FAQ Category: Elbow

Any time a young person (and especially an athlete) injures his or her elbow, an accurate diagnosis is absolutely essential to providing the best treatment. Whether the examiner is an orthopedic surgeon, physician’s assistant, or physical therapist, there is a recommended order to the patient history and physical examination.

In a recently published article, surgeons from the Center for Shoulder, Elbow, and Sports Medicine at Columbia University in New York City provided a step-by-step approach to the evaluation of elbow injuries in throwing athletes. They suggested that a thorough understanding of normal elbow anatomy and elbow joint biomechanics will help the examiner assess for and recognize abnormal or pathologic conditions.

The first step is to take a thorough patient history (e.g., what happened, when did it happen, how did the injury occur, what has been the patient’s health history up to the date of the examination). When taking a patient history there are the usual questions about the location, type, duration, and intensity of pain. Hand dominance (right or left handed) is also recorded.

The athlete is asked to give as many details as possible about the symptoms. Anything that the athlete can tell makes the problem better or worse is important information. Type of sport activity engaged in at the time of the injury is also important (e.g., overhead throwing, specific tennis strokes). Information about previous injuries or surgeries is gathered.

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 patient’s 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.

Moving the patient’s arm through elbow flexion, extension, supination (palm up), and pronation (palm down) can reveal important diagnostic information. Too much elbow motion suggests ligamentous injury. A block in motion, locking, catching, or other causes of decreased joint motion point more to a possible fracture, bone spurs, or other type of intra-articular (inside the joint) injury.

Tests can be done 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). There are various tests possible to perform (e.g., joint compression tests, pivot-shift test for stability, valgus-varus tests, hook test for biceps tendon rupture).

A well organized assessment of elbow injuries in throwing athletes will lead to the most appropriate treatment and therefore, faster return-to-sports. This may seem like quite a bit of poking and prodding, but by using a step-by-step interview and exam, the examiner can stay focused and produce an accurate diagnosis. An accurate diagnosis leads to proper treatment and faster return-to-sportsl

There are three major nerves around the elbow that can be affected by an injury such as you mention. These three nerves (radial, ulnar, median) can be cut, pinched, crushed, or stretched in ways that leave the hand paralyzed or sometimes less than functional.

Treatment often begins with hand therapy to improve motion, strength, and function. The hand surgeon uses this time to evaluate how quickly the nerves are healing and whether or not to do surgery. Knowing when to repair the problem versus reconstruct the damaged anatomy is a challenge for the hand surgeon. Use of nerve or tendon transfers early is advised with there are signs that motor function won’t occur, rehab will be lengthy, or recovery just isn’t possible.

It’s likely that your father has had many tests done to determine the extent of injury and help plan treatment. All muscles (and their attached tendons) are tested for loss of function against gravity and against resistance. Grip and pinch strength are measured. Special tests for sensation are carried out.

Surgery isn’t always needed for nerve injuries. Some patients recover completely with time and hand therapy. But if several months go by with no improvement or only minimal recovery, then it’s time for the hand surgeon to take a second look.

Special neurodiagnostic tests can be ordered to see if and how much the nerves are firing. The results of these tests along with clinical observations is often enough to suggest the need for surgery to repair or reconstruct the damaged area.

Time is still an important factor in recovery. Nerves recover very slowly at a rate of about one inch each month. After 18 months without nerve stimulation, the motor endplate (junction where the nerve connects to relay messages) starts to degenerate. If the nerve gets there too late, the patient won’t regain motor control. In other words, the muscle doesn’t get the message to contract and use of the hand is limited.

In cases where it looks like recovery will be delayed too long, the surgeon has the opportunity to perform a tendon or nerve transfer. This means a piece of tendon or nerve from another area of the elbow or forearm is used to replace the damaged structures. Often there are extra branches or even duplicate fibers that can be used without damaging the donor tissue.

If your father is approachable, you may want to let him know of your interest and concern. He may be open to your questions about what the doctor has said and what is his prognosis (what will happen, how much recovery he will get). He may be able to explain the plan for treatment down the road as well.

If you don’t feel comfortable asking these questions directly, perhaps there is some other adult family member (your mother, an uncle) or close friend of your father’s who could explain what’s going on and answer your questions. If none of that is possible, then just wait and watch carefully what happens over time as recovery and healing take place. With nerve injuries, it is a long, slow process that can take months up to two years or more.

Nerve injuries such as you describe can be very difficult to recover from. When a nerve is torn, crushed, or pinched, it takes about a month for an inch of that nerve to heal. If the injury is high up by the elbow, that same nerve goes all the way down to the hand. So sensation and muscle control in the hand and fingers may not return for months.

If too much time goes by, scar tissue and degeneration of the motor endplate (where the nerve meets the muscle) may prevent full recovery from occurring. The motor endplate is the highly-excitable region of muscle fiber responsible for the start of action potentials (firing signals) across the muscle’s surface, ultimately causing the muscle to contract. Without a nerve signal, the motor endplate remains silent. And over time, that silence translates into a breakdown of the endplate. If that happens, permanent silence occurs and loss of motor recovery.

Surgeons monitor patients carefully week-by-week and month-by-month for any signs of nerve regeneration and motor recovery. They use pinch and grip strength and sensory testing to measure change. A special test called Semmes-Weinstein monofilament exam measures the patient’s ability to feel two points of touch on the skin. If no change or improvement is seen, then special neurodiagnostic tests can be done.

They use the rule of 18 to gauge recovery and plan treatment. The rule of 18 says that motor recovery won’t happen past 18 inches from the nerve injury after 18 months have passed. This is because as we said earlier, nerves regenerate at the rate of about one inch per month. And motor endplates degenerate 18 months after nerve damage.

If by four months after the injury there has been no recovery or very little improvement, then testing is repeated and repeat neurodiagnostic tests are ordered. Surgery is often recommended at this point to explore what’s going on and either repair or reconstruct the damaged nerves, tendons, and muscles. So, at three months, you are probably still within the acceptable and recommended wait-and-see period of time. You should have some answers in the next four to six weeks. If not, ask the surgeon for a review of your husband’s case and be prepared to ask some questions based on the information here. Good luck!

From the description of your symptoms it sounds like you may have a problem called ulnar nerve compression, also known as cubital tunnel syndrome or CuTS. Most people are familiar with carpal tunnel syndrome (CTS). That is a problem with nerve compression affecting the hand, too.

Just like carpal tunnel syndrome, cubital tunnel syndrome causes pain, sensations of numbness and tingling, and weakness of the hand. But the areas of the forearm and hand affected are different. 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, while sleeping, or when sewing. 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 (the kind your physician has suggested). Nerve conduction tests and electromyography to study muscle function are the two main electrodiagnostic tests used for nerve compression.

Treatment for cubital tunnel syndrome (CuTS) is usually conservative at first. 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.

The value of electrophysiological testing is in confirming the diagnosis (making sure you have cubital tunnel syndrome) and in determining the need for surgery. The test also guides the surgeon in making the best recommendation for timing of surgery and provides prognostic information about expected recovery.

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, you 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. Waiting too long could mean permanent damage to the nerve and a missed opportunity to return normal sensation and motor control.

The elbow is the second most commonly dislocated joint in adults (after shoulder dislocation). But children and teens also experience a large number of elbow dislocations from simple to severe. The expression “simple” elbow dislocations means is that surgery was not needed to put the elbow back in place and there were no bone fractures.

Elbow dislocations can be complete or partial. A partial dislocation is referred to as a subluxation. The amount of force needed to cause an elbow dislocation can be enough to cause a bone fracture at the same time. These two injuries (dislocation-fracture) often occur together. Any trauma severe enough to dislocate a joint can also cause soft tissue damage.

So, how often do simple elbow dislocations occur? Based on data collected from 102 hospital-based emergency departments or trauma centers, there are approximately 37,000 cases of simple elbow dislocation in the United States each year.

The majority of those occur from falls in 10 to 19 year olds engaged in sports activities. Football, wrestling, and basketball seem to be the activities males are involved in most often when this type of injury occurs. Younger males sustain elbow dislocations more often than females. In older adults, the tables are turned and women are more likely to experience elbow dislocations.

Young females with elbow dislocations are more likely to be participating in gymnastics or skating at the time of the injury. Elbow dislocations were also reported in both males and females as a result of biking accidents, skiing or snowboarding, hockey, lacrosse, track, volleyball, and trampoline.

There may be a genetic link in your family if everyone has a type of collagen fiber that results in joint laxity (looseness) but it is more likely that the sports activity is the real risk factor for your family. This is certainly something you can ask your family physician or the orthopedic surgeon who treated each one.

Anyone who has had one elbow dislocation should take some steps to prevent such injuries. The proper use of protective equipment along with education and training may prevent recurrence. A few visits with a physical therapy may help. The goals of therapy are to restore normal motion, joint proprioception (sense of position), and motor control. The program will progress to include strengthening and sport-specific training for athletes.

The term simple elbow dislocation may be a bit of an oxymoron (contradicting terms). As you said, there’s nothing simple about the elbow or dislocations. What the expression “simple” elbow dislocations means is that surgery was not needed to put the elbow back in place and there were no bone fractures. But with any trauma severe enough to dislocate a joint, there can be some soft tissue damage.

The elbow is made up of three bones: the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).

The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down.

At the same time, it has to slide against the end of the humerus as the elbow bends and straightens. The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well. As a result, the end of the radius at the elbow is shaped like a smooth knob with a cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna.

There are also ligaments, tendons, muscles, cartilage, nerves, and of course, blood vessels in and around the elbow. Any of these structures can be stretched or otherwise damaged during the dislocation. Simple elbow dislocations heal well with few (if any) problems. Once the joint is reduced (put back in place), any residual problems may become apparent.

There may notice a slight loss of elbow motion, especially when trying to straighten the arm. There can be altered joint proprioception (sense of position), weakness and impaired motor control. Any of these problems can make sports participation or athletic activities difficult.

There are three main nerves near the elbow that can be affected: the median nerve, the ulnar nerve, and the radial nerve. Whether it’s a sharp, high-energy injury (e.g., knife, saw blade, bullet) or a low-velocity injury (e.g., fracture, traction, crush), the rule of 18 guides treatment.

The rule of 18 says that motor recovery won’t happen past 18 inches from the nerve injury after 18 months have passed. This is because nerves regenerate at about one inch per month. And motor endplates degenerate 18 months after nerve damage.

The motor endplate is the highly-excitable region of muscle fiber responsible for the start of action potentials (firing signals) across the muscle’s surface, ultimately causing the muscle to contract. Without a nerve signal, the motor endplate remains silent. And over time, that silence translates into a breakdown of the endplate. If that happens, permanent silence occurs and loss of motor recovery.

Surgeons monitor patients carefully week-by-week and month-by-month for any signs of nerve regeneration and motor recovery. They use pinch and grip strength and sensory testing to measure change. A special test called Semmes-Weinstein monofilament exam measures the patient’s ability to feel two points of touch on the skin. If no change or improvement is seen, then special neurodiagnostic tests can be done.

This is where the rule of 18 comes in handy. Rate of recovery is matched against the time of injury to determine whether surgery to repair or reconstruct the damaged nerve is needed. For example, the rule of 18 tells the surgeon that the farthest recovery will occur is 18 inches from the injury. Any loss of sensation or motor function further away than that will require a tendon or nerve transfer.

For every month surgery is delayed, one inch of restored motor function may be lost. In other words, say the repair is done six months after the injury. Motor recovery is possible up to 12 inches from the level of the injury.

When making the decision when to do surgery, the surgeon also takes into account the type of injury, the patient’s age, and the nerve(s) involved. Your son’s young age and the fact that he is probably still growing is in his favor. When your son goes in for his next appointment, go with him and ask the surgeon this question. He or she will be able to give you a more definitive answer based on recovery so far.

Osteoarthritis is caused by degeneration of the articular (surface) cartilage of a joint. Degeneration is wear that happens over time. Doctors use the term degenerative arthritis to describe the wear and tear of a joint over many years. Degenerative arthritis is another term for osteoarthritis.

Some doctors use the term degenerative arthrosis. (Arthrosis just means that the joint is wearing out.) Arthritis is technically a condition of joint inflammation. Often, joints with osteoarthritis aren’t inflamed. The term arthritis should really only be used to describe true inflammatory conditions, such as gout, infection, and rheumatoid arthritis.

In almost all cases, doctors try nonsurgical treatments first. Surgery is usually not considered until it has become impossible to control your symptoms.

The goal of nonsurgical treatment is to help you manage your pain and use your elbow without causing more harm. Your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, to help control swelling and pain. Other treatments, such as heat, may also be used to control your pain.

Rehabilitation services, such as physical and occupational therapy, have a critical role in the treatment plan for elbow osteoarthritis. The main goal of therapy is to help you learn how to control symptoms and maximize the health of your elbow. You’ll learn ways to calm your pain and symptoms. You may use rest, heat, or topical rubs.

You may be issued a special elbow splint to immobilize and protect the elbow. Resting the joint can help ease pain and inflammation. Range-of-motion and stretching exercises can improve your elbow flexibility. Strengthening exercises for the arm help steady the elbow and protect the joint from shock and stress. Your therapist will give you tips on how to get your tasks done with less strain on the joint.

If conservative (nonoperative) care fails, it may be necessary to consider some type of surgical treatment. There are several operations to treat advanced osteoarthritis of the elbow. Your surgeon will consider many factors when deciding which procedure is best for you, including the severity of joint degeneration, your age, your activity level, and how you use your elbow.

In almost all cases, doctors recommend nonsurgical treatment first for any joint osteoarthritis. Surgery is usually not considered until it has become impossible to control your symptoms. The goal of nonsurgical treatment is to help you manage your pain and use your elbow without causing more harm.

But if you have already tried all the various options (e.g., antiinflammatory medications, physical therapy, splinting, activity modification, steroid injections), then surgery may be the only option left.

Surgical options range from arthroscopic release of the muscle contracture to debridement and removal of the head of the radial bone at the elbow. Debridement refers to the scraping away of loose bone, bone spurs, and opening up the narrowed joint space. Some surgeons have developed their own special techniques to deal with the problem.

For example, there is the open Outerbride-Kashiwagi (OK) procedure or the ulnohumeral arthroplasty procedure. These are two additional ways to perform debridement. Studies comparing open incision surgery versus arthroscopic (minimally invasive) approaches are ongoing. There is evidence that open surgery provides greater range of motion, while arthroscopic surgery reduces pain more.

An overall review of the studies done show that decreased pain, increased motion, improved function, and patient satisfaction are reported no matter what type of surgery is done. But long-term studies also show that the disease process continues unstopped. More bone spurs develop. Pain and stiffness eventually return.

Some hand surgeons tell their patients to expect “modest” and “unpredictable” improvements. They are honest and forthright in saying the osteoarthritis won’t go away but will get worse over time. It is clear we need more research to find better ways to treat this problem. Understanding the underlying cause and pathology of the disease might help scientists find a way to prevent the disease in the first place or at least stop the progression of disease once it starts.

Biceps tendon ruptures are linked with lifting when there is a sudden eccentric load on the muscle. Eccentric means the muscle was full contracted (arm flexed) and starting to extend. This can occur with weight lifting but also in manual laborers lifting, carrying, and putting down heavy loads.

Men are affected most often though there are some cases reported in women. The average age of these types of biceps ruptures is between 47 and 50 years so there may be some age-related factors. Bilateral (both sides) distal biceps tendon ruptures have also been reported though these injuries don’t usually occur at the same time. There may be a period of months to years between the first arm (biceps) and the second rupturing.

Surgeons think there may be some anatomical reason why the biceps tendons in these patients give way. There may be a load involved but some pathologic change in the tendon puts it at increased risk for injury.

Exactly what that anatomic change may be is still unknown. Some experts suggest an extra lip of bone where the tendon attaches may be the culprit. Or in some people, there may be an area of decreased blood supply just above where the tendon pulls away from the bone. Examination of the torn tissue under a microscope has revealed some degenerative changes in some cases.

Other studies have reported additional risk factors including smoking (nicotine use) and the use of anabolic steroids (illegal use of steroids to bulk up muscles). Whatever the cause, this study confirms it’s more than a coincidence that bilateral distal biceps ruptures occur. Patients who have the first biceps tendon rupture may be at increased risk for injury to the other arm. More study is needed to fully identify predictive risk factors that might help with prevention of these injuries.

In the case of weight lifting and body building for middle-aged adults (and older), it is always advised that you work with someone who fully understands the anatomy and physiology of the aging body. A physical therapist or exercise physiologist is the best person to guide you.

According to a recent study, biceps tendon ruptures in both arms may not be as uncommon as was once thought. Up to eight per cent of adults may experience bilateral (both sides) distal biceps tendon ruptures. The damage doesn’t occur in both arms at the same time. Usually the biceps tendon in one arm ruptures and then some years later the patient has the same thing happen in the other arm.

The biceps muscle is located on the upper arm. It mainly flexes or bends the elbow but also supinates the forearm (turns the hand palm up). It is a large and very strong muscle — the first one many children learn to “flex” to show their strength.

So what’s going on for you and these other patients? Is it really a fluke that both biceps muscles tear? Or is there some reason why the same type of injury would occur on both sides? By taking a backward look at a large number of cases (321 patients), the authors of this study may have some new insight to share about this problem.

They found that most (92 per cent) of the bilateral ruptures occurred in men as a result of lifting heavy loads. One-third of the group was involved in heavy manual labor at the time of the injuries. In a smaller number of cases, women were affected but without a known cause. The fact that these people had a second biceps rupture on the other side suggests that even the first injury was more than just an injury.

Surgeons think there may be some anatomical reason why the biceps tendons in these patients give way. There may be a load involved but some pathologic change in the tendon puts it at increased risk for injury.

Exactly what that anatomic change may be is still unknown. Some experts suggest an extra lip of bone where the tendon attaches may be the culprit. Or in some people, there may be an area of decreased blood supply just above where the tendon pulls away from the bone. Examination of the torn tissue under a microscope has revealed some degenerative changes in some cases.

Other studies have reported additional risk factors including smoking (nicotine use) and the use of anabolic steroids (illegal use of steroids to bulk up muscles). Those risk factors were not heavily represented in this patient population.

Whatever the cause, this study confirms it’s more than a coincidence that bilateral distal biceps ruptures occur. Patients who have the first biceps tendon rupture may be at increased risk for injury to the other arm. Whether or not you might have this same injury happen a second time can’t be predicted at this point. More study is needed to fully identify predictive risk factors that might help with prevention of these injuries.

Steroid injections are no longer routinely recommended for lateral epicondylitis (tennis elbow). But there are times when a physician or physician’s assistant (PA) may make this recommendation.

Steroid injections have fallen out of favor for the treatment of lateral epicondylitis but are still used by some physicians in certain carefully selected patients. The disadvantages of steroid injection include only short-term pain relief and disruption of the body’s natural healing process.

Steroid injections do not change the underlying pathology. And in the case of degenerative rather than inflammatory epicondylitis, steroids can actually delay healing. Since steroid injections offer only temporary benefit with potential drawbacks, the question has been raised: why use them at all?

Pain relief (even if temporary) is valuable. Turning off pain signals at the tendon-bone interface can help break the pain cycle. This gives the patient an opportunity to rehab under the guidance of the therapist.

And it may not be the medication itself that is the problem but rather the method of delivery (injection). Future studies are needed to compare patients who receive no treatment with those who are given a placebo treatment. It’s important to sort out the real reason(s) why some patients improve while others don’t (or improve at a slower rate).

Is it truly the method of drug delivery or just a matter of time, or the hand therapy? There are questions the authors intend to pursue further in future research efforts to find the fastest, most effective treatment for lateral epicondylitis.

Physical therapists offer an alternative treatment in the form of something called iontophoresis. Iontophoresis uses a small electric current to drive steroid medication through the skin. It is a noninvasive method of reducing the pain of tennis elbow. If you don’t want a steroid injection, you may ask your physician’s assistant (PA) about the possibility of trying iontophoresis instead. If you don’t get the desired results with iontophoresis, you can always go back for the injection later.

There’s no easy answer to this question but we can offer you some things to consider when making the decision. First, there are two types of lateral epicondylitis (tennis elbow): acute inflammatory and chronic degenerative.

Treatment may vary depending on the underlying pathology. For example, steroid injection or other antiinflammatory medication is more appropriate in the acute cases where inflammation is ongoing. Strengthening and manual therapy such as soft tissue mobilization performed by a physical therapist may be a better approach for patients with degenerative disease.

Whether acute or chronic, iontophoresis is a possible treatment option to consider. Iontophoresis uses a small electric current to drive steroid medication through the skin. It is a noninvasive method of reducing the pain of tennis elbow.

Iontophoresis may be beneficial because it turns off pain signals. Turning off pain signals at the tendon-bone interface can help break the pain cycle. This gives the patient an opportunity to rehab under the guidance of the therapist.

Some experts suggest that a less than 15 per cent improvement in grip strength after therapy may be an indication that surgery may be the next step. But there are some studies that show the problem eventually goes away on its own. This can take up to a year or more and requires management of activity modification, work restrictions, and both stretching and strengthening exercises.

The first step is to see an orthopedic surgeon for an evaluation of the problem. A baseline measurement of pinch and grip strength, range-of-motion of the elbow, forearm, and hand, and test of sensation would all be helpful to document changes over time.

The ulnar nerve is close to the surface of the skin and most likely to be damaged due to direct injury. This is the nerve that causes pain when you hit your “funny bone” (the bony bump of the elbow closest to the body).

Damage to this nerve often requires a procedure called nerve transposition. The surgeon has to move the nerve away from the bone where it is being bumped or compressed. Moving the nerve shortens it and relieves tension. It’s possible that all you need is a minor procedure involving shaving the bone around the nerve.

Treatment may actually begin with a more conservative approach using an elbow support or splint to protect the nerve. Other more extreme surgical measures are possible but less likely. For example, if the carrying angle of the elbow (the natural angle that’s formed when your arm is down by your side) is part of the problem, the surgeon could do a procedure called an osteotomy.

A small wedge-shaped piece of bone is removed from around your elbow. The remaining edges of bone are collapsed down toward each other. The goal is to change the carrying angle and make it less likely you’ll bump the bone/nerve.

Again, the surgeon is the best one to advise you. Make an appointment today and see what you can find out about your own particular problem and possible solutions. Good luck!

With your self-study you now know that 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.

When pressure on the nerve is severe enough, constant pain, numbness, and electric shock sensations make it difficult to perform daily tasks at home and at work. The problem is usually treated conservatively with nonoperative care. Anti-inflammatory medications may help control the symptoms. The early symptoms of cubital tunnel syndrome usually lessen if you just stop whatever is causing the symptoms. This is called activity modification.

Since surgery has been recommended, we are assuming you have explored all nonsurgical options. The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. There are two different kinds of surgery for cubital tunnel syndrome. It is not clear whether one operation is better than the other.

Ulnar nerve transposition (the one you are considering) involves the formation of 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.

The other method simply removes the medial epicondyle on the inside edge of the elbow, a procedure called medial epicondylectomy. By getting the medial epicondyle out of the way, the ulnar nerve can then slide through the cubital tunnel without pressure from the bony bump. You can see images to illustrate both of these operations here:

A Patient’s Guide to Cubital Tunnel Syndrome

Recovery after elbow surgery depends on the procedure used by your surgeon. If you only had the medial epicondyle removed, you’ll have a soft bandage wrapped over your elbow after surgery. Therapy can progress quickly after this type of surgery. Treatments start out with range-of-motion exercises and gradually work into active stretching and strengthening. You just need to be careful to avoid doing too much, too quickly.

Ulnar nerve transposition can be a delicate operation. Studies report variable results. Therapy goes slower after ulnar nerve transposition surgery. You could require therapy for three months. This is because the flexor muscles had to be sewn together to form the new tunnel. Your elbow will be placed in a splint and wrapped in bulky dressing, and your elbow will be immobilized for three weeks.

When the splint is removed, therapy will begin with passive movements. In passive exercises, your elbow is moved, but your muscles stay relaxed. Your therapist gently moves your arm and gradually stretches your wrist and elbow. You may be taught how to do passive exercises at home.

Active therapy starts six weeks after surgery. You begin to use your own muscle power in active range-of-motion exercises. Light isometric strengthening exercises are started. You may begin careful strengthening of your hand and forearm by squeezing and stretching special putty. These exercises work the muscles without straining the healing tissues.

At about eight weeks, you’ll start doing more active strengthening. Your therapist will give you exercises to help strengthen and stabilize the muscles and joints in the wrist, elbow, and shoulder. Other exercises are used to improve fine motor control and dexterity of the hand.

Some of the exercises you’ll do are designed get your elbow working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don’t put too much stress on your elbow. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Your hesitation suggests the need for more time and perhaps more discussion with your surgeon. With this new information, you may have some additional thoughts and questions for your surgeon that will help you make the final decision. Move at the pace of guidance and listen to your own internal sense of direction and purpose.

If by “funny elow syndrome” you mean cubital tunnel syndrome, we may have some information for you. A recent review of 26 studies involving a total of 1500 patients addressed the question: What factors predict the outcome of surgery for cubital tunnel syndrome?

Six of the most commonly used prognostic factors were evaluated (including two that you mentioned). These included age, duration of symptoms, severity of preoperative status, results of preoperative electrodiagnostic testing, type of surgery, and Workers’ Compensation status.

This condition 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. Of course, that’s why it is referred to by some as the funny elbow syndrome.

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.

When pressure on the nerve is severe enough, constant pain, numbness, and electric shock sensations make it difficult to perform daily tasks at home and at work. The problem is usually treated conservatively with nonoperative care. Anti-inflammatory medications may help control the symptoms. The early symptoms of cubital tunnel syndrome usually lessen if you just stop whatever is causing the symptoms. This is called activity modification.

If the symptoms do not go away, even with changes in activities and nonsurgical treatments, then surgery may be advised to stop damage to the ulnar nerve. The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel.

The surgical approach reviewed in this study 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.

It’s a delicate operation that can have variable results. Your idea is a good one. It would be helpful to have some way to evaluate patients before surgery for potential factors that might cause postoperative pain and disability. Having what we call predictive or prognostic factors might help surgeons choose patients more careful (and specifically) for this procedure and/or change the way patients are treated.

But the results of these studies showed no clear trend and conflicting results when focusing on these six potential predictive factors. The authors of this review say that the reasons for the lack of convincing or consistent evidence may not have to do with the factors themselves. It’s more likely that the study design and general low-quality of the studies were the real problem areas.

They concluded that future prognostic (high-quality) studies are definitely needed. One step researchers could take is to use the same disease-specific outcome measure that is reliable. Research to find such a tool should be the first step. Studies with large numbers of patients would also be helpful. And research that doesn’t rely on retrospective design (patients have to recall or remember events over a long period of time) is preferred.

Athletes like yourself who are involved in repetitive elbow motions or overhead activities are at risk for the condition you described called osteochondral lesions. Osteochondral lesions refer to damage or defect to the joint cartilage (chondral) all the way down to the first layers of bone (osteo). Holes in the osteochondral layer and/or loose fragments of bone and cartilage in the joint can cause pain, locking of the joint, and eventually osteoarthritis.

There are many ways to treat this problem starting with conservative (nonoperative) care. When six months or more of conservative care does not yield the desired results, then surgical treatment is considered. The surgeon may remove the fragments and smooth the area over with a special surgical shaver. This procedure is called debridement.

Other surgical options include reattachment of the fragments, microfracture (drilling tiny holes to stimulate healing), or osteotomy (removing a wedge of bone to close up the hole). Sometimes these techniques don’t work as well as hoped and there is a risk of osteoarthritis later.

There is a newer approach under investigation called osteochondral autograft transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (in this case from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same patient’s elbow joint). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

Consultation with an orthopedic surgeon is advised. Smaller lesions do respond well to conservative care but yours sounds a bit more advanced than that. With your situation (attached fragment hanging by a thread), you may still be a good candidate for reattachment and rehab.

Finding out about all the different treatment choices is a good place to start. That will give you more information with which to ask the surgeon questions to help direct your choice. Your choices may be limited by the training the surgeons in your area have. Not all surgeons are trained to perform all the different techniques described here.

Osteochondral lesions refer to damage or defect to the joint cartilage (chondral) that extend all the way down to the first layers of bone (osteo). Holes in the osteochondral layer and/or loose fragments of bone and cartilage in the joint can cause pain, locking of the joint, and eventually osteoarthritis.

There are many ways to treat this problem starting with conservative (nonoperative) care. Have you tried any antiinflammatories, steroid injections, or physical therapy? These would be the first treatment ideas to discuss with your physician.

If you have tried at least six months of conservative care without change or improvement, then surgical treatment is considered. Surgery is often the only option when motion is very restricted and/or the joint if unstable.

The surgeon may remove the fragments and smooth the area over with a special surgical shaver. This procedure is called debridement. Other surgical options include reattachment of the fragments, microfracture (drilling tiny holes to stimulate healing), or osteotomy (removing a wedge of bone to close up the hole).

Another surgical option for more severe osteochondral lesions or defects is a procedure called Osteochondral Autograft Transfer or OAT. Osteochondral autograft transfer (OAT) involves removing a plug of cartilage and bone from a healthy area (e.g., from a non-weight bearing area of the knee) and transferring it into the osteochondral lesion (i.e., hole in the surface of the same patient’s lesion). The word “autograft” refers to the fact that the patient donates his or her own tissue for the procedure.

Studies show good coverage of the defects with full incorporation of the graft using the OAT procedure. Even for patients who have already had one surgical procedure, there may be other ways to address the continued problem. A second surgical procedure may be needed. The osteochondral autograft transplantation is an option for patients who have tried other surgical treatments that failed to bring satisfying results.

It doesn’t sound like you have had any surgery yet, so this may not apply to you now but perhaps may be useful information down the road. The next step for you may be to see an orthopedic surgeon to discuss treatment options. A physical examination and perhaps some imaging tests will help you and the surgeon formulate a plan of care that best suits you at this time.

Tennis elbow (also known as lateral epicondylitis) doesn’t always occur in tennis players. Anyone can develop tennis elbow. It is usually the result of overuse of the elbow. Not everyone who plays tennis or who engages the elbow in repetitive motions develops tennis elbow. There is evidence that abnormal healing responses combined with mechanical overload may be part of the problem.

Various treatments have been tried, combined, studied, and compared with no one single approach being successful for everyone. Based on current evidence, there is some agreement that a program of eccentric exercise should be included no matter what other treatment is used.

Eccentric exercises place the wrist extensor muscles in full contraction with motion to slowly allow the muscle to lengthen. A physical therapist can set you up on a program of stretching and eccentric exercises. The therapist will guide you through a gradual progression of movement and exercise during healing and recovery. Eventually you will need to retrain the muscles and tendons to fire normally during all motions and activities (not just eccentric lengthening).

Another newer treatment that has been shown beneficial for chronic tennis elbow is the use of platelet-rich plasma (PRP). PRP is the plasma (clear) portion of the blood with eight times the number of platelets as regular whole blood.

Platelets contain special growth factors that are normally released during a healing or tendon reparative process. Depending on how the platelet-rich plasma is prepared, there can be up to 25 times the normal number of growth factors available. Platelet-rich plasma has been shown to increase the number of cells needed to stimulate collagen production but without creating scar tissue. Collagen is the basic building material of tendons.

Some people get good results combining platelet-rich plasma injection with a follow-up rehab program as described. Others may have to work a bit longer to find the right combination of treatment that works best for them. This may include rest, acupuncture, steroid injection, or iontophoresis (a technique using a mild electrical current to push anti-inflammatory medicine through the skinto the sore area).

Sometimes nonsurgical treatment fails to stop the pain or help patients regain use of the elbow. In these cases, surgery may be necessary. The best thing to do is see your primary care physician, an orthopedic surgeon, or a physical therapist for an evaluation and treatment plan. Get started with conservative (nonoperative) care and see what kind of response you get before thinking or worrying about the potential for surgery.

Blood as a healing agent is a fairly new approach to problems like chronic tennis elbow. It was first used in the 1990s for facial and plastic surgery and has since expanded in its application to include orthopedic treatments as well. There are two different types of blood injection currently being used and studied.

The first is platelet-rich plasma or (PRP). PRP is the plasma (clear) portion of the blood with eight times the number of platelets as regular whole blood. Platelets contain special growth factors that are normally released during a healing or tendon reparative process. Depending on how the platelet-rich plasma is prepared, there can be up to 25 times the normal number of growth factors available.

The second form of blood injection is the use of autologous whole blood. Autologous tells us that the patient’s own blood was used in the procedure. It sounds like this is the type of blood injection you may have had. Both types of blood treatment have been shown to increase the number of cells needed to stimulate collagen production but without creating scar tissue. Collagen is the basic building material of tendons.

Paatients receiving the whole blood injection report more pain after their injection. This may be because the white blood cells contained within the blood sample signal an intense inflammatory response. Studies comparing platelet-rich plasma (PRP) with whole blood suggest that platelet-rich plasma (PRP) injection is superior to autologous whole blood in the treatment of chronic tennis elbow.

Patients receiving the platelet-rich plasma (PRP) (with the higher concentration of growth factors) have better results at first (during the first six weeks). But after that, the results are about the same between the two groups. So PRP treatment gives earlier pain relief but no greater function in the end. Pain relief is still welcomed by anyone with chronic elbow pain.

Researchers in this field suggest that the influence of white blood cells with and without platelets should also be investigated more closely.