early use of these disease-modifying medications. DMARDs are designed to slow or prevent the structural damage from RA. This type of drug therapy may be combined with other medications and other non-pharmaceutical (non-drug) approaches. Alternative treatment can include acupuncture, natural herbs and supplements, massage, and other forms of complementary therapy (e.g., touch therapy, Reiki, BodyTalk, myofascial release).

    RA can be a frustrating and complex disease. The more you understand it, the better you can help treat your own symptoms and prevent flare-ups. Treatment that requires some effort and lifestyle changes from you. For example, daily range-of-motion and strengthening exercises may be prescribed. These will most often be designed and monitored by a physical or occupational therapist.

    The therapist will also provide useful equipment and gadgets, such as canes and jar openers that can help you go about your daily business without putting too much stress on affected joints. Gentle aerobic exercise at least three times each week is advised.

    Please be aware that at least half of RA patients don’t find much relief from treatment and eventually need surgery on the affected joints. A delayed diagnosis and delayed treatment for any reason increases the risk of poor results. Surgery, including total joint replacement, can be a very effective way to help you overcome the pain and loss of movement of RA. Every effort should be made to avoid surgery and especially joint replacement early in life.

    I have a very persistent case of tennis elbow — probably from my work at a meat packing plant. I’ve tried a couple of steroid injections. They helped for about a week and then the pain started again. I’ve heard there’s a new blood injection treatment I could try but that it is more painful than the steroid injections. What can you tell me about this?

    Lateral epicondylitis, more often referred to as “tennis elbow,” is a fairly common problem in the work place. Workers with strenuous jobs in various industries are often affected. And since an episode of lateral epicondylitis can last six months to two years, effective treatment is a must to keep workers on-the-job, productive, and earning a living.

    But the best, most effective treatment for tennis elbow remains unknown. Many things have been tried including antiinflammatory drugs, exercise, bracing or splinting, injection therapy, and surgery. Short-term pain relief may be obtained but no long-term benefit has been reported.

    Platelet-rich plasma (PRP) is a fairly new treatment procedure for tennis elbow. PRP refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets and growth factors. This treatment enhances the body’s natural ability to heal itself. PRP is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

    According to some patients who have had both steroid injections and PRP injections, the platelet-rich plasma (PRP) injections are more painful than steroid injections. They seem to experience additional pain lasting up to three weeks in some cases. That may be because delivery of PRP requires five to seven pokes into the tissue as opposed to only one with steroid injections.

    Studies show that steroid injection give the best pain relief and improved function in the first month after injection (compared with PRP or a placebo saline injection). At the end of three months, there is often no difference in treatment results between steroid injection and PRP for pain and disability.

    Tendon thickness may increase with PRP (a positive benefit of blood injection therapy). Tendon (and skin) thickness often decrease (atrophy) with the steroid injection (a negative or adverse effect of steroid injections). The long-term benefits of PRP have not been proven yet. Researchers continue their efforts to find a successful way to treat tennis elbow for everyone!