FAQ Category: Elbow

Elbow replacements are fairly new compared to hip or knee replacements. They can be very helpful in relieving pain and improving function. But there a few downsides to be aware of and discuss with your surgeon.

In terms of reliability and durability, results are not as good for elbows as they are for hip and knee replacements. There’s a much higher failure rate (15 per cent) for elbows compared with hips and knees (less than five per cent).

Loosening of the implant without infection (called aseptic loosening) is the number one complication with elbow replacements. But there have been other problems reported that require a second surgery (e.g., implant breaks, bushings wear out, mechanical failure of linkage pins).

Researchers are trying to get to the bottom of this problem. They are looking at all patient, implant, and surgical factors. For example, is younger age (with a higher activity level) the reason why TEAs come loose? Is there a specific feature (flaw?) in the implants that just doesn’t work well with joint damage from trauma or the degenerative effects of osteoarthritis?

There is more than one kind of artificial elbow joint (also called a prosthesis or implant). Each one of these design features addresses a specific problem such as torn ligaments or other soft tissue damage, bone loss, and elbow deformities. Perhaps the various design features make a difference in results. Or maybe it’s the underlying patient problem that contributes to complications.

So far, it looks like people of all ages with inflammatory arthritis like rheumatoid arthritis (RA) have the best results with elbow joint replacements. The implant holds up well over time. Elbow function is improved and patients are satisfied with the results.

But younger patients who either have osteoarthritis, arthritis from an injury, or a severe acute injury of the elbow seem to have a high rate of complications. This group is also more likely to need a second (revision) surgery.

Right now, there’s more unknown than known about outcomes with total elbow arthroplasty (TEA). One important discovery is that there is a higher rate of revision surgeries when the implant is done outside of a joint replacement specialty hospital or center. This finding may influence where you have your surgery done.

Many people begin with physical therapy and learn how to modify activities to avoid aggravating the irritated tissue. Sometimes activity restriction is required. This means you may have to stop doing some activities or motions and give the joint and surrounding soft tissues a rest.

The therapist may suggest using bracing and/or heat treatments such as ultrasound and laser therapy. Activities, movement, and exercises to improve proprioceptive (joint sense of position) techniques may be helpful.

Other nonoperative approaches used with some success have included manual therapy and extracorporeal shock wave therapy (ESWT). Manual therapy is a hands on technique provided by the physical therapist. It involves moving soft tissue and bone to restore normal alignment and tissue tension.

Shock wave therapy is thought to work by causing microtrauma to the tissue that is affected. The body responds to the microtrauma with a healing response. The result is blood vessel formation and increased delivery of nutrients to the affected area. The final outcome is pain relief from the tendinopathy.

There are other treatment ideas that have not been tested yet. These are on the integrative side of medicine and provide an alternative way to approach the problem. Reiki, acupuncture, craniosacral therapy, BodyTalk, Healing Touch, and even hypnosis have been used with some success.

When the inside of the elbow develops a painful problem, it’s usually called medial tendinitis or “tennis elbow”. When the side away from the body is affected, the label given is lateral epicondylitis or “golfer’s elbow”.

In either case, the problem is given the -‘itis’ ending when it is an acute (just developing) problem. When it becomes a chronic problem that lasts for months or more, then it’s not really a tendinitis as much as it is a tendinopathy.

Tendinopathy refers to the fact that tissue samples taken of tendons on the affected side of the elbow show no inflammation at all. Scarring and fibrosis can be seen on microscopic exam but there are no signs of acute tendon damage or healing.

Unless you have tried nonoperative methods of treatment, surgery may not be the right choice for you. Most surgeons recommend at least a three (sometimes six) month trial of conservative care. This might include steroid injections, physical therapy, bracing, and activity restriction or modification. Many patients improve enough with this type of treatment that they can avoid surgery.

Surgery is usually not considered until and unless the patient has had extensive nonoperative care that has failed to change the symptoms or improve function. When surgery is indicated, the surgeon has many options to choose from: muscle resection, debridement (shaving away frayed edges), reattachment of torn tendons to the bone, repair with tendon grafts, release of tendons, and combinations of these treatments.

The specific approach will depend on the type of soft tissue damage present, your activity level, and your overall health. Problems like high blood pressure, diabetes, or heart disease can have a bearing on the type of surgery you can handle. Once your surgeon evaluates you, the treatment of choice will likely become clear.

To confirm the diagnosis, the surgeon can order MRIs, which will show exactly what’s happening in the soft tissues around the elbow. Of course, the diagnosis is confirmed if/when surgery is done. But sometimes, operative repair isn’t needed.

Older adults or people who are fairly inactive may regain enough strength and motion to remain functional without surgery. The arm is placed in a sling for a few days up to a few weeks. Medications may be used to control pain and make the patient comfortable.

Physical therapy is a key part of conservative (nonoperative) care. The therapist helps the patient learn how to regain motion, strength, and proper motor control. The therapist will also use manual (hands on) techniques to help the healing tissue fibers line up correctly during the healing process.

Surgical repair is really the most common treatment approach and recommended for those who want to regain full strength, motion, and return to work at their preinjury level. The method of operative care isn’t as straight forward as nonoperative care. Surgeons have a wide range of methods they can use to complete this repair.

The first decision is whether to try and reattach the tendon to its proper (native) location or stitch it to a muscle nearby (the brachioradialis muscle). Reattaching it where it belongs is called an anatomic repair. Suturing the tendon to the brachioradialis muscle instead is referred to as a nonanatomic repair.

Once the operation has been completed, the work of rehab and recovery begins. Studies have shown that it is acceptable to follow a more aggressive postoperative plan than was used in previous years.

Immobilizing the arm is still done in the early days but motion is started much earlier than before. Different surgeons use different approaches. Some put the patient in a splint right after surgery (limiting all motion), while others use a hinged elbow brace (set to allow certain movements).

When to start motion and how much to allow also varies from surgeon to surgeon. Some of this is determined by the type of surgery that was done. Some decisions are made based on reports from other studies. And, of course, surgeon training, experience, and preferences play a part in the plan of care.

For the most part, patients can expect to get back to normal daily activity four to six weeks after surgery. Full strength and return-to-work (especially manual labor or activities requiring lifting) may take longer.

The symptoms you describe: a tearing sensation, pain, and weakness could be an indication of soft tissue damage. You’ll need an examination by an orthopedic surgeon to know for sure. Given the mechanism of injury (arms extended with a force applied to the elbow during the lift), the most likely area affected is the distal biceps tendon.

The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. It is attached to the bone by tendons at the top and bottom. Two separate tendons connect the upper part of the biceps muscle to the shoulder. One tendon connects the lower (distal) end of the biceps to the elbow.

A distal biceps rupture occurs when the tendon attaching the biceps muscle to the elbow is torn from the bone. A distal biceps rupture is rare compared to ruptures where the top of the biceps connects at the shoulder. This injury occurs mainly in middle-aged men during heavy work or lifting. Similar injuries in women are extremely rare. Smokers are more 7.5 times more likely to rupture the distal biceps tendon than nonsmokers.

The diagnosis is made using a combination of patient history, visual inspection, palpation, clinical tests, and imaging studies. The history is often an important clue because patients usually describe a sudden force applied to the arm followed by a tearing sensation on the inside of the elbow. There is immediate pain and then weakness when trying to bend the elbow.

Two clinical tests that are very useful are the squeeze test and the hook test. You can actually do these tests on yourself to try them out. The squeeze test is done by using one hand to squeeze the upper portion of the biceps muscle of the other arm. You’ll see and feel the hand of the arm being squeezed turn slightly toward a palms up position. This happens automatically when the muscle is squeezed.

The hook test is done with the elbow slightly bent. Use your fingers of the opposite hand and feel the tendon as it attaches to the front of the elbow. You can actually use your index finger to grab or “hook” that tendon and pull it up. If the tendon is ruptured, you won’t be able to see the hand turn when you squeeze the biceps muscle and you won’t be able to find the tendon to hook a finger under it.

To confirm the diagnosis, the surgeon can order MRIs, which will show exactly what’s happening in the soft tissues around the elbow. Of course, the diagnosis is confirmed if/when surgery is done. But sometimes, operative repair isn’t needed. The surgeon who examines you will give you the proper diagnosis and proposed plan of care. Don’t put it off as early diagnosis and treatment can improve your odds of good outcomes.

Osteochondritis dissecans (OCD) is a condition in which a piece of cartilage and the underlying bone have been damaged. In some cases, the damaged fragment separates from the bone and floats freely within the joint.

Shear stresses from repeated motions probably start the problem. Poor mechanics and fatigue of the muscles and ligaments are added to the shear load. Combined together, these forces cause the cartilage to separate from the bone, taking a piece of the underlying layer of bone with it.

OCD is not self-limiting condition. In other words, it doesn’t get better on its own. But other than that bit of information, the natural history (what happens over time) and the best way to treat this condition isn’t known. There are some studies that show over time, OCD lesions can lead to further degenerative changes in the elbow.

How can the orthopedic surgeon tell if someone has osteochondritis dissecans? Of course, the patient history helps — for one, participation in overhead throwing sports or activities that repeatedly compress the elbow joint (gymnastics, weight lifting, tennis, cheerleading) is a red flag.

The symptoms reported are usually pain along the outside of the elbow that gets better with rest. Stiffness, locking, catching, and loss of full elbow extension complete the picture.

To confirm the diagnosis, the physician relies on X-rays, MRIs, and sometimes CT scans. Once it has been determined where the damage is located, how severe the lesion is, and how stable (or unstable) the elbow is, then a management plan can be formed.

In many cases, the final diagnosis is made when the surgeon performs an arthroscopic exam. By inserting a scope inside the joint, the surgeon can take a look around and see what’s going on. For the elbow, it may be necessary to enter the joint from several different portals (insertion sites for the scope) in order to examine all locations.

The final outcome of this condition may depend on the age at diagnosis, the activity level during healing and recovery, the treatment (conservative care versus surgery), and whether there are any complications after surgery. More study is definitely needed to better understand the natural history of osteochondritis dissecans.

Definitely call and check with your surgeon about his or her guidelines. Each surgery has its own unique management plan. The goal is to protect the joint and soft tissues while they heal. Saving the soft tissues that have been damaged and preserving the joint surface are the top priorities.

When it’s a simple dislocation that is reduced (relocated), putting the arm in a splint is usually just for no more than two weeks. Patients are told not to move the arm away from the body. That motion puts a lot of stress on the elbow.

The key anatomical feature of elbow dislocations is the lateral collateral ligament (LCL). When this important stabilizing structure is torn or damaged as a result of injury, elbow instability is often the result. Instability means the joint keeps slipping out of place. There can be a partial dislocation called subluxation or a full, recurrent (repeated) dislocation.

After reduction or after surgery, the patient with a repaired elbow dislocation is watched closely for elbow instability. Surveillance (observation) is especially important during the recovery period for those who have had surgery and throughout the rehab process for everyone. Wearing the splint according to the doctor’s instructions is an important part of that process.

The elbow is normally a very stable, solid joint. It doesn’t dislocate easily. But when a traumatic injury occurs and enough force is placed on it, fracture and dislocation can be the result. In this continuing medical education (CME) article, orthopedic surgeons from the Hand and Upper Extremity Service at Massachusetts General Hospital in Boston present an update on the surgical repair of traumatic elbow instability.

Injuries from a sudden fall that result in a simple dislocation can damage any of these soft tissue structure. “Simple” means there is no bone fracture.

More complex elbow dislocations involve fractures of any of the bones that make up the joint. This can include either of the bones in the forearm (radius, ulna) or the bottom of the humerus (upper arm bone) where it joins the forearm bones to form the elbow. The exact type of elbow dislocation and which soft tissues or bones are affected depends on the force(s) placed on the elbow at the time of the injury.

Simple elbow dislocations can often be reduced (put back in place) without surgery. More complex dislocations require a surgical procedure to reduce the joint and repair the damage.

Long-term problems that can occur after a traumatic elbow injury include chronic, recurrent elbow dislocations, joint stiffness, and/or eventually degenerative changes in and around the joint.

The goal of treatment is to restore joint stability and prevent these kinds of problems. The bottom line is that a stiff but located (in place) joint is easier to save than one that is so damaged that the joint surface has been disrupted.

With epicondylitis, it is known that the damaged tendon doesn’t heal correctly. Degeneration occurs with fibrotic (scar) tissue forming instead of new, healthy tissue.

However, there may be some other reason for your elbow pain. For example, cervical radiculopathy (pinched nerve in the neck) can also cause elbow pain. In the case of medial epicondylitis linked with cervical radiculopathy, weakness of the muscles supplied by the pinched nerve leads to problems at the elbow. The spinal nerve roots affected and thus associated with golfer’s elbow are C6 and C7.

Weakness compounded by repetitive motion and overload of the muscle-tendon junction can then lead to microtearing and tendon damage. But we also know that weakness from cervical radiculopathy can be enough to put the elbow at risk for the development of medial epicondylitis.

Now let’s go back to the idea that with chronic elbow pain (golfer’s elbow or tennis elbow), we know there is a lack of healing at the tendon-muscle-bone interface. The failure to heal properly is possibly another end-result of the compromised (pinched) nerve tissue in the neck. The connection between poor tendon healing and the cervical radiculopathy has not been proven yet, so this is just a suggested theory for now.

Without knowing where the pain is located and what tests have been tried, this is a little difficult to answer. There are specific tests for suspected tennis or golfer’s elbow. Tennis elbow typically presents with pain along the outside of the elbow. Golfer’s elbow (also known as pitcher’s elbow) tends to show up as pain along the inside of the elbow.

Your history, along with a postural assessment, palpation, muscle testing, and motion testing (joint and nerve mobility) direct further testing if needed. Sometimes there is enough information gained from these tools to direct the initial treatment. A hand therapist is often involved at this point, providing rehab to resolve the symptoms and restore full pain free function.

The therapist’s treatment is somewhat diagnostic. If there is no improvement with conservative care, then it may be necessary to conduct additional tests. Electrodiagnostic testing including nerve conduction velocity (NCV) or electromyography (EMG) are used to see what’s going on with the nerves causing the painful symptoms. These tests also help pinpoint the location of the problem.

Imaging studies can also be helpful. Plain X-rays help show if there are any structural reasons for the symptoms such as tumors, bone spurs, or even disc protrusion in the neck pressing on the nerves. Cervical spine degeneration with or without disc involvement can produce painful elbow problems whenever the spinal nerve roots are pinched or impinged.

MRIs are also diagnostic. The images can confirm (or rule out) cervical radiculopathy (the medical term for pinched nerve in the neck).

Most surgeons take a step-by-step approach in ordering tests. Everyone is interested in reducing health care costs. By letting your physician know of your situation, the most conservative, yet appropriate tests can be ordered as needed.

The statistical method called Number Needed to Harm (NNH) is a way to evaluate data pooled from many studies. It is used when comparing two different treatment techniques for the same problem.

Number Needed to Harm refers to the number of patients treated in a certain way before someone gets hurt or has a complication. It might seem like an odd way to look at something. But using the Number Needed to Harm is more meaningful to a surgeon than using mathematical ratios or odds.

Using the Number Needed to Harm gives the surgeon a better perspective of the benefits and risks of a procedure. Likewise, it gives patients a way to make an informed choice about surgery. Your surgeon may have read a recent study on two different pinning methods for elbow fractures. The results were reported using Number Needed to Harm.

Without going into too much detail, they compared using a crossed pin to straight (lateral) pinning method for elbow fractures that had been displaced. A displaced fracture means the broken bone fragment separates and shifts away from the main bone. The crossed fixation technique may increase the risk of injuring the ulnar nerve, which runs through the affected area.

The results showed that for every 28 patients who were treated with the crossed pin fixation method, one would have an ulnar nerve injury. This was the number of patients who would have to be treated by crossed pinning to have one more nerve injury compared with the lateral pin method.

Using the Number Needed to Harm (NNH) as the only measure to show that one method is safer than another is not necessarily recommended. Together with other measuring methods, it provides some additional information for patients and surgeons. This information can be used when deciding on the relative risks and benefits of this particular fixation technique.

Pin fixation is a general term used to describe any method used to hold bone fragments together during the healing process. Words such as pin, nail, or hardware refer to devices such as plates, screws, wires, and pins used to hold the pieces of bone to the main bone. The hardware remains until the body can fill in and around the break with new bone. Sometimes it’s not removed at all but left in to avoid disrupting the bone a second time.

Wire can be the easiest method to use when there are a number of fragments to hold together. In a small child with tiny bones, thin wire also makes the most sense. There simply isn’t enough bone or room for large screws or plates.

When you take your son in for a follow-up appointment, ask the surgeon this question. There may be other details related to your child that you will find interesting.

It sounds like your daughter may have ended up with an elbow deformity called cubital varus. This is a common problem in children who have a supracondylar elbow fracture.

A supracondylar fracture occurs in the lower portion of the humerus (upper arm bone) just above the elbow. In the normal arm, the bottom end of the humerus flares out on each side forming a part of the bone called the condyles. A fracture just above the condyle is a supracondylar fracture.

A cubitus varus deformity gives the elbow an unnatural outward curved angle — like a bowed leg only affecting the elbow instead. Cubitus refers to the inner soft side of the elbow. Varus is the outwardly bowed angle. When the person with cubitus varus looks down at the carrying angle of the elbow, it’s curved in the opposite direction from normal.

Correction of the elbow deformity isn’t always necessary because there isn’t a loss of function. The shoulder works together with the elbow to make up any missing motion. Cosmesis (appearance) requiring surgery may be an issue for some people. There is also the aspect of other complications that can occur later.

For example, the uneven angle can put more pressure on one side of the elbow than the other. Arthritis may be a natural result of the uneven load on the joint. This problem is not as common in the elbow joint as it is in the knee, but it can happen. Another problem that can develop is a nerve palsy.

The ulnar nerve runs along the inside edge of the elbow. The varus position changes where the muscles are located enough to put compression on the ulnar nerve. Loss of normal sensation and/or motor function can occur. The nerve can be moved slightly to form a different pathway down the arm. This procedure is called a nerve transposition.

The best way to find out what is needed for your daughter is to see the surgeon who did the original surgery for an evaluation. If that’s not possible, then look for another surgeon, possibly one who specializes in arm and hand surgery. He or she will be able to evaluate your daughter and formulate the best plan based on current knowledge and information about this condition.

The elbow is a very complex joint when viewed in three-dimensional (3-D) space. Getting the broken bone lined back up in all three dimensions isn’t always easy. Viewed from the side on X-ray, the fracture might look fine. But viewed from the front, back, or from above, the malalignment remains and is much easier to see.

To help you understand what’s going on, we need to talk about the elbow carrying angle. Straighten your arm and let the forearm drop down to your sides. Now turn your hands so the palms are facing forward. Look at your elbow and notice the angle formed from the shoulder to the wrist with the center at the elbow. This is called the carrying angle of the elbow.

Deformities affecting the carrying angle are equally difficult to correct. Surgery is required and in particular, a supracondylar osteotomy procedure is usually the preferred treatment. There are many different ways to do an osteotomy on the distal humerus (lower end of the upper arm bone).

Some correct the angle in one dimension (i.e., as seen from the side). Others correct in three-dimensions. Using this type of osteotomy, the surgeon can correct for deformities in all three planes. The result is to correct the carrying angle, reduce the excess elbow extension, and realign the internal rotation malunion.

Loss of correction after a three-dimensional ostetomy may occur as a result of an unstable osteotomy from the way the bones were cut and arranged. Pins were used to hold everything together until complete bone union took place. But the decrease in contact area between the bones makes it difficult to stabilize the osteotomy site.

There may be some other reason for your child’s loss of correction. The best thing to do is make a follow-up appointment with the surgeon to take a look at what’s going on. If the change in the elbow carrying angle isn’t causing any problems, then it may not be necessary to do anything at this time.

The ulnar collateral ligament (UCL) is a thick triangular-shaped band of fibrous tissue. It connects between the bottom portion of the humerus (upper arm bone) and the upper portion of the ulna (one of the two bones in the forearm). The UCL is on the medial side of the elbow (side closest to the body).

The elbow ligaments can be torn when there is an injury or dislocation of the elbow. If they do 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 overhead throwing motion of baseball pitchers, volleyball players, and tennis buffs.

Orthopedic surgeons have been trying for years to find a technique that can stabilize an elbow joint disrupted by a UCL rupture while still allowing for a normal arc of motion. The docking technique is one of the common methods used to reconstruct the ruptured ulnar collateral ligament.

The surgeon drills two holes in the ulna (bone in the forearm connecting to the elbow) and three in the medial epicondyle (the small bump of bone on the inside of the elbow at the end of the humerus).

The two holes in the ulna form a tunnel that a tendon graft to replace the damaged ligament will be looped through. The three holes in the medial epicondyle form a triangle. The bottom hole will be bigger than the top two holes, so that the surgeon can slide the end of the tendon graft into the bottom hole. The two top holes are used to pull the tendon graft into the tunnel using sutures that are attached to the graft and threaded through the two holes.

After the tendon is harvested, sutures are attached to both ends. The tendon is looped through the lower tunnel formed in the ulna, and stretched across the elbow joint. The two sutures attached to the ends of the graft are threaded into the larger bottom tunnel in the medial epicondyle and each is threaded out one of the upper, smaller holes.

Using these two sutures, the surgeon pulls the end of the graft farther into the upper tunnel until the amount of tension is correct to hold the joint in position. The surgeon carefully puts the elbow through its full arc of motion and readjusts the tension on the sutures until he is satisfied that the proper ligamentous tension is restored. The two sutures are tied together to hold the tendon graft in that position.

Another common technique to reconstruct the ulnar collateral ligament is the figure of eight technique. In this technique, the tendon graft is threaded through two pairs of holes – two drilled in the medial epicondye and two in the ulna. The graft is looped through the holes in a figure of eight fashion. The two ends of the tendon are sutured to the tendon itself.

There are several newer techniques being developed that hopefully will make the procedure less invasive while still being as successful as the docking and figure-eight techniques. One new method under investigation combines a ZipLoop, the docking technique, and an interference screw. The ZipLoop device makes it easier to tighten or loosen the graft once it’s in place.

There are several important ligaments in the elbow. Ligaments are soft tissue structures that connect bones to bones. The ligaments around a joint usually combine together to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid.

In the elbow, two of the most important ligaments are the ulnar collateral ligament (UCL) and the lateral collateral ligament. The UCL is also known as the medial collateral ligament. It’s very likely that one of these two ligaments has been torn in your son’s elbow.

The ulnar collateral ligament is on the medial (the side of the elbow that’s next to the body) side of the elbow, and the lateral collateral is on the outside. 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.

Together these two ligaments, the ulnar (or medial) collateral and the lateral collateral, connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus.

These ligaments are the main source of stability for the elbow. They can be torn when there is an injury or dislocation of the elbow. If they do 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 used by baseball pitchers.

Surgical treatment is designed to restore medial stability of the elbow. Full return to previous activities is the main goal. This is especially true for those athletes who want to remain active and competitive in sports.

Radial tunnel syndrome happens when the radial nerve is squeezed where it passes through a tunnel near the elbow. The nerve roots coming from the spinal cord in the neck join together to form three main nerves that travel down the arm to the hand. One of these nerves is the radial nerve. The radial nerve passes down the back of the upper arm. It then spirals outward and crosses the outside (the lateral part) of the elbow before it winds its way down the forearm and hand.

On the lateral part of the elbow, the radial nerve enters a tunnel formed by muscles and bone. This is called the radial tunnel. Passing through the radial tunnel, the radial nerve runs below the supinator muscle. The supinator muscle lets you turn your hand palm up as if you were holding a bowl of soup.

After the radial nerve passes under the supinator muscle, it branches out and attaches to the muscles on the back of the forearm. The posterior interosseous nerve is a part of the radial nerve in the forearm. After the radial nerve has crossed the supinator muscle, it continues on as the posterior interosseous nerve. If the painful symptoms go away after cutting this
branch the surgeon can safely assume the diagnosis was radial tunnel syndrome.

Pain, numbness, and tingling in the wrist and hand are common features of compression neuropathies like carpal tunnel syndrome (CTS) and radial tunnel syndrome. These are problems that develop when nerves in the wrist or forearm get pinched or pressed.

Carpal tunnel syndrome is often diagnosed quickly and easily because there are well-known tests that reliably and accurately point to compression of the median nerve as it passes through the bones of the wrist that form what is called the carpal tunnel.

But with radial nerve syndrome, there are no definite tests that prove the patient has radial nerve compression. The surgeon must rely on patient report and clinical findings to make the diagnosis.

For example, elbow pain along the outside of the elbow is typical with radial tunnel syndrome. There is often tenderness with palpation of the common extensor muscles just below the bump on the outside of the elbow. That bump is called the lateral epicondyle. But patients with pain at this place don’t always have radial tunnel syndrome. And people with radial tunnel syndrome don’t always have pain or tenderness there.

Surgeons rely on several other tests to help identify radial tunnel syndrome as the problem. The first is the forearm and finger extension test. The patient attempts to turn the palm up with the elbow extended (straight), a motion called supination. At the same time, the examiner resists the movement. The test is considered positive if there is pain with resistance. Another resistive test involves asking the patient to extend the middle finger. Pain with resistance to this movement is another sign that the radial nerve is entrapped somehow.

With carpal tunnel syndrome, the orthopedic surgeon can order electrophysiologic tests to confirm the diagnosis. A delay in the speed or signal along the nerve to the muscles suggests the median nerve is compromised. But with the radial nerve, electrophysiologic tests are almost always normal even when there’s a problem.

Imaging studies such as X-rays or magnetic resonance imaging (MRIs) have not proven helpful unless there is an obvious bone spur or abnormal anatomy causing nerve compression. The number of those cases is small compared to the total number of patients with radial tunnel syndrome.

Like electrophysiologic testing, imaging studies just don’t clearly verify this disease process in the majority of patients. And that’s probably why your diagnosis was difficult and delayed.

Tennis elbow, also known as lateral elbow tendinopathy can be very hard to predict. Physical therapy often helps reduce painful symptoms, improve motion, and restore function. But after months of therapy, some patients may still need surgery. On the other hand, some people heal up nicely on their own and don’t need rehab or surgery.

Athletes are especially interested in knowing if there is some way to predict in advance who needs what? In a recent study, orthopedic surgeons and radiologists teamed up to explore the usefulness of ultrasound studies in tennis elbow.

They were looking for sonographic predictors of prognosis for tennis elbow. They wanted to know if it’s age, sex, or even which elbow was injured that might predict who would get better and who wouldn’t. They hoped to find specific factors that are linked with successful conservative treatment of tennis elbow.

What they found was that the larger tears (bigger than four millimeters) were less likely to heal without some outside help. Early on, it may be possible to use some of the newer treatment methods such as blood injection, platelet-rich plasma, or cell therapy to stimulate tendon repair. There wasn’t a significant link to the rest of the factors (age, sex, right or left elbow).

The results of this study confirmed the benefit of ultrasound as an imaging tool for the diagnosis and assessment of tennis elbow. Ultrasound assessment early in the diagnostic process may help triage (sort) patients into the best treatment approach based on severity of findings, not severity of pain. Failed tendon healing may be avoided with this type of approach.

Ultrasound studies of tennis elbow have been able to show that ultrasound is an excellent test tool to see what’s going on inside that painful elbow. It shows structural changes like tendon thickening, tendon tears, and blood flow (increased or decreased). Increased blood flow suggests an active healing process is going on. Decreased blood flow signals a pathologic condition.

Ultrasound also provides the physician with some idea of how much collagen fiber degeneration is present and whether or not there is any inflammation going on. They look for the presence immune inflammatory cells like neutrophils and macrophages as indicators of an active inflammatory process.

So many studies showed that chronic tennis elbow doesn’t have any inflammation that the condition was renamed from tendinitis to tendinosis. There aren’t any immune blood cells present but plenty of scar tissue called fibrosis and necrotic (dead) cells.

Ultrasound studies performed early on in the condition can help guide treatment. Instead of focusing on pain with steroid injections, for example, physicians can recommend treatments that improve the blood supply to the area and foster tendon healing.