FAQ Category: Elbow

The incidence of ulnar collateral ligament (UCL) injuries of the elbow in young athletes is on the rise. With more and more young children playing sports, we may expect to see many unexpected injuries.

Chronically overloading the joint can cause microtears of the ligament. Too many pitches over too many practices and games can eventually lead to a partial tear or even complete rupture of the UCL.

Fortunately, it may be possible to rehab these injuries. It takes three or four months, but a physical therapy rehab program can be very successful. The athlete can return to his or her previous level of sports play without invasive surgery.

But if instability and/or pain persist, then surgery may be needed to repair or reconstruct the area. Repair is more likely in the younger athlete who hasn’t damaged the entire length of the ligament or developed bone spurs from chronic abuse.

If the ligament has torn just at one end (instead of both ends), reattaching it is a possible option. More than one tear in the tendon may require more advanced (reconstructive) surgery. Repairing rather than reconstructing the elbow is less invasive with a faster recovery and return-to-sport time.

A favorable outcome has been reported in several studies of young athletes with this type of injury.

Many athletes with elbow instability from a ligamentous injury can be treated successfully with rehabilitation. And it can be done without invasive procedures. At first, symptoms may be treated with rest and/or activity modification.

Resting from the aggravating activity is a challenge for most competitive athletes. But it can make a big difference in the speed of recovery. Sometimes activity modification is all that’s needed. This can range from fewer cartwheels, back flips, and round offs to shorter practices each day or fewer practices per week.

Antiinflammatory drugs and analgesics may be used to reduce pain and inflammation. Icing may help but must be used with caution. Too much cold can cause a worsening of the swelling as the body sends more blood to the area to warm things up. And cold can be an irritant to the already damaged (and irritated) nerve.

Other modalities such as electrical stimulation and ultrasound with cortisone (called phonophoresis) may be used by a physical therapist when needed. The athlete will work with the physical therapist to develop a daily program of stretching and strengthening.

The athlete’s posture, strength, and performance of activities must be analyzed and corrected. Stretching exercises for the muscles of the forearm are included. A strengthening program for the entire shoulder/elbow/arm complex will be prescribed. High repetition, low weight exercise training is used to increase endurance without placing additional stress across the joint.

Pain relief is often immediate with rest, activity modification, and antiinflammatories. With time and the proper rehab program, many athletes are able to return to play without further treatment.

Studies consistently report that pitch volume is still a major risk factor for shoulder and elbow injuries. Some things have changed in the last few decades that might help you prevent such injuries.

For example, overuse of the throwing arm is accomplished by keeping a log of number of pitches thrown for each practice, game, season, and year. There are recommended guidelines and standards for maximum number of pitches allowed.

Video and computer analysis of pitching mechanics have also contributed helpful information about the effect of different types of pitches. For example, a recent study comparing curve balls with fastballs and change-up pitches showed that curve balls aren’t more dangerous than fastballs for youth pitchers.

Just as you recall from your previous coaching experience, it’s the overuse of the throwing arm that’s the problem. Other risk factors include physical condition of the athlete and pitching mechanics. Differences in stride length and forearm and wrist action can affect ball release. It’s wise to pay attention to all of these factors during practice and preparation of the athlete.

Weakness from injury of the medial collateral ligament (MCL) is a common cause of inner elbow problems for the throwing or pitching athlete. Sometimes rest and rehab can take care of the problem. But when pain and loss of motion and function interfere, then surgery is often the treatment of choice.

The torn or damaged MCL is replaced using donor tissue from another tendon. The palmaris longus is used most often. This tendon comes from a long, slender muscle in the wrist and forearm. Not everybody has one but if you do, you will see it by touching the pads of the thumb and little fingers and bending the wrist. If the palmaris tendon is present, a cord of tendon-like tissue will stand out along the front of the wrist.

Although other tendon grafts have been tried, they don’t seem to be any better than the palmaris longus. The difference may be in the surgical technique used. Type of sutures and suture technique can result in a stiffer, stronger graft. The closer the graft approximates the normal tissue, the faster rehab and recovery can proceed.

Complications after surgery can also make a difference. If there’s been any problem with infection or failure of the incision to heal, recovery can be delayed. Two holes are drilled in the bone to thread the graft through and hold it in place. Sometimes the elbow bone fractures between these two drill holes.

And there may be differences in the load or force placed on the graft during the healing phase. Too much load, too soon can cause the tissue to stretch out and fail. All other factors being the same, there are sometimes just differences between people that we can’t account for. There may be no way to know why one procedure works for one athlete but not another.

You may have injured the medial collateral ligament (MCL) along the inside of the elbow. It is the main stabilizer of the elbow in the bent position. Without it, the elbow may dislocate.

Microtrauma to the MCL can occur from repetitive load such as occurs during throwing activities. The ligament suffers tiny tears and starts to elongate or stretch out. The tissue loses its stiffness as well as its ability to withstand load and force during the pitching motion.

You may need to see an orthopedic surgeon for an evaluation. Tests can be done to look for instability. X-rays showing an abnormally wide joint space on the medial (inside) elbow may indicate a tear of the MCL. An MRI is often used to make the diagnosis. Changes observed in the image help identify the area and amount of damage done.

You may be able to treat the problem conservatively with rest followed by an appropriate rehab program. It takes a long time (months) but many nonathletes can eventually return to recreational play. Chronic joint laxity may require surgery to repair the damage and restore joint stability.

Tennis elbow (also known as epicondylitis) has become better understood now that we have more advanced technology available. What was once thought of as a chronic condition of inflammation (tendonitis) is now understood to be tendon degeneration (tendinosis).

With tendinosis, there is an increased amount of blood flow to the area but the tendons aren’t inflamed. Instead, the nerve tissue is irritated and inflamed, which may be what’s causing the long-term pain and other neurogenic symptoms.

Blood flow can be assessed using a device and testing procedure called real-time color Doppler ultrasonography. Doppler ultrasonography shows blood volume and velocity (speed). In a normal tendon, there is a low-rate of blood flow so it can’t be detected. But with a chronic tendinosis, Doppler ultrasonography shows increased blood volume and velocity.

In some patients, the increased blood supply results in intratendinous calcifications. These are tiny streaks of calcified bone material in between the tendon fibers. This finding tells the physician that the condition has been present a long time. Based on the presence of these calcium deposits, the condition is classified as a stage four epicondylitis.

Treatment decisions are more easily made when the physician has a better idea what’s going on inside the elbow. Stage four may not respond to conservative care, requiring surgery to address the soft tissue abnormalities. The results of Doppler ultrasonography are usually combined with MRI findings to guide treatment decisions.

Tennis elbow is also known as lateral epicondylitis. Lateral means the outside of the elbow is tender and/or painful. Tennis players are most often affected by this condition because of the way they use repetitive force to swing the racquet.

Golfer’s elbow affects the inside (medial portion) of the elbow. The symptoms are the same. The difference is the location and the motions that lead to one or the other developing.

With tennis elbow, the muscles and tendons along the back of the hand and forearm react to overuse. With golfer’s elbow, it’s the muscles and tendons along the inside of the forearm that are torn or aggravated.

Athletes are much more prone to tennis elbow than golfer’s elbow. In fact, tennis elbow is 10 times more common than golfer’s elbow. And in either case, participation in the sport for which it is named, isn’t necessary. Often there is some kind of repetitive motion or traumatic event affecting the specific tendons mentioned.

Usually, with a little thought and observation, the person can figure out what activities aggravate (and probably brought on) the problem. Avoiding those movements or modifying the activity is often the first step in overcoming the problem. Once it becomes a chronic condition, then tendon inflammation isn’t a problem as much as tendon degeneration becomes the issue.

In either case, treatment is needed to restore normal tissue structure and movement.

A terrible triad elbow injury is a fracture and dislocation of the elbow joint. In particular, the elbow has dislocated in a posterior (backward) direction (away from the hand). The coronoid bone is fractured.

The coronoid is a curved, triangular piece of the ulna (forearm bone). It is along the upper and front part of the ulna and fits around the bottom of the humerus (upper arm bone) to form the hinge joint of the elbow.

The third part of this injury is a fracture of the radial head. The radius is the second bone of the forearm. Rotation of the radial head allows the hand to turn into a palm up or palm down position.

This term is used because of a high rate of complications that often occur. Damage to the bone and surrounding soft tissues (especially the ligaments) can lead to elbow instability, malunion, or nonunion. Synostosis of the radius and ulna at the elbow is also possible. This means the two bones form a bony bridge between them. This union forms a joint where there shouldn’t be one.

Surgery is needed with this type of injury to repair and reconstruct the elbow. A rehab program is usually started early in recovery to help avoid these problems.

Your physician’s advice is consistent with current evidence-based clinical guidelines. Conservative care includes a wide range of possible treatment modalities. Non-steroidal anti-inflammatory drugs (NSAID) are recommended when there is an acute case of tendinitis or acute flare-ups that may occur from time to time.

Splints, braces, or special compressive bands around the forearm may be used during repetitive or aggravating motions. A physical or occupational therapist may work with you to identify modifiable risk factors. This can include an ergonomic review of your home or work site.

Changes in posture may be needed. Other therapy techniques such as spray and stretch for trigger points, cross transverse massage, and electrical stimulation may be used by the therapist. Before considering surgery, your surgeon may want to try corticosteroid injections. Up to three injections can be tried over a period of weeks to months.

If all efforts fail to relieve pain and improve function, then surgery may be the next step. Most experts recommend a minimum of a six-month trial of conservative care. In the case of symptoms that come and go, there may be aggravating factors that can be identified and eliminated.

The average patient waits 12 to 14 months before having surgery. Sometimes patients struggle with this condition for years before trying surgery. Researchers haven’t been able to identify the optimal (best) time for surgical treatment. Even the most effective surgical approach remains a matter of debate.

There still remains much about the treatment of chronic epicondylitis (tennis elbow) that we just don’t know. Conservative (nonoperative) care is always recommended first. Patients are encouraged to try a variety of treatments from medications to acupuncture to physical therapy before considering surgery.

When operative management is indicated, the surgeon may use a percutaneous (through the skin) or an open incision technique. Arthroscopic or endoscopic methods are also available. In these approaches, the surgeon inserts a long, thin needle or tube into the area. A tiny TV camera at the end of the needle or threaded down the tube allows the surgeon to see into the area. Open incision is still used in some cases.

The surgeon may release some or all of the soft tissues along the lateral (outside of the) elbow. This may include the extensor carpi radialis brevis (ECRB) tendon, joint capsule, or debridement of any visible pathologic tissue. Debridement refers to removal of the tissue. A small, motorized shaver may be used to gently remove the diseased tissue.

Studies show good to excellent short-term results with any of these operative techniques for lateral epicondylitis. There isn’t enough scientific evidence to support one method over another. Some studies also report a high rate of satisfactory results on a long-term basis. Pain was relieved and function was improved. Patients were often able to return to their previous level of work or play. Only a small number of patients had to change jobs because of continued elbow pain and dysfunction.

There are two types of injections possible for the knee joint. Steroid injections place an antiinflammatory drug right inside the joint. One to three injections are used after patients have tried and failed more conservative measures.

Usually, they have had a trial of three to six months’ of oral antiinflammatories, activity modifications, and/or physical therapy. The therapist helps each patient find ways to use the affected joints more gently and with less force. Range of motion, nerve and joint mobilization, and strengthening exercises can result in less pain, more motion, and more function.

A second type of injection into the joint is called viscosupplementation. A special substance (hyaluronan; also known as hyaluronic acid or hyaluronate) is injected into the joint.

This slippery or gooey substance is a lubricant that cushions the intra-articular surface of the joint. The overall effect is to reduce pain and improve motion and function.

Both types of injections (steroid and viscosupplementation) are used for the treatment of painful joints from osteoarthritis (OA). Treatment of the hip, knee, and ankle are most common.

Not enough studies of intra-articular injections of hyaluronan for the elbow have been reported to know for sure if this is a safe and effective treatment.

Talk to your doctor about what treatment might be best for you. A proper diagnosis must be made first before assuming what you have is OA. Most often, conservative care is advised first before any kind of injection or invasive treatment.

Total elbow replacement (TEA) is used most often for patients over the age of 65 with moderate to severe elbow osteoarthritis (OA). These patients have tried many other forms of conservative care without success.

There are two basic types of TEAs: linked and unlinked. Unlinked means the two pieces (humeral and ulnar) are not hooked together. Unlinked implants are less likely to loosen. They rely on the surrounding soft tissues to hold them firmly in place.

If there is bone loss or soft-tissue deficiency, then maltracking or partial or complete dislocation can occur with the unlinked implants. Linked implants have some mechanical connection between the separate parts. This type of device allows more angle and rotation in the elbow.

The linked implants allow some amount of joint laxity (looseness). This feature permits the soft tissues to absorb stress on the joint. These loads would normally be translated to the implant-to-bone interface.

Studies show that linked devices last at least 10-years for most people. The unlinked system has a lower survival rate. Older adults with fewer loads and less activity are really the best candidates for either of these TEA systems. Younger, more active patients may put too much stress on the artificial joint causing fracture, loosening, or dislocation.

Arthroscopic surgery for lateral epicondylitis (tennis elbow) is considered minimally invasive (MI). This means a very small incision is made. The surgeon is able to minimize the amount of damage to the soft tissues while still repairing the problem.

But there are some potential problems with this approach. In order to use the arthroscopic technique, portals or openings are made to pass the scope through the joint. Although it is minimally invasive, the joint is still entered for a problem that occurs outide the joint.

There is a risk that nerve tissue or blood vessels will be damaged unintentionally with this procedure. And some experts question whether all the damage present (all that needs repair) is seen clearly with such a small incision. An open incision may alter the soft tissue structures but the surgeon has clear access and a clear view of what’s going on inside.

Other complications may depend on the exact type of surgery performed. If the tendon is released, instability and loss of grip strength can occur. Some patients report worse pain than before the procedure. Others report no relief of painful symptoms present before the operation.

Studies show that surgery to treat chronic pain and loss of function from tennis elbow is usually very successful. It’s always recommended that the patient try a good program of rehab first before having surgery.

But sometimes even quality rehabilitation doesn’t change the patient’s symptoms. Surgery to release the extensor carpi radialis brevis (ECRB) is the procedure done most often. This reduces the force transmitted from the muscle through the tendon to the bone.

Some surgeons remove the damaged tissue called tendinosis. They may restore the normal anatomical relationship between the extensor carpi radialis longus (ECRL) and the extensor digitorum communis (EDC). A single hole drilled into the bone along the lateral (outside) of the elbow helps bring an increased blood supply to the area. This step speeds up the healing process.

The expected results include pain relief and restoration of motion and function. You may be able to return to your previous level of athletic and recreational sports activities. Improved grip strength and ability to perform all daily activities without pain is another expected outcome.

Sometimes patients report less than perfect results. They may have difficulty fastening the top button on a shirt. They may have trouble with other similar activities like turning a key, combing the hair, or using uensils to eat. Or they may report pain with strenuous activities. Grip strength may be less than normal. Patient satisfaction may be decreased because of these (or other) limitations.

Extracorporeal shock wave therapy (ESWT) is a way to generate sound waves outside the body that can be focused at a specific site within the body. This treatment technique is also referred to as pressure or sound wave therapy.

Pressure waves travel through fluid and soft tissue to sites where there is a change in tissue density. A common interface is where the soft tissues meet bone.

A special ESWT device delivers shockwaves to the target point where treatment is needed. The shockwaves break down scar tissue that has built up. The body’s repair mechanisms are stimulated to promote healing. New blood vessels develop in the injured area to help jump start the healing process.

ESWT is a noninvasive, outpatient procedure. In some cases, only a single, 30-minute session is needed. Early studies report it is safe and effective. More research is needed to find out who can benefit the most and how and when to use this type of therapy.

Tennis elbow, also known as lateral epicondylitis can be a very difficult problem to treat. For a tennis player, switching back and forth between forearm pronation (palm down) and supination (palm up) positions can bring on this condition.

Repetitive wrist extension adds to the microtrauma occurring at the elbow. The extensor carpi radialis brevis (ECRB) tendon, joint capsule, and surrounding ligaments can all be involved.

Many people with tennis elbow do get better over time with rest and over-the-counter (OTC) antiinflammatories. But further care may be needed for those who don’t and for athletes like you.

There are many ways to treat tennis elbow without surgery. For example, if needed, your physician can prescribe a more powerful antiinflammatory medication than you can get OTC. Only about 10 per cent of patients who see their doctor for this problem need surgery.

You may be helped by a physical therapist. He or she can provide supportive forearm bracing, ultrasound to the tendon, and friction massage to realign the tendon fibers during the healing phase. Specific muscle strengthening called eccentric muscle training is a new treatment approach that works well with other tendon problems and may be equally useful for lateral epicondylitis.

There are also some treatment options that are semi-invasive but do not require surgery. For example, BOTOX injections can partially paralyze and numb the elbow. This method keeps you from repeatedly using the muscles that are aggravated. Steroid injections combined with a numbing agent have also been found effective for some patients.

See your doctor and find out what are all of your options. Choose the one that best fits your goals and expectations. If one method is not successful in eliminating your pain and improving function, you can try another one. It may take a while, but you should be able to find the right combination of treatment techniques to help.

Tendinitis refers to an inflammatory process of the tendon. This occurs where the tendon inserts into the bone. Tendinosis is a degenerative process. With tendinosis, it’s likely that a repair process that included early inflammatory changes took place.

But the events were disrupted. When tissue is examined from the area, there are no signs of inflammatory cells. Instead, fibroblasts and immature blood cells are present. The tendon becomes fragmented and frayed.

Tendinosis describes a chronic, degenerative process. Tendinitis refers to an inflammatory lesion. The terms tendinitis and epicondylitis are no longer used to describe chronic tennis elbow. With improved understanding of the underlying problem, the more accurate term (tendinosis) is used instead.

There are many, many ways to treat tennis elbow. Most doctors advise conservative care first before considering surgery. Nonoperative care starts with rest, ice, and antiinflammatories.

If these are not successful, then splinting or bracing and physical therapy may be the next step. Other treatments such as acupuncture, laser, and shock wave therapy may be tried. For some patients, steroid injections are helpful. However, there is the potential for significant side effects with this treatment.

If a long course of conservative care is not successful in changing the clinical picture, then surgery may be needed. But with all treatments, recurrence of symptoms is common.

Researchers are actively looking for new and improved methods of treatment for this very resistant problem. One of these modalities may be the new ForeArmed Active implant. This brace fits over the elbow and applies direct pressure to the areas where muscles and tendons merge and attach to the bone.

By dissipating the flow of energy to and through the tendon, pain is reduced. Grip strength is improved. Patients who have tried the brace report that it is easy to put on. It doesn’t disrupt their work or recreational and sports activities. And they have full elbow motion.

Early test results using this new brace have been reported as very favorable. It appears that the brace can be used to prevent and treat tennis elbow. More studies are needed to confirm these results.

If the torn ligament in question is along the outside of the elbow, it’s likely to be the ulnar collateral ligament (UCL). Injuries to this ligament are common in throwing athletes.

Thirty years ago, such an injury might have ended his playing days. Today there are several different ways to repair damage to the UCL. Reconstruction using a tendon graft from some other place in the body is a popular way to go about this.

Taking tissue from the patient eliminates the problems of graft rejection that can occur with donor tissue. In the case of the UCL, the surgeon may use one of the round tendons located elsewhere. For example, the palmaris tendon in the palm of the hand is suitable. Likewise, the gracilis tendon along the inside of the upper thigh works well.

Nerve entrapment syndromes of the upper extremity are fairly common. There are more and more work-related cases being reported each year. Overhead throwing athletes are also affected.

There are many possible causes for the kind of pressure on the nerve that can cause painful symptoms, numbness, and weakness. The most common are from anatomical variations in the shape of the bones near the nerves. The location of the nerves as they pass through muscles can also be a factor.

Changes in the cervical spine (neck) can cause problems from nerve compression. Bone spurs, joint hypertrophy, and other arthritic changes can impinge nerves in the upper neck and arm causing ulnar nerve compression.

Tumors, cysts, and fibrous tendon or muscle bands can apply pressure directly to the nerve. Knife wounds, fracture, crush injuries, or other trauma can result in bleeding in and around the nerve. All of these problems can occur anywhere along the length of the nerve as it leaves the cervical spine and travels down to the hand.

The specific cause of ulnar nerve entrapment may be identified with further testing. X-rays, EMG studies, physical exam, and lab values all help point to the etiology (cause) and the location of the problem. Treatment is determined based on these findings.