FAQ Category: Elbow

The ulnar nerve is a branch of the bundle of nerves that start in the neck and come down the arms. It’s located on the inside of the elbow. It supplies messages to muscles in the forearm and hand. The ulnar nerve also provides sensation over the fourth and fifth fingers of the hand, palm, and the back of the forearm.

The ulnar nerve can get trapped inside the soft tissue around it. The most common site of entrapment is in the elbow. The result is a condition called tardy ulnar palsy. This problem was first described in 1878. Tardy refers to the fact that the problem is delayed. It doesn’t happen until thickening or scarring of the tunnel around the ulnar nerve closes down on the nerve.

This pressure on the nerve sets up the symptoms your mother is having. At the same time, normal nerve signals may not be getting through. It’s probably time for a follow-up evaluation to see what’s wrong. Waiting too long can result in permanent damage. Even as it is, nerves can be slow to heal an without full recovery.

Management with conservative care may be all that’s needed. If not, then surgery is a final option. Your mother’s physician will be able to advise her best.

If you express your concerns to your doctor, he or she should be able to help you narrow down your choices. A history of what happened and what your symptoms are will guide the physician. A physical exam can also help identify the potential problem.

X-rays may be of limited value for soft tissue injuries. Bony fractures and bone spurs show up on X-rays. The doctor also looks at the joint spaces to determine if there’s been a ligamentous tear. Whereas a narrowing of the space occurs with degeneration, a widening of the space is seen with ligament rupture.

MRIs show areas of thickening of the ligament from chronic injuries. If a contrast dye is used, then leakage of the dye into torn tissue can be seen.

Not all tears will show up on MRI so sometimes an ultrasound (US) is the best diagnostic imaging study. US shows joint spaces as well as an X-ray or MRI. Arthroscopic exam is not advised because too often the surgeon can’t see a torn ligament if that’s the problem.

Throwing athletes who experience a pop or sharp pain after throwing or pitching may have an elbow injury. The elbow is a complex joint with three bones and all the soft tissues attached between them.

The most common injury along the medial (inside) of the elbow is a strain or tear of the ulnar collateral ligament (UCL). There are three distinct parts or sections to the UCL. Which one may be affected can be determined by the history and an exam.

For example, if pain occurs when the athlete is just starting to throw, it suggests a UCL tear. If the symptoms don’t start until the throw is completed, then it’s more likely the soft tissues are getting pinched between two bones along the back of the elbow. This is called a posterior impingement.

An orthopedic surgeon or sports specialist will use special tests and imaging studies to make the diagnosis. Areas of tenderness point to a diagnosis of tendinitis vs. impingement vs. UCL injury. Special loading tests then narrow the diagnosis to the specific tissues involved.

X-rays, CT scans, and/or MRIs can be helpful. CT scans will show if there are any loose fragments in the joint causing impingement. MRIs using contrast dyes may reveal tears in the soft tissues. Treatment is based on the diagnosis once it’s made.

Current recommendations for ligamentous insufficiency (tear) is absolute rest from throwing. Thirty days is the minimum amount required. Many experts advise up to three months’ rest.

It may be necessary for some throwing athletes to immobilize the elbow at night. A long-arm splint or hinged brace holds the elbow in a flexed position. This allows for tissue healing and helps decrease the pain.

The rest phase is followed by a two- to three-month progression of throwing practice. A conservative program starts at 30 feet with 25 warm up throws alternating with 10 to 15 minute periods of rest. The distance is gradually increased to 45, 60, and then 90 feet.

Not all athletes are able to rehab the elbow. You may complete the entire rehab program and still not be at your former compentitive level. If symptoms persist, you may be a candidate for surgery.

Injuries to the elbow are common among overhead throwing athletes. Recovery can take a long time even with surgery and rehab. And there is an expectation that the athlete should be able to get back to normal after a major injury.

Surgeons and rehab experts are working hard to find ways to help athletes get back to competitive sports. Full elbow motion, a stable joint, and strength to resist a repeat injury are all goals of treatment.

Studies show that even when the injured ligament is repaired, muscle strength around the elbow may not be back to normal. EMG tests show decreased activity in the flexor muscles.

The muscles don’t contract in the same sequence or with the same level of activity as they should for normal function. It is important to identify which muscles are affected and rehab them specifically.

If you’re serious about getting back to your previous level of skill, your surgeon and/or your physical therapist should be able to help you reach your full potential.

Snapping triceps syndrome (STS) occurs when the triceps muscle of the upper arm dislocates and snaps over the ulnar nerve and bone along the inside of the elbow.

Scientists studying this problem don’t have the complete answer yet. There was some thought that retraining the muscle to fire properly would help. But a recent study from the Mayo Clinic disproved this idea.

They used electromyographic (EMG) studies of the muscle’s three sections in patients with STS and compared them to patterns among normal, healthy adults. EMG was used to measure the electrical activity of contracting muscle. They showed that the muscle activation pattern in patients with STS wasn’t any different than the pattern in normal, healthy adults.

Since the condition affects weight lifters, overtraining causing a bulky muscle may be part of the problem. Size and position of the muscle with its three tendons may be the real cause of STS. Specific recommendations for training may be available after the exact cause of the problem is discovered.

Your surgeon has probably already taken X-rays and given you some options to consider. If the rest of the implant is in good condition and isn’t loose, then the surgeon may be able to cement the stem back together.

If there are other problems, the implant may have to be removed and replaced. Some of this decision will be made based on the condition of the remaining joint and strength of the surrounding bone.

If you aren’t a good candidate for revision surgery, then it may be necessary to fuse the joint. The surgeon can fuse the elbow in a “functional” position. You won’t be able to bend or straighten the arm but with the right position after fusion, you’ll still be able to use that arm. Usually the fused elbow means you’ll use the arm as an “assist” to the other arm and hand rather than as the primary mover.

Implant fractures after a total elbow replacement (TER) are fairly uncommon. When they happen, there are usually reasons for it. For example, decreased bone density (bone loss) around the implant can be a factor. This is usually more common in older patients.

Scratches or notches on the surface of the implant can decrease the strength and life of the titanium. This factor is called notch sensitivity. New implant designs may help with this problem. A special coating on the surface of the implant may increase its strength and decrease its vulnerability to damage.

Sometimes patients don’t follow their surgeon’s advice. They lift too much weight too soon after the operation. The result can be a fracture of the implant. Patients in high-demand occupations such as a waitress, truck driver, or farmer are especially at risk.

Titanium alloy remains the material of choice for elbow prostheses. It is strong but has some give and its accepted by the body more easily than cobalt-based or stainless steel devices. With the new plasma spray coating on implants, implant fractures have decreased considerably.

You have described a coronoid tip fracture of the elbow. In other words, the tip of the ulnar bone in the forearm has broken off. The elbow is a hinge joint made up of three bones. These include: 1) the humerus (the upper arm bone), 2) the ulna (the larger bone of the forearm, on the opposite side of the thumb), and 3) the radius (the smaller bone of the forearm on the same side as the thumb).

The end of the ulna at the elbow is called the coronoid process. It is shaped like a hook that fits around or hooks over the spool-shaped end of the humerus.

When a large fragment breaks off the coronid tip, joint dislocation is likely. Smaller fragments can also result in joint instability. The reason for this is because the joint capsule, a fibrous covering around the outside of the joint, attaches to the tip of the coronoid process.

If the tip is disrupted, the capsule is damaged too. Without the capsule to hold the joint together, dislocation can occur. According to a recent study of cadavers (human bodies preserved for scientific study), even small coronoid tip fractures can lead to elbow instability.

Surgical repair is the best way to prevent this from happening. The surgeon wires the bone fragments back together and holds everything in place until healing can occur. Your son may have a better chance of recovering full motion without further problems with this treatment plan.

The elbow has three main bones in it — the humerus (upper arm) and two bones in the forearm. The forearm bones are the radius and the ulna. The radius has a flat, round disc-like top where it connects to the bottom of the humerus at the elbow. Next to the radial head is a bony shelf at the top of the ulna. This part of the ulnar bone is called the coronoid process.

A terrible triad injury consists of three parts. The head of the radius is broken. The coronoid process is also fractured. The elbow is dislocated and most often, the lateral collateral ligament (LCL) along the outside of the elbow is torn.

The word terrible is used because these injuries are very hard to treat successfully. The elbow dislocates repeatedly and is unstable. Post-traumatic arthritis is common.

The best way to treat terrible triad injuries remains a topic of debate among surgeons. Some suggest removing part or all of the radial head. Other say the radial head should be repaired along with the LCL. The radial head can also be replaced with a titanium implant. The coronoid fracture must be repaired as well. Screws or wires are used to hold the coronoid together.

Sometimes pins are used outside the arm that go through the bone to hold everything together until it heals. This is called external fixation.

All in all, the terrible triad injury is a complex elbow joint problem that often results in an unstable joint. Careful surgical management along with rehab is the key to a good outcome.

The elbow has some unusual and very individual anatomy that can make a difference after injuries. Fractures and dislocations can alter the normal bumps and grooves that give the elbow joint its alignment. Elbow dislocation with even one bone fracture increases the risk of problems.

The elbow is a hinge joint with its major point of axis for movement and rotation where the bones of the forearm insert into the humerus (upper arm bone). The bottom of the humerus called the trochlea is spool-shaped. The top of the ulna wraps around this spool to form the hinge. The joint gets its stability from this alignment.

Besides the formation of the bones and joints, there’s also the strength and stability given by the surrounding ligaments. Many times when an elbow is dislocated, the ligaments are torn or damaged, too.

It’s the combination of dislocation, fracture, and soft tissue damage that creates an unstable joint. Until all three of these structures are repaired, restored, and strengthened, there is a risk of recurrent dislocation and instability.

Cubital tunnel syndrome is a pinched ulnar nerve at the elbow. Constantly bending the elbow puts pressure on the nerve causing pain, numbness, and tingling at the elbow and sometimes down the arm into the hand.

The nerve can be checked with two electrodiagnostic tests. The first is nerve conduction velocity (NCV), which measures the speed of messages down the nerve across the elbow. Any compression of the nerve will slow the messages down. The second is an electromyogram or EMG.

The EMG tests the muscles innervated by the motor portion of the nerve. Muscle weakness and atrophy may occur with a pinched nerve. If the nerve compression is mild, then the test may be negative. If only a portion of the nerve fibers are affected, then EMG and NCV may appear normal.

This may be the case for you. Ask your doctor to explain the results to you. If the symptoms persist or get worse, you may benefit from having the tests repeated to show any changes that have occurred.

You may be referring to a test called Tinel’s test. The doctor uses his or her hand or reflex hammer to gently tap the ulnar nerve as it passes close to the skin along the inside of the elbow. If the test causes pain, numbness, or tingling down the arm, then the test is considered positive for ulnar nerve entrapment. Another name for this problem is cubital tunnel syndrome (CuTS).

This test by itself isn’t considered reliable. In at least one-third of all normal adults tested, Tinel’s test was positive when there was nothing wrong. This is called a false positive test.

The doctor must rely on a series of tests to confirm or rule out CuTS. This may include the patient’s history, clinical exam, and special tests. Tinel’s test will be one as well as the elbow flexion test and perhaps even a test of electrical impulses along the nerve.

Cubital tunnel syndrome (CTS) is a common nerve entrapment. The ulnar nerve alongside the outside of the elbow travels down and around the elbow in a trough or tunnel called the cubital tunnel. Pressure on the nerve from inside or outside the tunnel can cause painful symptoms. Numbness, tingling, and weakness of the hand and fingers are also common.

Doctors aren’t sure the exact cause of CTS. It could be increased pressure by the wall of the cubital tunnel affects the nerve. It could be stretching of the nerve itself. Perhaps both factors occur together. A few studies have shown increased pressure from the angle of the elbow. Increased elbow flexion decreases the amount of space in the tunnel for the nerve.

A recent study from Japan suggests compression from outside the tunnel is part of the problem. During surgery for eight patients with CTS they measured the pressures inside the cubital tunnel. Pressure was measured at three separate locations with the elbow in two different positions.

The results of this study support the idea that pressure inside the tunnel affects the nerve and leads to CTS. Surgery to move the nerve away from the tunnel is advised.

Neuropathy is a general term that refers to any problem with the nerves. Any part of the nerve can be affected, but damage to the axon is most common. The axon sends signals or messages from one nerve cell to the next.

There are many possible reasons for neuropathy. Poor nutrition combined with chronic alcohol use, diabetes, or lead poisoning can cause neuropathies. Many people suffer from neuropathies without ever knowing the cause.

Complaints of symptoms of the last two fingers suggest involvement of the ulnar nerve. Once the location of the neuropathy is established, then the cause can be determined. Pressure on the nerve coming anywhere from the neck down to the wrist can cause this kind of clinical problem.

Elbow position can make a difference when mixed latency difference (MLD) is measured. MLD is a method of measuring the difference between the latency of the ulnar and the median mixed nerve action potentials (MNAP).

Their method entails recording MNAP of both nerves from the same position in the upper arm following the stimulation of these nerves at the same level at the wrist. The MLD increases when the elbow is bent. A small amount of flexion (less than 15 degrees) is acceptable for this test. Elbow position isn’t a problem if both tests are done with the exact same position.

It’s best to keep the patient’s forearm palm up (supination) during the test. It’s easier to stimulate the median and ulnar nerves in this position. It’s also easy to overstimulate the ulnar nerve in the supinated position, so extra care is required during the testing.

Don’t be afraid to ask your doctor this question. Your observations of test differences may make a difference in how the results of your tests are interpreted.

Elbow problems are common among amateur and professional golfers. And there’s a wide range of causes for the same symptoms. An orthopedic surgeon will have to sort out your symptoms before a diagnosis can be made.

Examination of your pain, motion, and strength is important. Special movement tests will help point to nerve, tendon, ligament, or joint problems. Many times golfers are told the problem is lateral epicondylitis also known as “tennis elbow.”

According to a recent study half of the patients with lateral elbow pain were given this diagnosis when it wasn’t the problem at all. Further testing with MRI and arthroscopy showed an extra piece of synovium called plica was the real cause of the symptoms.

Plica forms in the knee or elbow at the point where several pieces of synovium come together. The synovium is the thin layer of tissue that lines the joints and keeps the lubricating (synovial) fluid inside the joint.

The plica is an extra fold of synovium that gets caught in or pinched by the joint during motion. This may be what’s keeping your elbow from extending all the way. Seek professional help if the problem doesn’t go away. You may be able to get control of your symptoms with medications and exercise.

Most orthopedic surgeons will advise patients with elbow impingement to try nonoperative or conservative care first. A two or three month trial of drugs and/or exercise is always a good idea.

Antiinflammatories are the first choice. The doctor may advise over-the-counter ibuprofen or a prescription dose. Steroid injections into the area of discomfort give relief of symptoms in many patients. Results may be permanent or only temporary.

Activity modification is worth a try while taking the medications. Avoiding repetitive motions while the inflammation is getting under control may help. A short course of supervised physical therapy is also an option.

The therapist will help you avoid positions and activities that make your symptoms worse. Your posture will be evaluated and anything contributing to the problem will be addressed. Exercises to maintain and improve strength and range of motion without increasing symptoms will be offered.

If none of this helps or only gives minimal relief from symptoms, then surgery may be the next step. The surgeon will remove the troublesome tissue. There’s usually a rehab program after surgery. Modalities to control pain while increasing motion will be followed by specific exercises to regain strength.

Talk with your doctor about what options are best in your case. Express your interest in avoiding surgery and ask about conservative care. Give it at least three months before deciding the next step.

The ulnar nerve on the inner side of the elbow and forearm can get pinched or compressed causing problems. One way to treat this condition is by removing part or all of the bone along the inside of the elbow. The operation is called an epicondylectomy.

It sounds like you may have had a minimal or partial epicondylectomy. Elbow pain, finger numbness, and loss of elbow flexion are common after this operation. In most cases these symptoms resolve or go away on their own. You should see a gradual improvement from 30 days to three months.

Elbow pain and function is often better after this operation but many patients still report mild to moderate pain even years later.

You may have a condition called cubital tunnel syndrome. The cubital tunnel is a shallow groove in the bone alongside the inner elbow. The ulnar nerve lies inside this tunnel. Pressure on the nerve for any reason at this site can cause pain, numbness, tingling, and muscle atrophy with loss of strength.

Cubital tunnel syndrome can be caused by many different things. For example, bone spurs, tumors or cysts, and bands of fascia or connective tissue can put pressure on the nerve. Surgical treatment depends on the underlying cause of the problem.

The surgeon may release any soft tissue constricting or pressing on the nerve. A piece of the bone may be removed to give the nerve more room in that area. This operation is called an epicondylectomy. Sometimes it’s necessary to move the nerve away from the bone. This is called a nerve transposition.

Most often the final decision about which operation to perform is made at the time of the operation. Once the surgeon can see the condition of the nerve and the exact problem, then the best procedure can be carried out.