FAQ Category: Elbow

Lateral epicondylitis, otherwise known as “tennis elbow” can be a difficult problem to treat. Recent research has shown us that partial tears of the extensor carpi radialis brevis (ECRB) tendon just don’t heal right. After the acute injury, repetitive microtrauma results in an area of fibrosis (scarring) rather than inflammation. Understanding the underlying pathology may help you make decisions about treatment that are right for you with your surgeon’s advice, counsel, and guidance.

The idea that lateral epicondylitis isn’t really an “-itis” (inflammatory) condition at all has been made clear by microscopic studies of the affected tissue. The lack of blood supply to the area (called hypovascular zones) is a key feature of this problem.

What do the experts have to say about treatment? Well, everyone agrees that conservative care should be first and foremost. But what that should be remains a point of debate and controversy. There are many choices available from the wait-and-see approach, to the use of antiinflammatory medications, steroid or platelet-rich plasma injections, shock-wave therapy, physical therapy, and splinting.

And even within each of those treatment choices, there remains considerable uncertainty about what works best. Stretching, strengthening, soft tissue mobilization, deep friction massage, and electrical stimulation all seem to have some benefit. But is there some way to combine two or more of these approaches for the best results? And if so, which two (or three — or more) work together to produce optimal outcomes? These are questions current research has not been able to answer just yet.

We do know that in up to 90 per cent of all cases, conservative care has the intended effect. Patients report decreased pain, improved strength, and pain free return of full function of hand, wrist, and forearm. It may take up to a full year to get those kinds of results but most patients agree it is worth the time and effort.

For those few people who do not get the hoped for improvements, surgery is a final option. Here again, there are several choices and no real evidence that one approach works better than another. The surgeon may remove the diseased portion of the extensor carpi radialis brevis (ECRB) tendon, perform a tendon repair, or surgically release the tendon.

Percutaneous (through the skin) release has a good track record with decreased pain, improved strength, and return-to-work for many patients. The downside of this surgical approach is that the surgeon is unable to look inside the joint for any other damage or injury that might be part of the problem. There is also the potential risk for nerve damage and an incomplete release of the tendon.

If you started with conservative care, and gave it a full year, but didn’t make enough progress, then surgery may be the next option recommended. If you are feeling uncertain about the percutaneous approach, ask your surgeon to describe other possible surgical options and explain why the percutaneous release is advised for you. The information provided here may help you better understand the explanation.

We can summarize for you a recent report investigating this very question. Surgeons at several orthopedic centers conducted a review of all the studies done from 1992 to the present. They selected articles that specifically discussed treatment of unstable bone fragments caused by osteochondritis dissecans (OCD) of the capitellum (elbow bone).

To cut right to the chase, we’ll tell you they concluded that the best way to treat OCD when it is unstable has not been determined. High-level evidence is lacking to support one form of treatment over another. Here’s a little background on the condition and more about their findings.

Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to this odd and troubling elbow condition. In the past, this condition was called Little Leaguer’s elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.

The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. That’s when the condition is referred to as unstable. It sounds like that’s what you have.

Surgery is usually required for unstable OCD. The surgeon has several choices: the fragment can be reattached called fragment fixation. The broken piece can be removed with the remaining bone smoothed over (called debridement). Or the surgeon can do a procedure called osteochondral autograft transfer (OAT). The autograft transfer involves taking a fresh, healthy piece of bone from your knee and transferring or “grafting” it into the defective area.

By looking at past studies and reported outcomes, the researchers were able to get an idea of short-, mid-, and long-term results with each of these surgical approaches. Despite the lack of firm conclusions, hey were able to glean a few bits of information that might be helpful until better studies are done.

For example, debridement is able to get up to 85 per cent of competitive athletes with unstable capitellar OCD back to full sports participation. Debridement can even be used with defects large enough to cover more than half of the joint surface. But outcomes are usually worse with debridement in this group compared with debridement of smaller defects.

Osteochondral autograft transfer (OAT) is really used most often for those large, unstable defects. It can also be used as a revision (second) surgery if debridement is unsuccessful in reducing pain and restoring elbow function. Studies have not been done long enough to show whether the donor site (in the knee) develops osteoarthritis years later. That would be an important piece of information to have before recommending the OAT procedure. Poorer results with OAT are likely when the defect is located along the edge of the joint because it is difficult to get a graft in there.

Fixation was the other surgical method studied in this review. In fragment fixation, wires or bioabsorbable screws are used to hold the pieces of bone together until healing can occur. With this treatment approach, you may be able to get back to overhead (throwing) activities about six months after surgery.

Those who have the wires used must have them removed in a second surgery. Outcomes reported with fixation include good resolution (or at least improvement) of pain in 85 per cent of the athletes. X-ray evidence of healing without joint degenerative changes has been observed in most cases.

Problems that can occur after surgical correction of OCD include persistent pain, sensation of “catching” in the joint with motion, and an inability to return to full sports participation. In general, the larger the lesion, the poorer the results. And the farther out from the injury and surgery, the less favorable the outcomes reported in the studies available.

In conclusion, there is a need for a long-term study conducted at multiple centers with large numbers of patients. This is the only way surgeons will be able to determine the best, most optimal surgical treatment for athletes who suffer from unstable capitellar OCD defects. Until then, your team of surgeons will take all aspects of your case into consideration when making a treatment decision.

Your age, activity level, and type, location, and severity of the lesion will all be examined carefully. Hopefully, with the information we have provided here, you will have a better understanding of your choices and the reason(s) why one procedure might be recommended over another.

As you have probably discovered by now, OCD stands for osteochondritis dissecans. Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to this odd and troubling elbow condition.

In the past, OCD was referred to as “Little Leaguer’s” elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow.

The forceful and repeated actions of these sports can strain the surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. That’s when the condition is referred to as unstable.

Surgery is usually required for unstable OCD. The surgeon has several choices: the fragment can be reattached called fragment fixation. The broken piece can be removed with the remaining bone smoothed over (called debridement). Or osteochondral autograft transfer (OAT) can be done. The autograft transfer involves taking a fresh, healthy piece of bone from the patient’s knee and transferring or “grafting” it into the defective area.

With a small to medium-sized bone fragment, it’s likely that you will be treated using the debridement approach. Studies show that debridement is able to get up to 85 per cent of competitive athletes with unstable capitellar OCD back to full sports participation. Debridement can even be used with defects that are large enough to cover more than half of the joint surface. But outcomes are usually worse with debridement in this group compared with debridement of smaller defects.

If debridement is unsuccessful in reducing pain and restoring elbow function, then the next treatment option might be osteochondral autograft transfer (OAT). OAT is really used most often for those large, unstable defects that don’t respond well to debridement.

Fixation is another surgical method that might be used for medium to large defects. In fragment fixation, wires or bioabsorbable screws are used to hold the pieces of bone together until healing can occur. With this treatment approach, the player can get back to overhead (throwing) activities about six months after surgery.

Those who have the wires used must have them removed in a second surgery. Most athletes are still able to return-to-sport even after wire removal. Outcomes reported with fixation include good resolution (or at least improvement) of pain in 85 per cent of the athletes. X-ray evidence of healing without joint degenerative changes was observed in most cases.

Most athletes will require a period of rehab to regain full motion, strength, function, and coordination. Not just the elbow will require some rehab but the entire arm from shoulder to hand. About 85 per cent of patients studied with this problem who had surgery return to full participation in sports.

Problems that can occur after surgical correction of OCD that keep athletes from getting back into competitive play include persistent pain and a sensation of “catching” in the joint with motion. In general, the larger the lesion, the poorer the results. And the farther out from the injury and subsequent surgery, the less favorable the outcomes reported in the studies available.

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.

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.

Cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow. The symptoms are very similar to the pain that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness may develop into pain. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Tapping or bumping the nerve in the cubital tunnel will cause an electric shock sensation down to the little finger. This is called Tinel’s sign. Grip strength may be affected to the point that the person can no longer lift objects or even hold a cup of coffee. This syndrome can be very disabling.

Treatment usually begins with conservative (nonoperative) care. First, it is important to stop doing whatever is causing the pain in the first place. Taking frequent breaks during activities and even modifying job activities is important. Antiinflammatory medications, physical therapy, and splinting are helpful. The therapist will give you tips on how to rest your elbow and how to do your activities without putting extra strain on the elbow.

It sounds like you may have gone through all the pre-operative kinds of treatment without help. For individuals like yourself, if the symptoms do not go away with changes in activity and nonsurgical treatments, then surgery to stop damage to the ulnar nerve may be recommended.

The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. The hope is to reduce pain and other symptoms, possibly to even eliminate all symptoms. But a full recovery is rare. And even those patients who experience a good result at first often experience a return of their former symptoms.

Patients like yourself express surprise and disappointment when they have a successful outcome and then the symptoms come back. The question arises: are these symptoms the same old (persistent) unchanged symptoms or are they a true recurrence of the previous problem?

The answer to this question is really still unknown. Certainly it is possible that a patient can be so hopeful for improvement that they feet a change in their symptoms even when there was no change in the nerve physiology or function.

And it is possible that another problem is present (e.g., painful neuroma over the nerve) that could be adding to the persistent symptoms. But studies show that removing the neuroma or performing a second surgery to take pressure off the nerve doesn’t seem to help. If anything, patients report worse results after revision surgery.

In fact, it is more often the case that the symptoms of pain or numbness, weakness, and muscle atrophy (wasting) are permanent. It’s possible the first surgery was unlikely to change anything. It has been suggested by some hand surgeons that there could have been symptoms of nerve dysfunction for a long time before the patients ever noticed them. By the time the problem became obvious, damage to the nerve was permanent.

There are some risk factors to suggest patients who might not be good candidates for surgery to treat cubital tunnel syndrome. These include depression or other mood disorders and/or problems with coping. Dissatisfaction with the results and disability are linked with these psychologic problems and may be the real key to poor outcomes.

There is also the possibility that poor results occur because of the surgery itself. There are different ways to surgically treat cubital tunnel syndrome. Studies are needed to show which technique is the best with the fewest complications. Until the procedure is perfected, patients should be told what to expect realistically. Sometimes patients are advised carefully as to what to expect in terms of possible complications or problems but they don’t remember this information later.

We are sorry your situation has not improved. It may still be worth your time to see a hand therapist for some rehab. Special nerve gliding exercises may help keep the nerve moving freely and prevent scar tissue from forming around the nerve making your symptoms even worse.

Predicting complications with any surgical procedure is not easy and simply can’t be done most of the time. Some of the more common complications following any surgery include infection, poor wound healing, damage to the blood vessels or nerves, blood clots, and in worse case scenarios, even death.

There are what researchers call predictive factors that point to patients who have an increased risk of good or poor outcomes. For example, in the case of nerve compression treated surgically, studies show that patients who are depressed, have other mood disorders, or who have poor coping skills are less likely to have a successful result following nerve decompression surgery. Dissatisfaction with the results and disability are linked with these psychologic problems and may be the real key to poor outcomes.

Patients should always be counseled (as you were) ahead of time that results of nerve decompression surgery are not always perfect or even satisfactory. A full recovery is rare. And even those patients who experience a good result at first often experience a return of their former symptoms.

So, the question becomes — were those symptoms there all along and the patient didn’t realize it? Or are these symptoms a recurrence (the problem got better at first and then worse later)? The answer to this question is unknown. Certainly it is possible that the patient can be so hopeful for improvement that they felt a change in their symptoms even when there was no change in the nerve physiology or function.

And it is possible that another problem is present (e.g., painful neuroma over the nerve) that could be adding to the persistent symptoms. But studies show that removing the neuroma or performing a second surgery to take pressure off the nerve doesn’t seem to help. If anything, patients report worse results after revision surgery.

In fact, it is more often the case that the symptoms of pain or numbness, weakness, and muscle atrophy (wasting) are permanent. It’s possible the first surgery was unlikely to change anything. If there have been symptoms of nerve dysfunction for a long time before you ever noticed them, results may be less than hoped for. By the time the problem became obvious, damage to the nerve was permanent.

Your surgeon is really the best one to advise you. Knowing your past medical history, current state of health, state of mind, and possible risk factors for a poor outcome will help him or her guide you in making the best decision for yourself and your situation.

When there is a complete rupture of the biceps where it attaches to the elbow, the question for a self-employed, self-insured, under insured, or uninsured individual becomes: will it heal on its own? The patient often wants to know, “Will I get back to ‘normal'”?

Most orthopedic experts agree that surgery is needed. And the best time to repair a biceps tendon that has retracted (snapped back up into the upper arm) is within the first six weeks after injury. In fact, the best results with fewest complications occur when surgery is done in the first two weeks after injury. After six weeks, reconstruction with a graft (rather than a repair procedure) is more likely.

Without surgical repair, the patient can expect about a 40 per cent loss of supination (palm up) motion. There can be another 30 per cent loss of strength. And there could still be other complications such as nerve injury, bone fracture, and even re-rupture of the biceps. It’s not likely the arm will get back to normal without intervention.

Without treatment someone with a biceps rupture can experience continued weakness whenever trying to turn or twist (supinate) the forearm. This type of motion is usually important for construction work. Easy fatigue of the injured arm may be likely as well. Some people can adapt to these changes while others cannot.

Whatever decision your employer makes (return to work immediately, take time off and heal, or have surgery) will likely be made in the next week. You will know then what your options are in order to make employment decisions for yourself.

Biceps rupture with tendon retraction (tendon snaps back up into the upper arm) seems simple but has some unseen complexities to it. If the tendon has retracted too far, a simple repair may not be possible.

The surgeon may have to use a soft-tissue graft to reconstruct the full length and function of the biceps. This is done when the surgeon can’t get the tendon back to its original place on the bone without putting the elbow in 90 degrees or more of elbow flexion.

Post-operative recovery takes so long for several reasons. First, in order to ensure tendon healing after surgery without re-rupture, immobilization (cast or splint) is necessary. This can take up to six weeks. Strengthening is not allowed for three months for the same reasons.

There really isn’t a lot of evidence to support one post-operative approach over another. More studies are needed to compare treatment methods and timing of treatment to find what brings about the best overall short-term and long-term results. The six-month projected time line is probably very reasonable. If any complications develop, you may expect an even longer recovery time.

There are many bone and soft tissue injuries that can contribute to posttraumatic elbow stiffness. It’s not always clear what all the factors are leading to this condition. But animal studies have revealed some new and helpful information that may help explain your situation.

It appears there are two major areas of soft tissue damage linked with posttraumatic elbow stiffness. The first area of interest is the joint capsule. The capsule is a group of ligaments and connective tissue that surrounds the entire joint. The second factor that can result in elbow joint stiffness is the increase in number of myofibroblasts (protein in the muscle cells) after injury.

The exact chain of events at the cellular level that lead to capsular and myofibroblast changes are very complex. The author does a good job providing details of the chemical and mechanical signals that occur after elbow injury. Growth factors, collagen expression, and mast cell production are all important in the molecular and cellular events that occur after an injury.

In fact, the discovery that mast cells are released in response to trauma and pain was an important clue. There is some evidence that mast cells may be the missing link between an acute injury that becomes chronic. And that’s where pharmaceutical (drug) treatments could be developed to help prevent posttraumatic stiffness.

There are other factors that might be part of the picture. Female sex hormones, prolonged immobilization right after the injury and genetic predisposition have been identified. Addressing these three risk factors might help physicians predict problems and prevent them. This concept is referred to as selective targeting.

Treatment is based on whether the stiffness is coming from inside or outside the joint and which specific structures are involved. Before treatment begins, imaging with X-rays and CT scans must be done. Imaging shows any fractures, loose fragments of bone or cartilage, or infection.

If nothing shows up, loss of motion could be caused by the your own apprehension and muscle tension more than a true mechanical problem. It may be necessary to examine the patient under anesthesia to find the true cause of loss of elbow motion. If you have not had any of this type of care, now would be the time to make an appointment with your primary care physician or an orthopedic surgeon.

Elbow stiffness after a traumatic injury is a common problem. Treatment is decided based on whether the stiffness is coming from inside or outside the joint and which specific structures are involved.

Treatment ranges from conservative (nonoperative) care to surgery. Various treatment options include physical therapy, bracing, splinting, manipulation under anesthesia, and surgical release of the capsule. For patients who do not respond to any of these approaches, an elbow replacement may be advised.

Before treatment begins, imaging with X-rays and CT scans must be done. Imaging shows any fractures, loose fragments of bone or cartilage, or infection. If nothing shows up, loss of motion could be caused by the patient’s apprehension and muscle tension more than a true mechanical problem. It may be necessary to examine the patient under anesthesia to find the true cause of loss of elbow motion.

When physical therapy is advised, the therapist may apply a number of different approaches. Ultrasound, electrical stimulation, laser therapy, and soft tissue mobilization are some of the techniques used. If appropriate, ther therapist may make a splint for you to help increase and maintain elbow motion. Most of these types of treatment can’t be done by yourself.

You will probably be given stretching and strengthening exercises to do on your own at home. If you don’t regain full, painfree motion after two to four months of active therapy (including your daily home program), there are some surgical options that might be recommended. Your surgeon and the physical therapist will both help guide you through this process.

Symptoms such as you describe (swelling, red joint with fever) may be an indication of a systemic infection that requires immediate medical attention. Any opening in the skin causes a small injury and infection of the skin over the bursa can then spread down into the olecranon bursa.

A bursa is a sac made of thin, slippery tissue. Bursae (plural) occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts. The olecranon bursa allows the elbow to bend and straighten freely underneath the skin.

The olecranon bursa can also become infected or septic. The sack fills with pus, and the area around the bursa becomes hot, red, and very tender. If the skin is infected too (a condition known as cellulitis), fever, chills, low blood pressure, and even confusion and other signs of mental impairment can develop.

With the history and type of symptoms you described, it might be best to seek medical attention first. A delay of even 24 to 48 hours while applying a home treatment could mean surgery instead of a simple antibiotic.

Olecranon (elbow) bursitis is the inflammation of the bursa at the tip or point of the elbow. A bursa is a sac made of thin, slippery tissue. Bursae (plural) occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts. The olecranon bursa allows the elbow to bend and straighten freely underneath the skin.

This bursa can become irritated and inflamed in a number of ways. Direct impact to the elbow (like you had) can cause bleeding in the bursa. This can cause the bursa to become swollen and tender. The olecranon bursa can also become infected or septic. Even a small injury can leave an opening into the elbow. Bacteria from the skin over the bursa can enter through this portal.

Treatment may depend on what is causing the septic bursitis. The most common approach is the use of antibiotics. A broad spectrum antibiotic is used at first (one that will kill as many different kinds of bacteria as possible). If the fluid in the elbow is aspirated (drawn out), then it can be tested to find out the specific bacteria present. That’s when the patient is switched to a antibiotic that will target the identified bacteria. With septic olecranon bursitis, it’s usually a staph or strep infection.

Antibiotics and aspiration used together is another common treatment choice. In some cases, the surgeon will put a tube into the bursa and remove fluid while cleansing the area twice a day over a period of three to five days. This type of treatment is called serial aspiration. When the fluid is tested clear and free of infection, then the tube can be taken out and antibiotics discontinued.

In all cases, if the elbow fluid is not aspirated and tested to see if antibiotics are still required, then patients are advised to take the full amount of antibiotics as prescribed. The total time varies depending on the type of antibiotic you are on. In a situation like this with the potential to develop a chronic elbow bursitis, patients are always advised to check with the physician or pharmacist before discontinuing antibiotics.

Tennis elbow (also known as lateral epicondylitis) can be the result of inflammation of the tendon where it inserts to the bone. Overuse or repetitive motion does cause an acute inflammatory response. Chronic tennis elbow may not have an active inflammatory process but it is still painful causing stifness, loss of strength, and loss of motion in some cases.

The same acute or chronic problems can occur at the knee when there is involvement of the patellar tendon. The patellar tendon attaches the quadriceps muscle along the front of the thigh to the bone below the knee cap. But patellar tendinitis (acute) or tendinosis (when it is chronic) is not the same as osteoarthritis (OA).

Knee OA is an active process of inflammation, swelling, and damage to the joint cartilage and joint surface. The treatment for these two conditions (tendinitis versus arthritis) is different. Although conservative (nonoperative) care is advised for both problems, surgery is more often needed for the knee arthritis.

If caught early enough, a simple debridement surgery (shaving and scraping the joint smooth) may be all that’s needed. More advanced stages of osteoarthritis may require a total knee replacement. Tennis elbow is never treated with a joint replacement but always conservative care.

UCL of the elbow stands for ulnar collateral ligament. The is a ligament along the lateral (outside of the) elbow that holds the humerus (upper arm bone) and radius (one of the two bones in the forearm) together. The UCL is actually made up of three separate “bundles” of ligamentous material.

The three bundles are strategically placed around the elbow in three separate directions and insert into the bone. There are also superficial and deep layers that weave into the joint capsule. This is what gives the lateral elbow so much strength and stability.

It also explains why when the ligament is torn, an athlete might be out for a while. It takes time to heal, recover, and rehab to be back at the preinjury competitive level. In the case of acute trauma, it is possible to treat the problem conservatively (without surgery). The athlete usually works with a physical therapist and/or athletic trainer to protect the healing tissue at first and then later regain strength, motion, and full function.

With more chronic injuries, the tendon wears away, fragments, and splits from repetitive overloading. This kind of damage is more likely to require surgical repair or reconstruction to make recovery and return-to-play possible. Surgery is also more likely if the athlete experiences elbow dislocation (instability) because of UCL disruption.

When it comes to surgical approaches to UCL injuries, the surgeon must evaluate each athlete individually to determine whether repair or full reconstruction is needed. There are several different ways to surgically approach the problem. In the case of ligamentous repair, good-to-excellent results have been reported for young athletes with an acute tear of the ligament where it attaches to the bone.

In general, many athletes are indeed able to recover and return to full sports participation. That wasn’t true 30 to 40 years ago but newer surgical techniques and medical treatments have changed the picture quite a bit. It’s very likely you will see your favorite pitcher back on the mound next season.

Symptoms such as you describe could be coming from the neck, shoulder, elbow, or wrist. Pressure on a nerve anywhere along that course could cause the sensory changes you notice as a cold sensation. Likewise, a change in pitching speed or accuracy could reflect motor nerve compression or impingement.

Chronic repetitive motion and especially the overload from pitching with force can slowly cause soft tissue degeneration around the elbow. Age is always a factor as the aging process combines with the chronic mechanical forces to create microtrauma that eventually catches up with us.

You didn’t mention any pain, numbness, or tingling or say anything about popping sensations. Additional symptoms like these can give clues to the underlying problem. A visit to an orthopedic surgeon or sports physician may be a good idea. A complete history and examination will most likely reveal an accurate diagnosis, which would lead to the appropriate treatment.

A simple X-ray may be all that is needed to reveal bone spurs, tumor, infection, or arthritic changes. More advanced imaging isn’t usually necessary but if needed, MRIs and CT scans both offer helpful images to determine the cause of the symptoms.

Of course, treatment will depend on the diagnosis. Many elbow problems such as you described can be managed nonoperatively. A carefully prescribed rehabilitation process can get you back into full sports participation again. Newer treatment involving blood injection therapy (called platelet-rich plasma) to help speed up healing may be a possibility as well.

But before jumping ahead to the actual treatment, get a medical examination and find out what’s wrong first. That’s likely your next best step.

Elbow pain is, indeed, a common problem among computer users, especially those who still use a mouse control. Like you, many people experience neck, shoulder, elbow, wrist, and hand pain and other symptoms from long hours at the computer. In fact, it is estimated that each year up to three per cent of the adult population are diagnosed with lateral epicondylitis (also known as “tennis” elbow). Half to two-thirds of those folks list workplace activities as the cause.

Repetitive use of any body part can cause problems. But sometimes the problem is poor alignment at the work station. For example, the table your computer sets on may be too high or too low for you. The chair you are sitting in may also need some adjustment. Whether at home or at work, ergonomics is a key feature of preventing musculoskeletal problems associated with computer use. Ergonomics refers to the study of designing equipment and devices that fit the human body, its movements, and its cognitive abilities.

An ergonomic specialist such as a specifically trained occupational or physical therapist can evaluate your workspace and advise you appropriately. Likewise, these therapists are able to provide some hands-on therapy to ease the painful symptoms and restore normal alignment and function. A postural assessment can be done to help you maintain good alignment.

Myofascial release therapy (MFRT) is another effective tool to help restore normal circulation and aid healing to the affected connective tissue and surrounding soft tissues. The therapist applies a low load, long lasting stretch to the myofascial tissue (connective tissue that support and surround muscles and tendons).

The therapist holds the stretch for up to five minutes. The desired result is to increase circulation, reduce sensitivity of nerves, and improve elasticity (flexibility and stretch) of the tissues. You will likely be given some stretches to do each day to help maintain the benefit received from the treatment. Acupuncture is another treatment approaches you might want to consider for this problem..

You don’t have to suffer with this problem forever but you may have to apply some at-home strategies as long as you use the computer. The therapist will evaluate your situation and outline the best program for you.

It sounds like the therapist has instructed you in a technique called myofascial release therapy (MFRT). Applied by the therapist or by yourself, the idea behind this treatment approach is to apply a low load, long lasting stretch to the myofascial tissue (connective tissue that support and surround muscles and tendons).

There are different ways to apply myofascial therapy (directly, indirectly, using hands or the special tool you are using that was designed for this purpose). The desired result is to increase circulation, reduce sensitivity of nerves, and improve elasticity (flexibility and stretch) of the tissues.

The exact mechanism by which myofascial release therapy is effective isn’t entirely clear. Experts in this area of study believe the technique allows the tendon to heal and restore a more normal soft tissue structure without restrictions.

Reorganization of the collagen fibers that make up the connective tissue may be another way in which MFR lengthens the fascia and aids in healing. The prolonged, slow pressure applied to sensitive nerve tissue may help slow down pain signals.

You may be interested in the results of a recent study from researchers in Malaysia and India providing evidence to support the value of myofascial release therapy. In this study, 68 computer professionals with lateral epicondylitis were divided into two groups. Group 1 received 12 myofascial release therapy treatments over a period of four weeks. Group 2 (control group) received a sham ultrasound treatment to or elbow surgery.

Everyone in both groups was tested before treatment began and retested at the end of treatment (four weeks), and three months later as a follow-up. Pain, function, and disability were measured using a specific test called the Patient-Rated Tennis Elbow Evaluation Scale.

Test results showed a consistent and significant value of myofascial release (MFR) for this type of lateral epicondylitis. The MFR group had a 78.7 per cent reduction in symptoms while the control group had only a 6.8 per cent reduction. And that significant difference between the groups was still observed at the end of 12 weeks.

There were no adverse effects from either treatment but a few of the patients in the MFR group noted their pain increased the first week after the first treatment. Painful symptoms went away within a few days and there was no need for pain medications. The authors concluded that myofascial release (MFR) was much more effective than sham ultrasound therapy in decreasing pain and improving function in computer workers with lateral epicondylitis.

The symptoms of cubital tunnel syndrome are very similar to the pain that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness may develop into pain. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Tapping or bumping the nerve in the cubital tunnel (Tinel’s test) will cause an electric shock sensation down to the little finger. This is called Tinel’s sign. Other diagnostic tests that can be done to confirm cubital tunnel syndrome include electrodiagnostic examination. Nerve conduction tests and electromyography to study muscle function are the two main electrodiagnostic tests used for nerve compression.

It sounds like you have had all of these tests done, but if not, surgery is not recommended without electrodiagnostic tests to confirm the diagnosis. Treatment for cubital tunnel syndrome (CuTS) is usually conservative. Antiinflammatory medications, changes in activities, a splint, and physical therapy may be helpful. If symptoms are not improved with nonoperative care, then surgery may be recommended to stop damage to the ulnar nerve. This is where you are in the process.

The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. One surgical treatment is called ulnar nerve transposition. In this procedure, the surgeon forms a completely new tunnel from the flexor muscles of the forearm. The ulnar nerve is then moved (transposed) out of the cubital tunnel and placed in the new tunnel.

Before doing this type of invasive surgery, it would be helpful if the benefit in terms of decreased pain and improved function could be predicted. That’s the kind of information you are looking for. There is actually a recent study that looked for ways to predict the benefit of surgery for cubital tunnel syndrome using the ulnar nerve transposition surgery.

In this study, a patient-rated tool called the Patient-rated ulnar elbow evaluation (PRUNE) was used to predict change 18 months after ulnar nerve transposition. Electrodiagnostic tests were also used to measure changes in nerve and muscle function. In this way prognosis for functional recovery could be tested and predicted.

One of the specific goals of this study was to see which aspects of the electrodiagnostic tests are the most predictive of pain during daily activities after surgery. By completing the PRUNE questionnaire patients were rated on pain and other symptoms during dressing, household chores, eating, and self-care (e.g., teeth brushing, face washing). Work and recreational activities are also assessed.

Testing took place before surgery (called the baseline) and again 12 to 18 months after anterior ulnar nerve transposition surgery. Seventy-three (73) patients (52 men and 18 women) were included in the study. Almost everyone had sensory changes before surgery and most (85 per cent) had motor changes (muscle action) affecting the hand.

After surgery, half the group still had abnormal sensation but there were still some improvements. Slightly more than one-third of the group experienced a full return to normal sensation. Motor improvement was also present but still not normal in most of the patients. PRUNE scores were significantly better for everyone.

The women in the group seemed to get the best improvements overall. The authors say this can be partly explained by the women’s symptoms and disability being worse than the men’s before surgery. There are other factors at play (e.g., severity of nerve damage, length of time between injury and surgery) but were not evaluated in this study.

The value of this study was to show the benefits of electrophysiological testing before surgery. The test results helped confirm the diagnosis of cubital tunnel compression syndrome and provided prognostic information about expected recovery.

The results also showed how the surgeon could use the information to plan the optimal time for the surgery. For example, when there is slowing of nerve signals but not complete loss of signals, then conservative care may be helpful. Likewise, if there are just isolated spots where nerve transmission is slowed, the patient may respond well to nonoperative care and surgery may not be needed.

The testing doesn’t provide all the answers but certainly contributes helpful information in planning treatment. More study is needed to identify clear cut-off points between what is normal and what is considered “abnormal” electrophysiologic values. This is especially true when trying to decide whether or not to have surgery by predicting recovery and outcomes.

Most likely you will want to see a medical doctor — either your primary care physician or an orthopedic surgeon. A proper examination is needed to identify the cause of your joint blockage. The fact that there was an audible popping sound that you felt may mean there is some kind of damage inside the joint.

For example, there could be a torn ligament or a fragment of bone floating around inside the joint. When a loose body gets lodged in just the right spot inside a joint, it can create the kind of blockage you are describing.

Bone spurs can also cause painful loss of elbow motion or other mechanical kinds of symptoms (e.g., catching, locking). Swelling can do the same thing. In your case, even though the major swelling has resolved, there could still be some fluid inside the joint limiting full motion.

The physician will have an idea what is going on by asking you questions about the injury, type of symptoms, location of symptoms, and what makes the symptoms better or worse. Pain during the middle of elbow motion is caused by different lesions compared with pain at the beginning or end of joint motion.

The examiner often has a pretty good idea what’s wrong with the elbow even before examining it. The list of possible diagnoses can be formulated just based on the your responses to questions. For example, pain on the medial (inside) of the elbow points to the possibility of a ligamentous problem.

On the other hand, symptoms like numbness and tingling down the arm may point more to a problem with nerve compression. There are special tests used to evaluate the status of the three nerves that pass through the elbow and other ligamentous tests to determine how stable the joint is.

Various tests can be applied to the elbow coming from all four directions around the elbow (anterior or front, posterior or back, medial or side closest to the body, and lateral or side away from the body). The information collected during the exam guides the examiner in selecting the most appropriate tests to rule in/rule out specific conditions. Are imaging studies needed? Do visual inspection and palpation suggest the necessity of an X-ray, MRI, or CT scan? Will an arthroscopic examination be necessary?

Once all the diagnostic information has been collected, then an appropriate plan of care can be determined. Don’t hesitate to get some medical attention sooner than later. Early diagnosis in cases like this can often help prevent problems from getting worse or becoming chronic.