FAQ Category: Elbow

It is important to have a clear diagnosis when trying to treat apparent (or real) lateral epicondylitis (also known as tennis elbow). Making the differential diagnosis is important because the treatment differs from trauma-induced (overuse) tennis elbow and cervical radiculopathy. Instead of just treating painful elbow symptoms locally (at the elbow), efforts are directed toward the neck as well. Unnecessary surgery can even be avoided.

Cervical radiculopathy refers to pressure on a nerve in the neck. This condition is caused most often by spinal stenosis (narrowing of the opening where the nerve exits the spinal cord) or by disc protrusion. But this condition can also be caused by bone spurs, infection, or tumors. That’s another reason it’s important to have a careful and confirmed diagnosis.

Now that you know you have both problems, attention should be directed toward improving spinal alignment, posture, and nerve movement. It’s possible and even likely that the elbow problems developed as a result of the neck pathology. The C67 spinal nerve exits the cervical spine but supplies nerve messages to the muscles of the elbow. Impairment of the nerve in the cervical spine can result in weakness of the elbow muscles. Then even everyday activities can seem like overuse trauma leading to tennis elbow.

A physical therapist may be the best professional to help you at this point. The therapist will evaluate you and design a program specific for your needs. Most likely the plan of care will include postural and strengthening exercises and manual therapy to restore normal neck alignment and movement. If needed, nerve mobilization techniques can be applied to help the affected nerves slide and glide smoothly. Neuromuscular training during daily activities and while performing work duties are incorporated until you can return to normal function and perform all activities in all positions (including uninterrupted sleep) without symptoms.

Don’t be surprised to find yourself doing postural, balance, strengthening, and flexibility exercises — and not just for the upper half of the body. Attention to restoring symmetry and balance from head to toe may be necessary for the best results. It takes a minimum of four to six weeks to progress the exercises to get the full benefit and prevent recurrence of symptoms. Be patient and you should be rewarded with the results you want.

This particular elbow problem comes about when some change in the normal anatomy alters the way the elbow moves. The ulna and radius may be stuck together preventing normal movement between the two bones at the elbow. Most often, the radial head has gotten trapped under the annular ligament. The annular ligament is a thin, broad fibrous layer that covers the front surface of the elbow joint.

The radial head is the top part of the radial bone (one of two bones in the forearm that makes up the elbow joint). Anything that changes the alignment of the annular ligament and the radial head can contribute to the elbow problems associated with congenital radioulnar synostosis. That could be a dislocated radial head or trapped radial head.

Just separating the two bones doesn’t usually do the trick. And it may depend on what the underlying cause is — dislocations can be relocated. Surgery is required to move the elbow through its full range-of-motion, a procedure called manipulation.

In very young children, when the radial head is trapped underneath the annular ligament, the problem may correct itself with a little time and patience. But in the older child who is less flexible and more developed, the surgeon may have to release the radial head. This is done by cutting the ligament and removing the radial head. Removing the top of the radial bone is advised because it prevents future elbow problems like pinching against the capitellum, another bony part of the elbow.

An open procedure is advised rather than an arthroscopic approach because of the way the soft tissues all blend together around the elbow. It can be very difficult for the surgeon to separate the tissues in order to release the annular ligament. An open incision makes it possible to see how the tissue is formed all the way around the elbow and do a thorough job removing the problem tissue.

True tennis elbow occurs when repetitive motion of the forearm and elbow causes microtrauma of the extensor carpi radialis brevis tendon where the tendon attaches to the elbow. It might seem funny but tennis elbow (also known as lateral epicondylitis) could be caused by a problem in the neck. In other words, it may not be coming directly from the elbow.

That same spot along the outside of the elbow that is linked with tennis elbow is where pain can also be referred when pressure is placed on the C67 nerve root. This condition is referred to as cervical radiculopathy. The C67 nerve root leaves the spinal cord in the lower cervical spine and travels from the neck down the arm. When this nerve gets pinched or compressed, neck and arm pain can develop with pain traveling down to the elbow and below.

With cervical radiculopathy at the C67 level, elbow pain can occur as a result of muscle weakness because the C67 spinal nerve is compromised. The elbow pain and dysfunction aren’t caused by local microtrauma of the tendon at all but from altered muscle function as a result of the cervical radiculopathy. When nerve innervation of the muscles is interrupted, then weakness can make even everyday activities seem like overuse resulting in what looks like traditional tennis elbow.

Making the differential diagnosis is important because the treatment differs from trauma-induced (overuse) tennis elbow and cervical radiculopathy. Instead of just treating painful elbow symptoms locally (at the elbow), efforts are directed toward the neck as well. Unnecessary surgery can even be avoided.

The fact that you are having symptoms in both elbows is a tip off to look for a problem in the neck. Further testing may be necessary such as MRI, EMG, and nerve conduction tests. This will help rule out local nerve entrapment at the elbow and confirm the presence of a possible nerve compression in the cervical spine area.

Treatment and management decisions around elbow injuries can be difficult to second-guess. There’s some evidence that early intervention helps prevent problems later on. But surgery puts you on the bench and out of the running for those upper division slots. On the other hand, the number of repetitive motions needed in practice to step up could turn a mild injury into a severe one.

There are several things to think about. Your age is one of them. Older players (late 20s, early 30s and older) are at increased risk for injury on top of injury. Combined injuries of more than one ligament, tendon, or other important soft tissue around the elbow are more common in older players and reduce the likelihood of a full return-to-play.

The severity of injury right now can also help direct your path. What can your surgeon tell you? Using your history, the clinical exam, and results of MRIs, there should be a fairly good idea of the extent of the damage you are trying to deal with. If it’s mild, then rest and rehab may be all that you need to get back into action. If there’s more to it than that, early surgical intervention to clean up the area and promote healing may set you back a bit but could keep you in the running.

Steroid injections provide short-term relief from pain and inflammation. But there is some evidence that it’s these very injections that add to the risk of tears (and retears of repaired tears). It appears that one injection may be helpful but multiple injections are more likely to be harmful in the long-term.

Don’t kid yourself. Top players in the major league have their fare share of injuries, too — especially older players (30 years old and older). The difference may be that this is their job and they spend quite a bit of time practicing, exercising, and staying in top condition. Sports trainers help them identify weaknesses and injuries early so they can deal with them right away. That’s a major part of why they can stay in the game in tip top shape longer than the average guy.

But there are some injuries that put major league ball players out of the game or at least demoted from major to minor league play. For example, older players are more susceptible to combination injuries of the elbow. Tears of the ulnar collateral ligament (UCL) can lead to flexor-pronator injuries.

The ulnar collateral ligament stabilizes the elbow. The flexor-pronator muscles bend the elbow and turn the palm down. The palm down motion needed to deliver the ball over the plate is called pronation is really a forearm motion that takes place at the elbow. When both of these soft tissues are injured, the player can no longer throw without pain that then alters the pitching action.

These combined soft tissue injuries are rare but can keep a player out of the game — permanently. Without full and unrestricted use of both the ulnar collateral ligament and the flexor-pronator muscle, successful return to play may be impossible for older pitchers.

But there is good news in all this. Thanks to advanced imaging with MRIs, elbow injuries are recognized earlier now than they used to be — early enough to prevent the more severe type of injuries suffered by older players. The hope is that these combined injuries will be eliminated in today’s young pitchers and catchers. Newer surgical and rehab techniques may also help improve final results.

Some arm fractures and elbow dislocations can be severe enough to need surgery. Sometimes the patient cannot or does not want to have surgery and when this happens, the doctor must find a way to manage the break without operating. Unfortunately, managing breaks and dislocations with just splinting and limiting activity is not ideal if surgery is the best approach. While the arm may heal, it may not heal properly and leave long-lasting effects.

Head on back to your surgeon’s office for a recheck and possibly further treatment. You may not necessarily need more surgery, but keep that in the back of your mind as a potential treatment plan. These nerve entrapments can be very difficult to pinpoint and treat. Because there are so many places along the pathway of the nerve from the neck down to the fingers, one release may not be enough. It’s possible there are other sites of nerve entrapment that must also be removed.

There are a couple of things you may be able do to alleviate the symptoms without surgery. One is to avoid extreme flexion of the elbow. This can put pressure on the ulnar nerve and irritate it enough to cause symptoms. You may need a splint to hold the elbow in a position of less than full flexion while sleeping. People who sleep all curled up with their arms held tightly against the body are at risk for ulnar nerve problems of this type.

It’s also possible a physical therapist trained in neural (nerve) mobilization (movement) techniques can help out. By restoring the natural slide and glide of the nerve inside the nerve sheath (outer, protective covering), symptoms can be alleviated.

If these conservative measures don’t help, then a second surgery may be needed to release any other structures pressing on the nerve. Ligaments, tendons, muscles, and even bone can put pressure on the ulnar nerve as it travels from the upper arm through the elbow down into the forearm, wrist, and hand. Moving muscles away from the nerve, moving the nerve away from pressing structures, and cutting off the funny bone (medial epicondyle) are just some of the ways this persistent problem can be dealt with.

Carpal tunnel syndrome is a condition where the ulnar nerve, the nerve that passes from your forearm into your hand through the wrist, becomes inflamed or irritated from pressure or constant friction within the carpal tunnel in the wrist. This ulnar nerve also must pass through your elbow to get down to the wrist and there, it passes through the cubital tunnel. As with the wrist, the ulnar nerve in the cubital tunnel can become irritated or inflamed if it is overused by constant or repetitive motions of the elbow. When this happens, the fourth and fifth fingers of the hand may become numb or tingly.

Just as repetitive motions with your hands can cause a repetitive stress injury in the wrist, repeated motions of the arms or putting excess pressure on the elbow where the nerve is exposed (the “funny bone” area), can cause nerve problems, or neuropathy.

The most common motions for such a problem include constantly leaning on your elbow on a hard surface, such as a desk or even chair arm rests, or using heavy machinery, that sends vibrations up the arm.

Children fall a lot – that’s part of the whole growing up thing. Unfortunately, some of these falls result in either broken bones or dislocated joints – or both. While broken bones don’t miraculously heal before the child gets to emergency, there are times when a dislocation can fix itself before medical help arrives. This is called a spontaneous reduction. The bone went out of place and then went back on its own.

When this happens, the doctors can only suspect this is what happened. There may be some left over damage in the joint, such as fluid that isn’t usually there, and pain, as well as reduced range of motion of the arm. In this case, the diagnosis of a dislocated joint may be made and then it will be treated as such to be on the safe side.

When a child (or adult) dislocates his elbow, there is always the possibility that one of the nerves that travels through the elbow gets trapped in a position it isn’t normally. However, this can’t be seen on an x-ray or any of the usual tests done with a suspected dislocated elbow.

It is only during follow up that doctors may see some signs that there is a nerve entrapment and it may not be very clear at first. If they suspect the nerve has been trapped, they may opt to wait a short while to see if the problem will resolve itself on its own. If it doesn’t, then they may step in and work on the problem – usually through surgery.

You’ll need to see a medical doctor to get a proper diagnosis — and that’s what we would encourage you to do. The first thought whenever a patient presents with numbness and tingling is that there’s a nerve entrapment somewhere above the level of the symptoms.

Since it’s your fingers that are affected, it’s possible that the ulnar nerve (not the median nerve</i, which is what gets pinched in carpal tunnel syndrome) is getting pinched at the wrist, in the forearm, or around the elbow. Nerve compression affecting the ulnar nerve in and around the elbow is the most common source of entrapment. When that's the case, the diagnosis is cubital tunnel syndrome. Problems in the cervical spine (neck) have also been known to cause sensory symptoms such as you are describing.

The physician will take your history and conduct an exam with specific tests to identify what’s happening to cause these symptoms and find out what’s behind the problem. Something as simple as a muscle contracting and pressing around the nerve could be the underlying anatomical reason for the nerve compression.

But certain diseases such as diabetes, thyroid disease, hemophilia, and tumors anywhere along the nerve pathway can also cause nerve compression. That’s why it’s important to make an appointment and have everything checked out carefully before deciding to ignore it.

Fractures of the elbow can involve the upper bone (humerus) or the two lower bones in the forearm (radius and ulna). The humerus (upper arm bone) obviously can be broken at the top near the shoulder, in the middle along the shaft of the bone, or at the bottom where it joins the elbow. A fracture at the bottom of the humerus is called a distal humeral fracture.

Bicolumnar is a more complex fracture pattern affecting both sides of the distal humerus where it meets the radius and ulma to form the elbow. The two sides of the humerus involved are the medial side (or inside next to the body) and lateral side (outside away from the body).

When the humerus breaks across or through both sides, different soft tissues (skin, ligaments, tendons, muscles), nerves, and blood vessels can be affected, too. For example, the radial nerve travels down the lateral (outside) of the elbow and forearm, whereas the ulnar nerve takes the medial (inside) track.

Two groups of patients seem to make up the majority of bicolumnar distal humeral fractures: young athletes involved in high-energy trauma and older adults (mostly women) with osteoporosis (brittle bones). Older folks who lose their balance and fall on an outstretched hand/arm or directly onto the elbow are at risk for elbow fractures of all kinds, especially bicolumnar.

The elbow is made up of three separate bones. The top part is actually formed by the bottom of your humerus or upper arm bone. It meets the top part of the two bones in your forearm (the radius and the ulna).

There are lots of ways the bones in the elbow can be fractured. We call these fracture patterns. When you say that both sides of the elbow are affected, we’re not sure if that means top and bottom (all three bones or at least the humerus and one of the two forearm bones) or if both sides of just one bone (the humerus) are broken.

In either case, you know there is going to be surgery. So that tells us the broken pieces of bone will be put back together like the pieces of a puzzle. When the surgeon gets everything back as close to normal as possible, then the pieces are held together with bits of wire, or screws, or sometimes metal plates screwed into the bone. This is called fixation with hardware.

When everything is stable and in one place with the fixation, then the surgeon puts the arm in a cast, splint, or sometimes a sling to keep it immobile (not moving). Your grandpa will have to take it easy for a few weeks. But then a physical therapist will work with him to keep his shoulder and wrist moving. When the immobilizer is taken off, the therapist will show him how to move the elbow and keep it from getting it stiff.

Your love and concern are the best therapy your grandpa can get. Keep up those prayers and maybe even send him a card you made yourself. That usually cheers up any grandparent who has had a bad injury!

The triceps tendon is a broad three-sectioned muscle that comes down along the back of the upper arm from the shoulder and inserts into the back of the elbow. The place where these three sections meet into one tendon and attaches to the bone is called the triceps footprint.

When the muscle is completely torn, the tendon usually pulls away from its footprint. Sometimes the traumatic event is so powerful that the tendon pulls away still attached to the footprint, taking a piece of the underlying bone with it. Because the muscle functions to straighten the elbow, when it is ruptured, arm extension is compromised.

The triceps muscle doesn’t tear or rupture very often. In fact, of all the tendons in the body that do get injured, injuries affecting this one are reported the least often. When it does happen, it’s usually in a professional-level football player or weight lifter. Of course, the nature of these sports with potentially violent contact or powerful lifts increases the risk of this type of injury.

Current treatment guidelines for triceps tears include: conservative care for anyone with less than half the tendon torn and for older adults with more than half the tendon thickness torn who are inactive. Surgery is always advised when the triceps has ruptured completely away from the tendon footprint. When surgery is indicated, it should be done as soon as possible (within the first two weeks of injury). A delay in diagnosis and/or in treatment can result in significant loss of muscle strength and other complications.

When surgery is not the first-line of treatment, the patient is instructed to keep the arm in a splint (or cast) for 30-days. The arm will be immobilized in a position of 30 degrees of elbow flexion. This position helps protect the triceps tendon from tearing more by avoiding muscle contraction needed to get the last bit of elbow extension. If the conservative (nonoperative) approach doesn’t work, then surgery is the next option considered.

Recovery time depends on whether you are treated with a conservative (nonoperative) or surgical approach. Either way, you are looking at at least a four to six week period of time while the soft tissues knit back together — possibly longer with surgery. You will want to follow your doctor’s directions carefully to avoid reinjury, microtears, or even rerupture.

Returning to a training regimen will require some time and patience as you gradually build up the muscle to its former tensile strength and ability to handle repetitive loads. A sports physical therapist can help guide you through this process in the most safe and efficient way.

You’ll need an examination by a medical doctor to know for sure. Depending on his or her findings, an X-ray may be ordered to rule out elbow dislocation, bone fractures, or bone fragments pulled away from the bone because of a tendon tear. Depending on the results of the radiographs, an MRI may be ordered as well. MRIs can help show if there is any bleeding into the joint and/or the location and extent of any soft tissue damage.

The divet or indentation you mention might be a defect caused by a tendon tear. If the triceps tendon (which attaches to that pointy part of the bone called the olecranon) is pulled away from the bone, a hole or opening is left where the muscle bulk is usually located.

The examining physician can do a clinical test to look for a triceps rupture. It’s modified from a test for ruptures of the Achilles tendon at the back of the foot/heel. A squeezing pressure is applied by the examiner to the triceps muscle. The test is done with the patient lying face down on an examining table. The elbow is bent and the forearm is dangling over the edge of the table.

When the triceps is intact or only partially torn, squeezing the muscle belly causes the elbow to extend (just as if the muscle contracted on its own). No movement of the elbow with this test is a sign that the tendon is fully ruptured. There may be weakness with elbow extension against resistance. You may not be able to extend (straighten) the elbow at all or only through part of the normal range-of-motion.

It’s best to have something like this looked at right away. Early treatment for injuries of this type have the best results. Waiting too long can create changes in the tissues with local scarring and fill-in with fibrotic tissue that isn’t strong enough to stabilize the joint or prevent rerupture.

You may be observing the first signs of a nerve entrapment. The anterior interosseous branch of the median nerve in the forearm is responsible for that movement. Pressure on that portion of the nerve could be affecting the nerve impulses to the muscles that make it possible to form a pinch grip.

The median nerve starts up in the upper arm when it is formed by the brachial plexus (a group of nerves leaving the neck and traveling down the arm). Midway down the forearm, the median nerve divides to form a branch called the anterior interosseous nerve (AIN).

The anterior interosseous nerve has no sensory branch. That’s probably why you don’t have any pain or numbness. It only controls movement of the flexor muscles on the inside of the forearm. It’s this nerve that makes it possible for you to hold a piece of paper or make the OK sign with your thumb and index finger.

There’s no way to know for sure what’s happening without some diagnostic work. An orthopedic surgeon or a hand specialist will be able to perform the necessary clinical and imaging tests to figure out what’s going on and what to do about it. Early, accurate diagnosis can make the difference between full recovery and permanent palsy. Make an appointment as soon as possible in order to get to the bottom of the problem.

Spontaneous recovery of nerve entrapment causing pain, numbness, and loss of function can occur. In fact, such recovery has been reported in the literature. Usually these cases take a long time — sometimes as much as a year.

It’s possible that the cause of your symptoms was really a virus affecting the nerve. In that case, you would have had a case of neuritis (nerve inflammation), not a compression neuropathy. As you think back over the past weeks to months, do you recall ever having a fever, unusual fatigue, or muscle pain along with the symptoms of nerve compression? These are all symptoms of an inflammatory process.

Nerve damage or irritation from repetitive overuse can also be affected by rest, change in activity level, and modification of activities. In time, the irritated nerve (without the irritating factors) gets enough rest to recover. The recovery may seem spontaneous, but it has really taken weeks to months to get there.

There’s much we still don’t know about nerves — what affects them, what heals them, and/or how to treat them. You are among the fortunate to experience a healing recovery. If your symptoms return, don’t hesitate to check back in with your physician. It may yet be possible to diagnose the problem accurately and treat it specifically.

Cubital tunnel syndrome is the second most common nerve entrapment problem after carpal tunnel syndrome While carpal tunnel affects your wrist, cubital tunnel affects your elbow.

As you lean on your elbow, the same way ever day, the body tissue surrounding the ulnar nerve that passes through your elbow to your forearm begins to press in the nerve. This is what causes the tingling and pain.

If the pain goes away not long after you’ve stopped, it’s possible there hasn’t been much damage, although you should get it checked. In the meantime, try to break yourself of that habit as the pressure on the ulnar nerve can only get worse if you continue to do so.

Both carpal tunnel syndrome and cubital tunnel syndrome may be caused by repetitive motions or pressure on the nerves, if not by trauma. The carpal tunnel affects your wrist and hand and the cubital tunnel affects your elbow and lower arm. If your wife is performing a task that requires her to do the same motions with her hand and her arm again and again, it is possible that she develop both injuries, even so close together.