What’s the best way to get relief from tennis elbow? I’m retired so my job doesn’t depend on getting my arm back to normal but I do like to golf, fish, and play tennis.

The best, most effective treatment for lateral epicondylitis, otherwise known as “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 relatively new treatment approach to consider. 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.

In a recent study from Denmark, the results of three different types of treatment were compared on 60 patients who had lateral epicondylitis. Painful symptoms along the outside of the elbow (and diagnosed as tennis elbow) had been present for more than three months for each person in the study. Twenty patients received a single injection of platelet-rich plasma, 20 received an injection of saline (salt water for a placebo treatment), and 20 people got a steroid injection. Change in pain was the main outcome measured.

One surgeon performed all of the procedures. In each case, the physician knew what type of injection was being given but the patients did not. In fact, they were blindfolded during the treatment. Results were measured at three, six, and 12 months after treatment using an ultrasound test of tendon thickness and pain intensity. Function was also evaluated by having the patients fill out a survey called the Patient-Rated Tennis Elbow Evaluation (PRTEE).

The authors reported a very high dropout rate from this study in the first three months. The patients said they left the study because the treatment didn’t work. At the end of 12 months, only 16 or the original 60 patients were still participating. Their overall findings are summarized below:

  • Steroid injection gave the best pain relief and improved function in the first month.
  • At the end of three months, there was no difference in treatment results between the three choices for pain and disability measures.
  • Tendon thickness increased with PRP (blood injection therapy) and saline. Tendon (and skin) thickness decreased (atrophy) with the steroid injection.
  • Platelet-rich plasma (PRP) injections were the most painful (additional pain lasting up to three weeks in some cases). That is because PRP requires five to seven pokes into the tissue as opposed to only one with steroid or saline injections.

    The authors concluded that their study repeated what other studies have shown regarding steroid injections: they provide early pain relief but have a thinning effect on the soft tissues (skin and tendon). Results using platelet-rich plasma (PRP) were not as favorable as has been reported in other studies. In this study, PRP wasn’t any better than a placebo treatment. And so, the search for a successful treatment for tennis elbow continues.

    Some people do get relief from the treatment approaches described above. So it’s worth trying one or several techniques. It’s just that there isn’t one known way to treat tennis elbow that consistently works for everyone. Consult with your physician and/or physical therapist for what might help you get started in looking for some pain relief so you can stay active. With a little trial and error, you may hit upon the best treatment or combination of approaches that works for you!

  • I just watched a You Tube video of my brother who dislocated his elbow in a high school wrestling match. Gruesome! He’s so strong, I can’t figure out how this could have happened. If I download it to you, could you look at it and tell me what you think?

    Thanks to You Tube we now know that elbow dislocations don’t occur the way previous investigations using cadavers led us to believe. In the past, researchers had no choice but to rely on cadavers (human bodies preserved after death) to study the patterns and mechanisms of elbow dislocation. And those studies suggested that forces placed on the flexed (or bent) elbow led to traumatic elbow dislocation.

    But a recent (published) review of 62 You Tube videos clearly showed that most acute elbow dislocations occur when the elbow is extended (relatively straight). A closer look at all aspects of elbow dislocation revealed some interesting information.

    For example, more than two-thirds (68 per cent) of cases, the forearm is 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. 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 tend to be from sporting events such as wrestling (most common!), 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. This is most likely what happened to your brother.

    The authors of this study of elbow dislocations using You Tube videos 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. And this could possibly explain what happened in your brother’s case as well.

    I just started a rehab program for golfer’s elbow. The physical therapist told me: if it hurts, don’t do it. If it hurts the next day, back off — you overdid it. Does that make sense to you? What about the old saying, “no pain, no gain”?

    There are some times when pushing through pain is advised. But there is more and more evidence from studies that this idea is not appropriate for tendon healing. The physical therapist you are working with clearly understands the phases of healing and is tailoring the program to meet your specific needs. That is very important in moving ahead and avoiding re-injury (even microtrauma from overdoing it can set you back).

    The guidelines your therapist gave you are consistent with current practice. Mild pain after exercise activity that goes away within 24 hours is also usually acceptable. This is another way to gauge your program. As you progress through rehabilitation, the therapist will guide you on how much pain or discomfort is allowed.

    For example, pain with activity that changes the way you hold yourself or the way you move is not acceptable. That just sets up asymmetries within the body (uneven motion or strength from one side to the other) and compensation patterns in the soft tissues. The end result can be re-injury or new aches and pains developing.

    Likewise, constant pain, pain that keeps you awake at night, or pain that wakes you up after you drift off to sleep should be reported to your therapist. He or she will reevaluate you to make sure healing is continuing to progress as it should and that there isn’t something else more serious going on.

    Any time a health care professional gives you advice or guidelines, don’t hesitate to ask for the reasoning behind them. A patient who understands why he or she is doing something is more likely to be compliant and do it! That could be the key difference between a successful rehab outcome or failure.

    Our daughter is just starting a rehab program at a sports physical therapy clinic for her tennis elbow. She’s actually a volleyball player but they still call it tennis elbow. We are wondering what to expect and how long she’ll be in this program.

    Overhead athletes (e.g., tennis players, javelin throwers, baseball pitchers, volleyball players) can lose significant function of the arm after an elbow tendon injury. Physical therapists are often in charge of getting these players back to full force in hitting, pitching, serving, and spiking.

    But what is the optimal rehabilitation program for athletes who injure their elbows? In a recent publication, an expert in sport rehabilitation and research addressed the current recommendations for treatment of elbow tendon injury. We offer you a brief summary here.

    The basic idea presented is that physical therapists must first know the specific pathologic process going on in the injured tendon. And second, it is equally important to understand the healing mechanism occurring throughout the rehab process.

    To accomplish step one (recognize and diagnose elbow injury), it involves an examination of the entire arm (upper extremity), baseline X-rays, and specific clinical tests applied to the arm. For example, it’s not enough to just measure the available elbow range of motion. The physical therapist must evaluate individual motions of the shoulder, scapula (shoulder blade), and wrist. It’s not unusual for athletes to lose motion in one direction while gaining motion in another. Asymmetries (differences in strength and motion from one arm to the other) can create significant problems in stability and mobility.

    There may be ligamentous laxity (looseness) in the elbow joint that put increased stress on the nearby muscle tendons that are trying to compensate. When the muscle/tendon unit has to do the job of the ligament (to stabilize the joint), it can’t do its own job (move the arm). Eventually, other problems can develop as the body adapts but loses optimal function.

    The physical therapist views each athlete as a total person — not just the elbow or the arm. The clinical evaluation takes into consideration other structures and injuries (or compensations) in other areas of the body. The therapist must determine what phase of injury and healing the player is in and provide treatment that 1) protects function, 2) restores strength, and when appropriate, 3) returns the player back to full sports activity.

    The goals of physical therapy in the rehabilitation of tendon injuries are to restore strength, endurance, and flexibility. Before returning an athlete to activity, it is advised that strength and motion on the injured side equal the other arm. Of course, the therapist who evaluates and develops a plan of care to treat your daughter is the one to ask this question but it doesn’t hurt to get a general idea of what to expect. We hope this information helps!

    I am stumped and so is my surgeon (I think). I have a case of chronic pain from tennis elbow along the outside of my elbow. A tiny tissue biopsy showed there isn’t any inflammation. So why hasn’t anything we’ve done for treatment helped me? I even had an epicondylectomy (if I spelled that right) and still it hurts. Do you have any possible explanation?

    Pain along the outside (lateral) elbow from chronic overuse and repetitive activities describes what many patients with chronic epicondylitis experience. Conservative treatment (without surgery) isn’t always successful.

    The reason chronic tennis elbow doesn’t get better sometimes is because the tiny microtears of the extensor tendons that are involved don’t heal fully. A partial repair gets interrupted and ends in distortion of the collagen fibers and degeneration of the tendon fibers. Many microscopic studies of the affected tissues have proven there is a lack of actual inflammation in these chronic cases.

    When nonoperative treatment fails, surgery to release the tendon from its attachment to the bone is often suggested. That’s the epicondylectomy you had (and yes, you did spell it correctly!). A failed epicondylectomy may be the result of a second compounding problem known as radial tunnel syndrome.

    Radial tunnel syndrome happens when the radial nerve is squeezed where it passes through a tunnel near the elbow. The symptoms of radial tunnel syndrome are very similar to the symptoms of tennis elbow (lateral epicondylitis). There are very few helpful tests for radial tunnel syndrome, which can make it hard to diagnose.

    It is possible that the radial tunnel syndrome is really the reason why some patients do not respond fully to other treatment (conservative and/or operative) for epicondylitis. When surgery is performed, the surgeon can take a look in the area and see if there might be other potential causes for the persistent pain. Further study of this problem is needed to determine whether additional treatment of this second problem will eliminate the painful symptoms and weakness.

    In your case, a follow-up arthroscopic examination may help identify secondary problems that might be contributing to your ongoing problem. If you feel your surgeon has done all he or she can do for you, you may want to seek a second opinion and ask about ways to determine what’s wrong.

    I’m looking for any information I can find to help me avoid surgery for chronic tennis elbow. I’ve spent the last year chasing after every other kind of treatment but nothing has helped. The surgeon has recommended lopping off the tendon and a piece of the bone where the tendon attaches. I’m kind of attached to my tendons and bones and don’t want to go whacking them off. Is there anything else you can suggest?

    Without knowing the details of everything you’ve already tried (e.g., acupuncture, diet and supplements, cortisone shots, physical therapy, splinting, pain relievers, myofascial release, and so on), we can report on an alternative treatment that has been proposed for tennis elbow also known as lateral epicondylitis.

    Pain along the outside (lateral) elbow from chronic overuse and repetitive activities can be ended by interrupting the nerve pathways. In a study from Johns Hopkins University, a partial nerve denervation was tested as a possible alternative to the more common treatment approaches.

    By cutting the tiny nerve branches to the lateral epicondyle (side of the elbow away from the body), the authors hoped to provide pain relief without altering elbow function. They used pain and grip strength as their main tests of treatment effectiveness.

    Thirty elbows were included in this study. All patients had tried more than six months of conservative (nonoperative) care without success. They took antiinflammatory medications. They tried bracing and physical therapy. They had at least one cortisone shot into the tendon at fault. Nothing changed their pain significantly enough to be considered effective.

    Many times when nonoperative treatment fails, surgery to release the tendon from its attachment to the bone is suggested. But in this study, hand surgeons tried a different approach. They used a small open incision to carefully identify the tiny nerve branch to the lateral elbow, injected it with a numbing agent, and then cut it. They moved the nerve branch up into the main belly of the triceps muscle (along the back of the upper arm) where it could not reconnect or cause any further pain.

    Before trying this approach, each of these patients did respond well with pain relief and improved grip strength to a temporary diagnostic nerve block. The specific area numbed (and later cut) was the posterior cutaneous nerve of the forearm just above the lateral humeral epicondyle (outside of the elbow bone). None of the patients had any previous elbow surgery or nerve blocks before this study.

    Everyone was followed for at least two years. Early follow-up included assessment of pain and testing grip strength. Final follow-up was done using an emailed survey of pain and level of patient satisfaction. Each patient contacted was also asked if they would have this same type of (denervation) surgery if the other elbow developed chronic tendonitis.

    As it turned out, 80 per cent of the group reported good to excellent results with pain relief and improved grip strength. The treatment was considered a “failure” if the patient still had significant persistent pain and/or had to have another surgery. Because a superficial nerve (to the skin) was cut, some of the patients had numbness along the forearm for a while. This was temporary for all but one patient but no one was bothered by it because the pain was gone!

    Of the five patients who had a “failed” response, four of them also had a condition known as radial tunnel syndrome. Radial tunnel syndrome happens when the radial nerve is squeezed where it passes through a tunnel near the elbow. The symptoms of radial tunnel syndrome are very similar to the symptoms of tennis elbow (lateral epicondylitis). There are very few helpful tests for radial tunnel syndrome, which can make it hard to diagnose.

    It is possible that the radial tunnel syndrome is really the reason why these few patients did not respond fully to the denervation procedure. Further study of this problem is needed to determine whether additional treatment of this second problem will eliminate the painful symptoms and weakness.

    But for now, this study showed that a partial denervation is a simple and effective, alternative way to treat persistent lateral epicondylitis. And it showed that using a diagnostic local numbing agent is a good way to tell who might benefit from partial denervation.

    Patients may prefer this partial nerve denervation treatment over epicondylectomy (to remove the damaged tendon and bone). They can get back to daily activities right away and return to work faster without the need for rehab. It might be something worth asking your surgeon about for you. The diagnostic numbing injection would help determine whether this approach could be successful in your case.

    We are trying to decide on a surgeon for our 14-year-old son who has a torn lateral collateral ligament (LCL) injury of the elbow from playing sports. There are two active orthopedic surgeons in our community. One is young and closer to being out of school. The other is older but with more experience. How do the older docs keep up with new techniques? It would be great if we could find out he has experience and recent know-how.

    Continuing education takes many different forms and approaches for the health care professional. On-line courses, hands on conferences, and even review articles in published journals offer a variety of ways to keep up. For example, in a recent article, orthopedic surgeons are brought up-to-date on the diagnosis and treatment of lateral collateral ligament (LCL) injuries of the elbow (exactly what you asked about!).

    The article presented many facets of management of an elbow lateral collateral ligamentous injury. It was designed to create understanding, reflection, and thought on the part of the surgeon treating these kinds of problems. The authors made use of patient photos, X-rays, drawings of the soft tissue anatomy (muscles and ligaments), and even photographs of dissected cadavers showing specific locations of muscles, nerves, tendons, and ligaments.

    Topic areas discussed included functional anatomy, etiology (cause), classification (how to describe the extent of injury), clinical examination and findings, as well as diagnostic imaging. The second half of the article addressed surgical considerations for reconstructive surgery and post-operative care.

    The two main causes of lateral collateral ligament (LCL) damage are injury (e.g., torn or stretched joint capsule and/or ligaments) and dislocation (e.g., fall on the outstretched arm). Chronic, recurrent dislocation is referred to as instability and requires surgery. The surgeon uses tendon grafts to restore elbow joint stability and tries to return normal motion of the bones of the forearm.

    The authors lead the reader through the details of the complex anatomy and coordination of all the soft tissues of the elbow. These are required to move the elbow and forearm through its full motion. This concept is referred to as functional anatomy. An understanding of functional anatomy is important because the surgeon will be called upon to return the patient’s anatomy to as normal as possible. The goal is to help the patient once again regain full, smooth, and coordinated motion, strength, and function.

    Based on the findings of the physical examination, X-rays (plain and stress radiographs), and MRIs, the surgeon will decide what is the best way to repair or reconstruct the anatomy to achieve these goals of restoration just described. There are many key factors to think about when planning the surgical procedure.

    For example, the surgeon evaluates whether there are any fractures that must be addressed. Are there other soft tissues (besides the LCL) that are torn or damaged? What was the patient’s anatomy like before the injury? There are always variations in shape, symmetry, and position of bone and soft tissues from person to person.

    The surgeon must decide: is this going to be a repair procedure or reconstructive surgery? Studies have not been done to compare results of these two approaches. Therefore, the surgeon does not have evidence-based research on which to base his or her decisions in these matters. There are some studies reported. There just isn’t enough evidence to support one approach over another.

    Repair techniques becomes another area of surgical decision-making. What type of sutures should be used (bone anchors with nonabsorbable sutures are preferred by many surgeons). Should the sutures be placed through tunnels that require drilling through the bone? Even the position the arm is placed in during surgery becomes an important consideration.

    Likewise, reconstruction techniques are being investigated. A table representing study results from 1991 to the present date is provided. Type of reconstruction, graft type, outcomes, and complications reported for 12 different studies are summarized for the reader’s consideration.

    And finally, a focus on postoperative protocols (i.e., how to treat the patient after surgery) concludes this continuing education document. Another table is presented summarizing treatment after surgery for the 12 studies mentioned above.

    Elbow immobilization in a splint or brace was common for anywhere from one to six weeks. Position of the elbow in the device was reported and also varied from 45 degrees of elbow flexion up to 90 degrees with either full or slight forearm pronation (palm down position). Range-of-motion activities, progression through strengthening exercises, and return to sports (usually six months after surgery) were also reported for these 12 studies.

    Anyone interested in the diagnosis, treatment, and follow-up for patients with recurrent lateral instability of the elbow due to lateral collateral ligament damage of the elbow will find this article of interest, relevant, and helpful.

    I saw a video at my surgeon’s office on the arthroscopic procedure she plans to do on my elbow. I have a bit of loose cartilage in there that keeps getting caught so she is going to remove it. In the video, the patient was completely covered in surgical linens so that all that was visible was the forearm from the elbow down. This is probably a silly question, but is that really necessary?

    You are referring to a technique we call “surgical draping”. The patient is indeed covered from head to toe leaving only the surgical field visible. This approach has been developed over the years to help prevent infection to the patient. It also helps protect the surgical team from any contact with the patient.

    The procedure of covering a patient and surrounding areas with a sterile barrier is actually carefully orchestrated. Surgical staff must do it perfectly each time to create and maintain a sterile field during the surgical procedure.

    Draping materials may be made of paper or plastic (disposable) or linens (nondisposable). These materials are sterile and again, are designed specifically to maintain a sterile field and prevent the passage of any microorganisms (especially bacteria) from the nonsterile area to the patient.

    Elbow arthroscopy is usually done with the patient under general anesthesia. The patient will be relaxed and comfortable. If there is concern for postoperative nausea from the anesthesia, then a regional anesthesia (just the arm is numbed) can be used. Using a nerve block like this has one major disadvantage. The surgical staff cannot assess the patient’s neurologic status for quite some time after surgery (until the nerve block wears off).

    Careful patient positioning is as important as draping. The right patient position gives the surgeon the best view inside and around the joint. Depending on the procedure, you may be supine (on your back) with the arm suspended by traction or prone (face down) with the arm hanging off the table in a special arm holder. All of these tools and materials must also be sterilized to help maintain a sterile environment and prevent infection.

    My surgeon wants to do an arthroscopic exam on my elbow to find out what’s wrong. I know this is supposed to be a simple procedure. But I seem to be the kind of person where nothing is ever very simple. Can you tell me more about what to expect?

    Elbow arthroscopy is a surgical technique used routinely now for the evaluation and treatment of many elbow problems. Since the first arthroscopic elbow treatment became available, the ways and reasons to use this tool have expanded. Now surgeons use it to clean the joint out from any infection, remove any loose bodies (fragments of bone, soft tissue, cartilage), and repair defects (holes or other lesions) in the bone.

    Some patients can’t be treated with arthroscopy but require an open incision instead. Anyone with abnormal or distorted anatomy and anyone with severe heterotopic ossification (bone formation in the soft tissues). Patients with burns or who have skin grafts are not good candidates for this type of procedure because of the danger of damage to the nerves and blood vessels.

    The procedure itself is usually done with the patient under general anesthesia. The patient will be relaxed and comfortable. If there is concern for postoperative nausea from the anesthesia, then a regional anesthesia (just the arm is numbed) can be used. Using a nerve block like this has one major disadvantage. The surgical staff cannot assess the patient’s neurologic status for quite some time after surgery (until the nerve block wears off).

    Careful patient positioning is important to give the surgeon the best view inside and around the joint. Depending on the procedure, you may be supine (on your back) with the arm suspended by traction or prone (face down) with the arm hanging off the table in a special arm holder. There are advantages and disadvantages of each position your surgeon can discuss with you if you are interested in those details.

    Though elbow arthroscopy is a well-used procedure now, it still takes expertise and experience on the part of the surgeon to be successful. There are many factors to take into consideration including knowledge of the elbow anatomy and correct patient positioning. Inserting the scope into the joint also requires careful selection of placement to avoid complications.

    As you might guess from what has been said already, the most commonly reported complication is nerve injury. Damage to the nerve usually results in a temporary neurologic injury but sometimes the nerve gets cut completely. This is more likely to cause permanent damage. Infection and damage to the soft tissues are the other most common problems surgeons must try and avoid. Good surgical technique and proper portal placement go a long way in preventing complications.

    My 69-year-old father thinks he may have dislocated his elbow but popped it back in place. Now whenever he goes to get up from his chair, he cannot push up with his arm on that side without feeling like it’s going to pop out again. What do you make of this kind of problem?

    You may be describing what is referred to as a positive chair sign. Essentially he is performing a sitting pushup. With the elbows bent to 90 degrees and the arms out to the side, extending the elbow fully while pushing up on the arm of the chair causes a feeling of apprehension. The patient cannot put full pressure through that elbow without a sensation that the joint is going to pop or redislocate.

    This type of report suggests instability of the joint from damage (tear or rupture) of the joint capsule and/or surrounding soft tissues (ligaments, tendons). It may be advised to see an orthopedic surgeon for a proper evaluation and treatment of the problem.

    The physician will review your father’s history (what happened, when, and how). Special clinical tests will be done to evaluate all of the structures of the elbow to identify what might be damaged. Imaging studies such as X-rays (plain and stress) or MRIs may be ordered.

    Treatment depends on the full extent of the injuries, your father’s overall general health, and his desires or goals for motion and function. The surgeon will decide whether conservative (nonoperative) care or surgical repair or reconstruction is the best way to go. The goal is to restore as much as possible normal anatomy, motion, and function.

    I’m 61-years old, so I’m no spring chicken but I’m also no wimp and stay active each and every day. Unfortunately, last fall, I fell and broke my elbow. The radial head was broken into tiny bits and pieces. I had surgery to put it all back together and I’m still in rehab but wondering if I’ll ever get my motion back. What is a realistic expectation for something like this?

    According to a recent update on radial head fractures published in The Journal of Hand Surgery, this type of fracture is the most common elbow fracture. Undisplaced (bones are not separated) fractures have the best results. More serious, involved fractures may take longer to heal with less “perfect” outcomes.

    For example, the type of fracture you describe having (“tiny bits and pieces”) is referred to as comminuted. Surgery with hardware to hold the bones together is advised but it can take quite a while for the bones to knit back together. Other factors such as general health, bone health (any osteoporosis or brittle bones?), nutrition, hormone deficiency, and activity level can all impact healing and outcomes.

    The more soft tissue damage around the joint, the more complicated treatment and recovery can be. It is not uncommon for the return of motion to take many months of hard work. But according to the studies done so far, most patients can expect a pain free elbow with full motion and normal function.

    In some cases, there can be stiffness that limits full elbow extension. But unless you are an extreme athlete, there aren’t very many activities that really require zero degrees of elbow extension. Most patients tolerate up to a 30-degree elbow contracture. Contracture means the elbow doesn’t move past a certain point and it normally should. Contractures can be caused by a mechanical block in the joint itself or tightness in the soft tissues around the joint.

    Since you are still in rehab, your surgeon and therapist are the best ones to advise you as to expectations and possible outcomes. They have some information that can help predict what might yet happen for you. Severity of fracture, type of surgery, and patient characteristics are all factors they take into consideration when advising someone like you.

    Don’t hesitate to ask them this question but don’t be surprised if you get different answers or less of a prediction than you hoped for. There can be a wide range of results; each person is unique and different outcomes can be seen from patient to patient even with what looks like the same injury.

    I’m new at this Internet thing, so I hope this reaches you because I need some help. I broke my elbow (radial head fracture) into a couple pieces that could be pinned back together. It’s been six months now and I’m still stiff as a board — can’t bend or straighten all the way either. I did (and still do) my exercise program. What’s holding up the works?

    If you took a poll of all adults who have had a radial head fracture, stiffness would probably be the number one lingering postoperative problem. There are a number of different possible reasons for this complication starting with the hardware used to hold it together. If the pins or screws come loose and start to back out, they can block motion. Some hardware may be in its proper place but prominent causing the same mechanical problems.

    Noncompliance with the rehab program is certainly one reason some patients don’t get their motion and function back. But it doesn’t sound like this is the case for you. Even the most compliant patients can end up with stiffness if the joint capsule (soft tissues around the joint) tighten up or contract. Other changes in the soft tissues such as heterotopic ossification (bone forming in the muscles) can account for stiffness weeks to months later.

    The best way to find out what is going on is to re-visit your surgeon. You may need some imaging studies (X-rays and/or CT scans) to determine the cause. But a physical examination may also reveal the underlying problem. If the soft tissues are stiff but the joint still has a little bounce or spring to it, then a splint may be helpful. But if the joint is blocked and has no “give” to it at all, then another surgery may be needed.

    Even if you have to have a second (revision) surgical procedure, good results are still possible. The surgeon may just remove the radial head and replace it with a spacer so you have normal forearm and elbow motion. Elbow joint replacements are available but this option is saved for last if and when nothing else works.

    Make a follow-up appointment with your surgeon sooner than later. Early follow-up may yield better results before the soft tissues become so stiff they can’t respond to treatment. Be prepared for some additional rehab and exercises but with your hard work and diligence, it’s likely you can expect a good result!

    I am a surgical scrub nurse so I have a little extra knowledge of orthopedic problems. I want to ask about surgery for my niece. She has a type two fracture of the elbow (capitellum and trochlea are still together but broken off from the rest of the bone. Her mother (my sister) is a physical therapist and wants her to have surgery. I always recommend people avoid surgery. What’s best in a case like this?

    From your description, it sounds like she may have what’s known as a coronal shear fracture of the distal humerus. As you probably know, the distal humerus refers to the bottom end of the upper arm bone, which forms the top half of the elbow joint. This lower end of the humerus bone is shaped with two round knobs on either side of a spool-shaped center. The bony knob is called the capitellum. The spool-shaped center is the trochlea. A coronal shear fracture tells us that one or both of those bony knobs is broken off.

    Classification of the fracture is based on severity and is important to help guide treatment. There are three basic types of fractures, depending on whether the fracture affects the medial side of the capitellum (type one), the capitellum and trochlea broken off as one piece (type two: this is what your niece has), or the trochlea broken away from each end of the capitellum as three separate pieces (type three).

    The classification scheme has an additional subgrouping to describe a clean fracture or one with tiny bone fragments (called communition). The fracture may be impacted (bony ends pushed together) or displaced (bony ends separated). If the fracture is displaced, the bone may be shifted posteriorly (back away from the humerus). X-rays and CT scans are used to identify all areas of damage and determine the type of classification. This information is essential in making treatment decisions.

    Treatment for any of these types of coronal shear fractures of the distal humerus requires surgery. Studies show too many problems develop when the nonsurgical approach is taken. Without surgical correction, patients end up with chronic pain, painful clicking of the elbow, and mechanical instability.

    Surgery to pin the bones together with metal plates and screws or just screws alone has the best results. As a surgical scrub nurse you have probably seen quite a few of these procedures called open reduction and internal fixation (ORIF). It is estimated that good-to-excellent results are obtained in more than 90 per cent of all cases treated with ORIF. Patients end up with a stable, durable joint with smooth joint function. There can be complications (e.g., arthritis, stiffness, infection, nonunion or malunion), but these are rare.

    In the end, the physician or surgeon’s recommendation based on examination and findings on imaging will be the best tools used to make a treatment decision. Hopefully, the information provided here will help aid in the discussion among all concerned.

    Our family has come up against what we’ve been told is a “rare” problem: a coronal shear fracture of the elbow. The surgeon is going to put some compression screws to hold it all together until healing takes place. We’ve been warned that there could be some complications and problems down the road but that this is rare. What kind of problems are we talking about here?

    Coronal shear fractures of the elbow describes a break in the lower end of the humerus (upper arm bone). 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. So it might help you to have a little idea of the anatomy in this area to appreciate some of the possible complications.

    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. The bottom of the humerus called the trochlea is spool-shaped. The top of the ulna (one of two bones in the forearm) wraps around this spool to form the hinge.

    There is also the humeroradial joint where the humerus meets the radius (the second bone in the forearm). This joint is formed by a knob and a shallow cup. The knob on the end of the humerus is called the capitellum. The capitellum fits into the cup-shaped end of the radius, also called the head of the radius.

    There are three basic types of fractures, depending on whether the fracture affects the medial side of the capitellum (type one), the capitellum and trochlea broken off as one piece (type two), or there is a fracture line on either side of the trochlea making three separate pieces (type three).

    Treatment for any of these types of coronal shear fractures of the distal humerus requires surgery. Studies show too many problems develop when the nonsurgical approach is taken. Without surgical correction, patients end up with chronic pain, painful clicking of the elbow, and mechanical instability.

    Surgery to pin the bones together with metal plates and screws or just screws alone has the best results. This procedure is called open reduction and internal fixation (ORIF). The goals of surgery are to match up the joint surfaces, allow for early joint motion, and reduce the risk of posttraumatic problems. Matching up joint surfaces (called restoring articular congruity) can be a challenge because the bottom of the humerus (where it meets the other half of the elbow) has five different shapes. Each of those five surfaces must slide and glide evenly to provide normal motion and prevent wear and tear and eventual joint degeneration.

    Complications occur if the bones don’t heal properly causing either malunion (mismatch of the bone edges) and subsequent deformity or nonunion (failure to heal). Joint instability, painful motion, limited movement, and loss of function are natural consequences of these kinds of problems. Other complications (though rare as mentioned) are possible such as infection, stiffness, or joint contracture (joint can no longer move through its full range of motion but gets “stuck” after only going so far). That all sounds very dire but in fact, it is estimated that good-to-excellent results are obtained in more than 90 per cent of all cases treated with surgery. Most patients end up with a stable, durable joint with smooth joint function.

    I have kind of a delicate question that I haven’t quite gotten the nerve up to ask my surgeon. I’m scheduled for an elbow replacement. I’ve done all kinds of other stuff and nothing has helped — medications, physical therapy, arthroscopic surgery, etc. I’ve been told there are some restrictions with this implant: no lifting heavy items, no push-ups or heavy loads through the joint, no bowling. What about sexual activities? I notice it does usually require me to put my weight through my arms. Is that going to be a problem?

    Elbow arthroplasty or implants used to replace the elbow joint have distinct advantages and disadvantages. As you have been told, before receiving an elbow implant to replace the diseased, degenerated joint, the patient must agree to limit lifting to less than 10 pounds for a single item and less than two to five pounds for repetitive loads. Activities and weight-bearing restrictions will also be advised.

    The patient who receives a TEA can expect a stable joint with near normal elbow motion. Complications and problems are fairly common though and the patient must be prepared for this possibility. The implants just haven’t held up on long-term studies. Loosening requiring revision (a second surgery) happens more often than anyone would like. Patients often outlive their implants. The bushings wear out, the parts crack and break apart or come loose. Any of these events will require another surgical procedure.

    These are the many reasons why the implant should not be overloaded. Your body weight suspended over the artificial joint is one of those activities that may be fine occasionally. But over time, this activity combined with others that stress and overload the joint/implant can undo what you have gained.

    It is always a good idea to bring your concerns and questions up to the surgeon before making a decision like this one. You will want to do everything you can to ensure a successful (long-term) outcome. Your quality of life should improve in terms of pain, motion, and function. But sexual function is an important consideration, too and worth at least one discussion to make sure you are clear on any and all restrictions.

    I dislocated my left elbow during a wrestling tournament in high school. The orthopedic surgeon put it back in place for me so I didn’t have to have surgery. But then I mangled the same elbow in a motocross accident about five years ago. So now at age 35, I have arthritis worse than my grandma. I asked my doctor about an elbow replacement. She said I am ‘too young’ for that. She gave me a prescription for some antiinflammatories. Is that all I can do?

    Joint replacements are available now for the elbow. But it’s a tricky joint made up of three separate bones and two distinct joints. And it is responsible for repetitive motion of the hand and arm as well as rotation of the forearm, and weight-bearing activities through the hand and wrist.

    Because of the high activity demand on a replacement implant and its limited lifespan, total elbow replacement (TEA) isn’t usually recommended for young patients. In fact, it is considered a salvage procedure — in other words, only used as a last resort to save the joint.

    Before considering a total elbow replacement (TEA) in anyone younger than 40 years of age, all other avenues of treatment should be explored. This usually consists of conservative (nonoperative) care as well as surgery. Conservative care starts with medications (antiinflammatories) such as were prescribed by your physician.

    Injections (e.g., steroid or hyaluronate injections) might give some temporary or short-term relief from pain. But usually, physical therapy to reduce pain, increase joint motion, and improve function is tried first. If three to six months of conservative care fail to bring the desired results, then surgery may be the next step.

    Surgical procedures available include: 1) debridement (surgical cleaning) of the joint, 2) interpositional arthroplasty (remove part of the joint and fill in with tendon or other graft tissue), or 3) partial arthroplasty (only part of the joint is replaced). These approaches are used in the management of young adults who have developed degenerative arthritis following injury to the elbow (like your situation).

    How does the surgeon decide which procedure to use for each patient? Well, the key is to evaluate each and every patient individually. There is not a one-solution-fits-all kind of treatment or management approach. As with conservative care, the goals of surgical treatment are to reduce pain and improve elbow function.

    Patients can be divided into two groups based on history and physical examination. The first group are individuals who have a painful, stiff elbow joint at the end-ranges of motion (full flexion and/or full extension). These patients seem to do best with the less invasive debridement procedure. Debridement can be done arthroscopically (minimally invasive approach) or with an open incision.

    Patients with pain any time they move the elbow and who have X-ray or CT signs of advanced joint degeneration are better candidates for a more involved surgical procedure. With many choices for surgical approaches, the surgeon must carefully review all aspects of each case.

    The most appropriate candidates for TEA are patients with painful elbow motion and X-ray evidence of joint destruction who have failed all other attempts at treatment. Before using an elbow implant to replace the diseased, degenerated joint, the patient must agree to limit lifting to less than 10 pounds for a single item and less than two to five pounds for repetitive loads. Activities and weight-bearing restrictions will also be advised.

    The patient who receives a TEA can expect a stable joint with near normal elbow motion. Complications and problems are fairly common though and the patient must be prepared for this possibility. The implants just haven’t held up on long-term studies. Loosening requiring revision (a second surgery) happens more often than anyone would like. Patients often outlive their implants. The bushings wear out, the parts crack and break apart or come loose. Any of these events will require another surgical procedure.

    Since you are just starting treatment with the antiinflammatory medications (the necessary and appropriate first step), this might be more information than you need right now. But it may help you understand your physician’s initial treatment approach and judgment regarding elbow replacement. Keep this information in mind when you go back for follow-up care — it will help you ask some additional questions about the best plan of care for you.

    When should a person with a biceps tendon rupture have surgery? My tear is down by the elbow and I use the arm a lot.

    A distal biceps rupture occurs when the tendon attaching the biceps muscle to the elbow is torn from the bone. This injury occurs mainly in middle-aged men during heavy work or lifting. A distal biceps rupture is rare compared to ruptures where the top of the biceps connects at the shoulder. It is estimated that distal biceps ruptures make up between three and 10 percent of all biceps tendon ruptures.

    The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. Tendons attach muscles to bone. Two separate tendons connect the upper part of the biceps muscle to the shoulder. One tendon connects the lower end of the biceps to the elbow.

    The lower biceps tendon is called the distal biceps tendon. The word distal means that the tendon is further down the arm. The upper two tendons of the biceps are called the proximal biceps tendons, because they are closer to the top of the arm.

    The distal biceps tendon attaches to a small bump on the radius bone of the forearm. This small bony bump is called the radial tuberosity. Surgery to repair the tear brings the torn end of the tendon back to the bump if possible. If the tear is too extensive and the arm has to be bent 70 degrees or more to bring the torn end back to the bone, then a tendon graft is used to extend the tendon long enough to reattach it to the radial tuberosity.

    Many patients are content to let the torn tendon heal where it retracts (pulls back) to. Nonsurgical treatments are usually only used for people who do minimal activities and require minimal arm strength. Nonsurgical treatments are only used if arm weakness, fatigue, and mild deformity aren’t an issue. If you are an older individual who can tolerate loss of strength, or if the injury occurs in your nondominanat arm, you and your doctor may decide that surgery is not necessary.

    Not having surgery often results in significant loss of strength. Flexion of the elbow is somewhat affected, but supination (which is the motion of twisting the forearm, such as when you use a screwdriver) can be very affected. A distal biceps rupture that is not repaired reduces supination strength by about 50 percent.

    Many doctors prefer to treat distal biceps tendon ruptures with surgery and the sooner the better. If the patient experiences cramping, ongoing pain, or the loss of strength that affects daily function, then surgery is advised.

    People who need normal arm strength get best results with surgery when the tendon is reconnected right away. Surgery is needed to avoid tendon retraction. Retraction occurs when the tendon has been completely ruptured and contraction of the biceps muscle pulls the tendon further up the arm. When the tendon recoils from its original attachment and remains there for a very long time, the surgery becomes harder, and the results of surgery are not as good.

    You should rely on your surgeon to evaluate your situation and advise you on the best course of action for you. The extent of injury, time since the trauma, your personal and work goals, and level of activity will all help guide and direct the decision-making process.

    I finally found out why I’ve been having so much trouble with my elbow. I have been having pain anytime I extend my elbow, push a door open, or try to throw the ball for my dogs. Turns out I have a torn ulnar collateral ligament. I guess it’s something they see with javelin throwers and pitchers. But I did take a fall last winter on the ice and that may have done it for me. What’s the best way to treat this problem this late in the game?

    The UCL is also known as the medial collateral ligament. It is located on the medial (the side of the elbow that’s next to the body) side of the elbow. The ulnar collateral ligament is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow. It has an anterior bundle, posterior bundle, and a thinner, transverse ligament. It helps keep the elbow joint stable and helps prevent dislocation during trauma or injury.

    The ulnar collateral ligament (UCL) can become stretched, frayed or torn through the stress of repetitive throwing motions. Professional pitchers have been the athletes treated most often for this problem. Javelin throwers, football players, as well as athletes involved in racquet sports, ice hockey, wrestlers, and water polo players have also been reported to injure the UCL. But as you have found out, a fall on an outstretched arm can also lead to UCL rupture.

    If it does not heal correctly the elbow can be too loose or unstable. Painful symptoms such as you describe can develop. If there are loose fragments or uneven joint surfaces, you may also notice popping, catching, or grinding. Sometimes swelling can be seen along the inside of the elbow. And some people notice a slight loss of elbow motion. Closing the hand and clenching the fist can reproduce the painful symptoms.

    Sometimes an injury to the UCL can be treated conservatively (without surgery). The nonoperative approach can work well for patients who have a partially torn but not completely ruptured ligament.

    The conservative approach may also be recommended for patients who are not athletes and therefore not involved in activities that require overhead throwing. Being able to throw the ball for your dogs without pain may not be a sign that you need surgery. It’s possible the surgeon will recommend rest from aggravating activities like throwing and a rehab program with a physical therapist.

    The therapist will evaluate your joint motion, alignment and posture, and strength. Depending on your symptoms and clinical picture, a program will be designed to meet your individual needs and goals. If you follow the program given to you, you can expect a gradual return of pain free motion and strength over a period of three to six months.

    I’ve heard that the majority of athletes who have surgery to reconstruct their torn UCLs are able to get back to serious competitive play. Can you verify this for me? Is it really true?

    According to a recent report from surgeons at the Rothman Institute in Philadelphia and the Hospital for Special Surgery in New York City, the answer to your question is “yes.” But there are a few qualifying statements to go with that “yes.”

    The ulnar collateral ligament is on the medial (the side of the elbow that’s next to the body) side of the elbow. It is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow.

    The ulnar collateral ligament (UCL) can become stretched, frayed or torn through the stress of repetitive throwing motions. If it does not heal correctly the elbow can be too loose or unstable. The ulnar collateral ligament can also be damaged by overuse and repetitive stress, such as the throwing motion. From the way you posed your question, it sounds like this might be your situation.

    Sometimes an injury to the UCL can be treated conservatively (without surgery). The nonoperative approach can work well for patients who have a partially torn but not completely ruptured ligament. The conservative approach may also be recommended for patients who are not athletes and therefore not involved in activities that require overhead throwing.

    On the other hand, when there is a complete tear, overhead throwing athletes are not good candidates for conservative care. Studies have conclusively shown that reconstruction is definitely needed for these athletes if they want to return to full sports play.

    There are several different ways to perform this type of surgery. The surgeon’s level of experience and expertise, the severity of the tear, and the health of the patient are all important factors in the outcomes. There are delicate nerve tissues in this area that must be moved without damaging or injuring them. The procedure is less invasive if it can be done arthroscopically.

    If it turns out you need a graft in order to reconstruct the ligament, then the procedure becomes a bit more complicated. The surgeon usually harvests graft tissue from some other area of your both. For the ulnar collateral ligament, either the gracilis tendon from the thigh or the palmaris ongus tendon from the hand is used.

    But if all goes well with the surgery, results from studies do suggest that the majority of athletes have good-to-excellent results. In the case of “good” results, athletes return to the sport of their choice but may not be able to play at the same level as before the injury. Some athletes have to change sports to avoid the repetitive motion and load that led to the injury in the first place. Those who experience “excellent” results return to full participation in the sport of their choice and at the same level as before the injury.

    Do you think it’s reasonable that my tennis elbow is going to take a full year to heal? That’s what both the surgeon and the physical therapist said. That seems like a very long time to me. I usually heal fairly quickly from most other injuries. Why does this take so long?

    Acute tennis elbow, known as lateral epicondylitis often occurs as a result of repetitive overuse of the elbow extensor tendons. In the beginning of the injury, the body responds to the microtrauma with an inflammatory process. If all goes well, the body regenerates the area and the person recovers.

    But in some cases (especially when the repetitive forces continue during the body’s attempt to heal), there is degeneration of the tissue and failure rather than a healing response. In the end, the tissue present at the injury site is poorly organized collagen, fibrosis, and scarring. The final product is referred to as tendinosis or tendinopathy rather than tendinitis.

    Tendinopathy describes a chronic condition present with epicondylitis — there is no active inflammation going on. Microscopic studies have shown us that the area has poorly organized collagen fibers. As mentioned, there is scar tissue and an area where acute inflammation was present in the beginning but just never healed right. Tendinopathy is more of a degenerative condition than one of inflammation.

    This is the scenario that the orthopedic surgeon and physical therapist are responding to. Research and ongoing studies show that many people respond well to three to six months of conservative (nonoperative) care. That includes pain medications, activity modification (stopping the repetitive motions), splinting, and physical therapy. The therapist will assist with pain control, splinting, stretching, and appropriate exercises for this problem.

    Sometimes steroid injections, platelet-injection (blood) therapy, or shockwave therapy might be recommended or tried. There are mixed results for each of these treatment approaches. Steroid injections provide short-term pain relief but don’t really have any long-term benefit (i.e., patients who don’t have the injections do just as well three to six months later).

    There may be some ups and downs during that time, especially for people who start to feel better and then overuse the area again before full healing has taken place. Microtrauma can create some acute inflammation on top of a chronic problem. The result is a cycle that prevents and extends healing — sometimes for months.

    Surgery is reserved for patients who faithfully follow the protocol for chronic tennis elbow and still end up with pain, loss of motion, weakness, and decreased function. But for most patients, the process of restoring normal elbow function does indeed take six to 12 months. That is what is referred to as the natural history of chronic tendinopathy.