FAQ Category: Elbow

Pressure on the nerve that goes through the wrist and into the hand is called carpal tunnel syndrome. It is the most common nerve entrapment injury and appears to becoming even more common given the every day activities that people do. The second most common type of this injury is the cubital tunnel syndrome, where the ulnar nerve, which passes through your elbow, is trapped, affecting your lower arm and hands.

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.

Don’t be surprised if your physician hasn’t heard of platelet-rich plasma (PRP) to treat sports injuries. It is a relatively new treatment development in the area of musculoskeletal injuries. It hasn’t been tested fully to prove its effectiveness. There aren’t many studies published just yet. Most of the studies presented so far have been with animals or small numbers of people.

Some folks are asking: what is platelet-rich plasma? Platelets are part of the blood that circulate around the body ready to help with blood clotting should you have a cut, broken bone, injury that bleeds internally, or any other type of injury. Besides containing clotting factors, the platelets release growth factors that help start the healing sequence. Plasma is the clear portion of the blood in which all the other blood particles such as platelets, red blood cells, and white blood cells travel.

Platelet-rich plasma refers to a sample of plasma that has more than the normal amount of platelets. To get this substance, a portion of the blood is removed from a patient and placed in a machine called a centrifuge. The centrifuge spins the blood fast enough to separate it into layers based on weight. Heavier parts (e.g., red blood cells) stay on the bottom. Platelets and white blood cells spin out just above the red blood cell layer. Lighter particles (plasma without platelets or blood cells) make up the top layer in the test tube.

The platelet-rich portion of the plasma is then injected into the damaged area (e.g., tendon, joint, bone). This treatment technique isn’t entirely new — just new to the realm of sports medicine. It’s been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing and wound healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

There is no clear direction on when, how, or why PRP should be used. In this experimental phase, surgeons have used it for patients who failed conservative (nonoperative) care for chronic tennis elbow and chronic patellar tendinosis (knee tendon damage). There was one study where it was used for acute (recent) muscle injuries in professional athletes. The results of that study really made the rounds: these high-level athletes recovered in half the expected time and with no bad side effects and no scar tissue or adhesions.

Similar findings have been observed when PRP was used during surgery to repair ruptured Achilles tendons and rotator cuff tears in a small number of patients participating in a pilot study. Once again, wound healing was much faster with fewer problems and less scar tissue. And the list of improvements with this treatment continues: patients use less pain medication, patients gain greater joint motion over a shorter period of time, patients get back to regular daily activities with greater speed and ease, and so on.

You can expect to see an increase in studies reporting results over the next months to years. Right now, there are clinical trials being carried out in a number of places with a wide range of conditions. While that’s being sorted out, physical therapists are turning their attention to the proper rehab protocol to follow for these patients. Developing optimal tendon healing and muscle strength, especially in high-level professional athletes who are eager to get back into the game will be a priority.

Cubital tunnel syndrome is a problem with nerve entrapment affecting the ulnar nerve of the arm. The ulnar nerve stretches several millimeters when the elbow is bent. Sometimes the nerve will shift or even snap over the bony medial epicondyle (the bony point on the inside edge of the elbow). Over time, this can cause irritation to the nerve.

One common cause of cubital tunnel syndrome is frequent bending of the elbow, such as pulling levers, reaching, or lifting. Constant direct pressure on the elbow over time may also lead to cubital tunnel syndrome. The nerve can be irritated from leaning on the elbow while you sit at a desk or from using the elbow rest during a long drive or while running machinery. The ulnar nerve can also be damaged from a blow to the cubital tunnel.

Rest and activity modification are often recommended at first. Anti-inflammatory medications may help control the symptoms. However, it is much more important to stop doing whatever is causing the pain in the first place. Limit the amount of time you do tasks that require a lot of bending in the elbow. Take frequent breaks. If necessary, work with your supervisor to modify your job activities.

If your symptoms are worse at night, a lightweight plastic arm splint or athletic elbow pad may be worn while you sleep to limit movement and ease irritation. Wear it with the pad in the bend of the elbow to keep the elbow straight while you sleep. You can also wear the elbow pad during the day to protect the nerve from the direct pressure of leaning.

Doctors commonly have their patients with cubital tunnel syndrome work with a physical or occupational therapist. At first, your therapist will give you tips on how to rest your elbow and how to do your activities without putting extra strain on your elbow. The therapist may be able to mobilize (move) the nerve in ways that take pressure off it. Exercises are used to gradually stretch and strengthen the forearm muscles.

But if it’s been two years already you may need more than a conservative approach — especially if these steps don’t bring about relief of your symptoms. Surgery may be considered. The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel.

There are different kinds of surgery for cubital tunnel syndrome. A simple nerve decompression involves removing any adhesions from around the nerve or cutting any soft tissues that might be pressing on the nerve. A second procedure is called an 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 transposed (moved) out of the cubital tunnel and placed in the new tunnel.

The third approach is to remove the medial epicondyle (bony bump) 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.

The best thing to do is see an orthopedic surgeon and/or a hand therapist for an evaluation. Once the full extent of your problem has been determined, then an appropriate treatment program can be prescribed.

For those who don’t know, cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow. Another way to describe this problem is to call it an ulnar nerve entrapment.

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.

There are various ways to measure patient satisfaction using symptom-specific scales or numerical ratings. Numerical ratings ask patients to rate their satisfaction from zero to 10 with zero being completely unsatisfied and 10 representing completely satisfied).

Other rating scales may ask patients to rate their outcomes as poor, fair, good, or excellent. From a statistical research point-of-view, if this scale hasn’t been tested and proven reliable and valid, then the reported evidence may not be a real measure of results. Some clinicians use the Disabilities of the Arm, Shoulder, and Hand (DASH) or the Short-Form-36 (SF-36), but neither of these are specific to cubital tunnel syndrome.

According to a recent systematic review looking for a comparison between patient and surgeon satisfaction after surgery for cubital tunnel syndrome, there isn’t such a tool for this specific target population. There is a need to development an instrument that could allow for such an assessment on the part of patients and/or surgeons. This would require a series of steps involving focus groups, expert review and consensus, testing of the tool, and reporting results. With such a tool, new evidence could be generated around this topic that could be relied upon for future patient management.

It sounds like he may have a broken and perhaps even dislocated radial head. The radius is one of two forearm bones that meet the humerus (upper arm bone) to form the elbow. The radial head is the top of the radial bone. It sits up under one side of the humerus and articulates (moves) against the other bone of the forearm (the ulna).

Orthopedic surgeons who specialize in the treatment of traumatic upper extremity injuries say there’s no best way to treat a badly broken elbow. If it’s dislocated and fractured into bits, it could be wired together. But it might be better to replace the elbow with an artificial replacement.

Today’s current approach with a radial head fracture is to take all the individual patient-factors into consideration. Then look at current opinion of the experts and combine that information with any evidence available from published studies. The result is a set of guidelines to help with the decision. There isn’t always a clear treatment path. In other words, one approach doesn’t work for everyone.

That’s why your surgeon has probably explained all the possible different ways to go and your husband has given permission for the final decision to be made in the operating room when the surgeon can see what he or she is dealing with.

The surgeon will evaluate the blood vessels and nerves to the area and see if there has been any damage there. Consideration will be given as to whether or not the patient has strong enough bones to hold pins, miniplates, screws, or wires necessary to hold the bone fragments together while it is healing. It is important that both bones of the forearm (radius and ulna) be kept equal in length. The surgeon must assess the entire arm for injuries in case there are other bones broken or torn soft tissues that might affect this relationship.

The more the bone is fragmented into pieces, the greater the chances that the patient will lose motion and function with any attempts at fixation. If the radial head is involved, forearm rotation is often compromised. And without the ability to rotate the forearm, the patient cannot turn the palm up, a movement called supination and palm down (pronation). The loss of forearm supination and pronation can be very limiting. Imagine trying to turn a key in the door, wipe yourself after going to the bathroom, or even carry a bowl of cereal without these motions.

Usually, surgeons will make every effort to repair complex, fragmented fractures of the radial head. No matter what decision is made, the goal is to restore forearm and elbow stability and motion.

The elbow is a very complex joint that allows elbow flexion and extension but also forearm rotations called supination (palm up) and pronation (palm down). In order to provide this rotational motion, the top or head of the radius (one of the two bones in the forearm that help form the elbow joint) rolls against the other forearm bone (the ulna.

Damage to the radial head can be very difficult to salvage. Over the years, bone grafting and improved fixation devices like the miniplates have made it possible to preserve more elbows than ever before. And that’s good because implants cannot successfully replace a natural radial head. It’s just such a unique and unusual bone in shape, form, and function.

But sometimes all efforts to stabilize the bones and hold them together until they heal just doesn’t work. In the end, the upper portion of the radius is removed and a prosthetic implant is inserted in its place.

Studies presenting outcomes of radial prostheses report a mix of results from poor to excellent, with equally varying levels of patient satisfaction. The implants are expensive and don’t always fit the patient well. One advantage the prosthetic head does offer is stability when torn elbow ligaments cannot be repaired.

One disadvantage is that overstuffing can occur. This means the implant is too large for the joint space available. Usually it’s a matter of the prosthesis being too long. Over time, the joint cartilage can get worn down and the elbow can start to dislocate. Revision surgery may be needed to correct the problem. Your surgeon will be able to advise you. It may be a case of wait-and-see how things work out for you. But if the loss of motion is disabling, then further treatment may be able to correct the problem.

Fractures of the humerus (upper arm bone) just above the elbow are difficult to treat. Surgery is the standard way to treat these fractures. But the optimal approach isn’t always clear at the out set. The surgeon must take into consideration many factors. How did it happen? What kind of break is involved? Are the soft tissues around the bone damaged in any way? Did the elbow joint surface crack in the process? How strong is the bone (i.e., does the patient have osteoporosis or brittle bones)?

Surgeons are seeing more of these injuries with the aging adult population in America. Most of these fractures occur in older adults with poor bone quality. That’s one of the things that really makes surgery so difficult. Conservative (nonoperative) care is possible but only when the fracture is stable and can be immobilized in a cast or splint. That type of fracture isn’t as common as the displaced (bones separate), comminuted (many tiny bone fragments) fractures that require surgery.

It’s true that delaying surgical treatment can compromise the results. But surgery comes with its own unique risks and potential problems and complications. If the surgeon thinks the arm is stable enough and your mother is savvy enough (mentally alert and compliant) to keep from disrupting the healing bone, then she will be spared the trauma of major surgery. If she is not an overly active individual and she is willing to follow the surgeon’s instructions about keeping the arm immobile, she should have a good-to-excellent result.

Distal humeral fracture means that the bottom of the upper arm bone is broken. Since the humerus forms the upper half of the elbow, this type of fracture certainly affects the elbow. Displaced means the bone is not only broken, but the fracture has separated. These fractures are complex and challenging to treat. Surgery is usually required.

This orthopedic injury is complex, multifactorial, and definitely challenging. The surgical choices are usually: 1) internal fixation, 2) external fixation, and 3) total elbow replacement. Each of these choices has its own indications (when to use them), advantages, and disadvantages.

One of the ways surgeons have of evaluating which approach to use is to examine the results from other patients who were treated with one approach versus another. The way to evaluate this is to look back at the results other patients had with this type of injury using X, Y,or Z treatment. Results referred to as outcome measures include elbow range-of-motion, return of normal muscle strength, function, bone healing, and quality of life.

In a successful case, the joint should be stable yet move freely. Length of time in the hospital and in rehab along with the associated costs might also be factored in when evaluating success versus failure. Complications such as infection, poor wound healing, and nonunion (failure of the bone to heal) are recorded. Implant failure (usually from loosening) and revision surgery are two other possible problems that surgeons keep track of as a way to evaluate the final results. Here’s what the evidence suggests from reviews of current research.

Internal Fixation. Internal fixation refers to an open procedure where the surgeon puts the bones back together and holds them in place with wires, metal plates, and/or screws. This is the most commonly used operation. Many decisions come into play with this approach. The surgeon sizes up the injury and decides how best to get into the joint: from the back of the elbow (posterior or from the sides? If it seems best to make the incision from the side, then which side: medial (side closest to the body) or lateral (side away from the body)?

Studies show that the posterior approach gives the surgeon a full view of both sides of the elbow but in order to get to the joint, it’s necessary to cut through the triceps muscle and take a chunk of bone out. Removing a wedge-shaped piece of bone for this approach is called an osteotomy. Anytime an osteotomy is done, there is an increased risk that the bone won’t knit back together nicely. The result would be a nonunion of the bone where the osteotomy was done.

As technology and surgical technique improve, new contoured plating with different shapes to choose from and locking screw techniques have become available. Researchers are just beginning to study and report on the results using these various options. Measurements of the healing site strength and stiffness as well as bending forces are under investigation when the various plating systems are placed in different locations and angles (called the configuration). For example, the surgeon may use a Y-shaped plate or the orthogonal plate and place them perpendicular (at a right angle to each other) or in parallel (one on each side of the joint).

Most of these studies are being done on cadavers. The bone strength can be tested until it breaks to determine the upper limit of force each configuration can withstand. Using cadavers with osteoporosis makes it possible to also study the results of fixation on patients with poor bone quality. Results using different length of screws and strength of the bone-to-screw interface are also being compared.

What they’ve found so far is that locking plates may work better than standard plates. And failure is more likely as a result of the bone-implant interface, not because the hardware itself breaks. There isn’t enough data yet to say at what bone mineral density results will be successful. More study is needed before this information will be available.

External Fixation. Like internal fixation, some type of rigid support is needed to hold the bones together during the healing. But instead of being inside the body and unseen, external fixation consists of pins placed through the skin and soft tissues into the bones with metal rods between them. The rods remain outside of the arm. External fixation is used when the fracture is displaced (separated) and poking out through the skin. The surgeon must get the bones lined back up and keep them there until healing takes place but is unable to do so from the inside. That’s where the external support can be helpful.

Elbow Replacement. If the patient doesn’t have strong enough bones to hold the hardware needed for fixation, then a joint replacement may be needed. The same is true if the joint surface has been too damaged to fix or repair. Older adults and/or patients who have had a failed internal fixation procedure may also qualify for a total elbow replacement.

Results from studies of elbow replacement for distal humeral fractures show good-to-excellent results for the majority of patients (85 per cent). Outcomes are better when the surgery is done right away as opposed to being delayed for a time. Complications such as nerve injuries, infection, implant loosening, and chronic pain are reported in 22 per cent of all cases studied. The use of elbow replacements may expand as surgeons are able to reduce the complication rates. Improved surgical techniques, better implant designs, and improved ways of cementing the implant in place may help move this along.

Elbow, wrist, thumb, and hand problems are fairly common — and they affect people of all ages from young to old. Many are the result of overuse syndromes. Overuse syndromes refers to pain, tenderness, and dysfunction from tissue damage caused by repetitive, prolonged, or forceful use of the thumb, hand, wrist, or elbow. Additionally, assuming awkward positions repeatedly can also contribute to the problem.

Just in the last five years, there has been an increase in the number of children affected by overuse syndromes. Increased participation in organized sports seems to be at the center of this phenomenon. Primary care physicians report that up to half of the sports injuries they see in children and adolescents are from overuse.

Even if your daughter isn’t playing golf, there may be some other activity she is involved in that could create similar problems at the elbow. Folf (a combination of golf and frisbee), also referred to as disc golf or even just playing frisbee could be a potential source of problems. Participating in musical endeavors involving the repetitive use of the arm and especially elbow may be a factor.

It would be a good idea to review her daily activities and look for any kind of motion that is repeated over and over. Check on her sleep pattern. Does she rest her head on her arm while watching television or while sleeping? Any awkward position or prolonged posture could be a major factor. Finding the underlying cause will be important in reducing the symptoms. Activity modification is important in the management of this problem.

The current standard of care in the rehabilitation of ulnar collateral ligament (UCL) reconstruction starts right after surgery and progresses through four stages or phases over time. Those phases include: immediate post-op, intermediate (weeks one through three), and advanced (weeks nine through 12). The fourth phase is the return-to activity stage, which takes place from week 13 through the first nine months post-op.

Programs vary slightly depending on the type of surgery done. The two most commonly used reconstruction procedures include the figure of eight (also known as the modified Jobe procedure) and the docking procedure. The basic method of either approach is to take a piece of tendon from another muscle (usually the palmaris longus or gracilis) and use it to replace the damaged ulnar collateral ligament.

The main difference between the two procedures is the way in which the tendon graft is anchored to the elbow. In either operation, the surgeon assesses the damage and performs a few extra steps when needed, like shaving off any bone spurs or moving the ulnar nerve if it’s rubbing against the bone.

After either procedure, a posterior splint is used at first to hold the elbow in 90-degrees of flexion. A posterior splint is placed along the back of the arm/elbow, specifically preventing extension. The patient is allowed to move the wrist and fingers but not the elbow. Acute injuries heal faster and progress more rapidly through the rehab protocol than chronic injuries. In all cases, the goals are to promote healing, reduce pain, limit inflammation, and return to normal motion, strength, and function.

Even though a small area of the body was operated on (the elbow), a gymnast will need a complete head-to-toe conditioning, strengthening, and endurance training program. Restoring joint proprioception(sense of position) and kinesthesia (sense of movement through space) involves the entire upper quadrant (neck, shoulder, arm), not just the elbow. Stabilization of the shoulder through strengthening of the rotator cuff and scapular (shoulder blade) muscles surrounding the shoulder joint reduces stress across the elbow.

Eventually, you will need to progress through training to restore control through various activities using the elbow. Advanced training incorporates plyometrics, a type of exercise training designed to produce fast, powerful movements. With plyometric training, muscles are loaded and then contracted in rapid sequence. Plyometrics is used to increase the speed or force of muscular contractions, a very necessary component of gymnastics in all events.

In the elbow, two of the most important ligaments are the ulnar collateral ligament and the lateral collateral ligament. The ulnar collateral is on the inside edge of the elbow, and the lateral collateral is on the outside edge.

Together these two ligaments connect the humerus (upper arm bone) to the ulna (forearm bone) 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 to the elbow. If they do not heal correctly the elbow can be too loose, or unstable.

That last statement is the most important one for patients to understand. Pushing too fast, too far in the rehab protocol can result in a failed surgery and long delays in returning to sports activities. It might help you to know that studies on cadavers have shown how the graft will fail with very low number of loads placed on the elbow. For example, a native (healthy, strong) UCL can withstand over 2500 pitches. The reconstructed graft gives out after only 300 to 700 cycles. Without the proper length of time needed for healing and without the necessary strength, you are at risk for graft failure.

Reconstructive surgery is meant to stabilize the elbow while rehab restores motion, strength, and function. But the rehab portion must go slowly and according to the load the healing tissue can handle. That’s why your therapist has given you a road map, so-to-speak. Athletes who know what to expect and can see the progression from beginning to end are more likely to follow the program exactly as ordered. For the best results, listen to what your surgeon and therapist tell you. Feel free to ask questions. The more you understand about the process, the more likely you will have a successful (and hopefully speedy) recovery.

A group of orthopedic surgeons from the Rochester, Minnesota Mayo Clinic recently published a study done on total elbow arthroplasty (TEA) in adults 40 years of age or less. They report having done elbow replacements on over 750 patients between 1982 and 2003. About eight per cent of those patients were 40 or younger.

All of the 55 patients in this Mayo study had severe osteoarthritis, nonunion of bone fracture at the elbow, or severe joint instability. They either had severe inflammatory or posttraumatic arthritis. Most of the patients had at least one previous elbow surgery. Some had several (up to six) prior surgeries. They were considered good candidates for a salvage procedure such as total elbow arthroplasty (TEA).

And despite 92 per cent of the group scoring good-to-excellent on the Mayo Elbow Performance Score (MEPS), there was still a 22 per cent revision rate. The surgeons consider this unacceptable and suggest pursuing non-replacement options for as long as possible.

The authors concluded their report by saying the surgical treatment of elbow arthritis is very difficult. There really aren’t very many good options. But before replacing the elbow, they suggest trying a synovectomy or interposition arthroplasty whenever possible. Your surgeon will explain the benefits, pros, and cons of these options.

According to the experts, whichever procedure your surgeon is recommending would be worth considering first before removing the joint and replacing it with an implant that probably won’t last more than 10 to 15 years. At age 23, that could mean even more surgery with the potential for further deformity and loss of function.

The usual reasons patients have an elbow replacement are severe osteoarthritis, nonunion of bone fracture at the elbow, or severe joint instability. Elbow replacements are available for younger adults (less than 40 years old) but usually only as a salvage procedure (in other words, to save the joint). Other nonreplacement options are usually recommended first.

Before replacing the elbow, they suggest trying a synovectomy or interposition arthroplasty whenever possible. Synovectomy is the partial removal of the synovial membrane that lines the non-cartilaginous surfaces within joints like the elbow. Usually the head of the radius (top of the forearm bone at the elbow) is removed at the same time.

Interpositional arthroplasty is the removal of the damaged joint and placement of a rolled up tendon (or other soft tissue) in the empty joint space. The main goal of interposition surgery is to ease pain where the surfaces of the elbow joint are rubbing together. The piece of tendon forms a “spacer” that separates the surfaces of the joint. This procedure is not recommended if the patient has significant bone loss, gross joint instability, or a severe elbow deformity.

Elbow replacement has been around for many years but the success rates have not always been acceptable. This is improving over time with better surgical techniques and better implants.
Studies show that complications following elbow replacement in younger adults that require revision surgery include deep infection, implant loosening, triceps weakness, and implant wear.

Patients with posttraumatic arthritis who need this type of surgery are more likely to develop problems leading to a second surgery. They have a much higher complication rate than patients with rheumatoid arthritis.

Even with the high complication and revision rates, there is still a place for elbow replacement in younger patients. Those with advanced arthritic disease who have already failed nonreplacement options may still be aided by a joint replacement. It is certainly preferred over an elbow fusion since the fusion eliminates elbow motion and creates a functionally disabling condition

It sounds like you have a realistic idea of the effect of your workload on your tennis elbow. That may not be negative thinking as much as a certain reality check. Most people with this problem know what their limitations are and if/when they are ready to go back to work.

Having said that, it’s also true that patients with chronic tennis elbow who have filed a worker’s compensation claim tend to take longer to recover and return to work (if they are even able to return). Depending on the job demands, it may be necessary to modify the workload (if possible), change jobs, or even retrain for a different type of occupation.

But before you go down that road, it may be a good idea at this point to revisit your orthopedic surgeon and explore your options. There are both conservative (nonoperative) and surgical ways to obtain relief. With a good rehab program, it is possible for some patients to regain strength, motion, coordination, and full function.

Studies show that patients do get better on their own after a bout of tennis elbow. But this can take 12 to 18 months. Many workers don’t have the luxury of that kind of time. Surgical release of the soft tissues around the elbow (usually a tendon that’s tight or rubbing across the bone) can give you pain relief. From there you can work to regain strength and motion. It may take six to eight weeks but that’s a lot faster than the months to years it could take on its own.

Lateral epicondylitis, commonly known as tennis elbow, causes pain that starts on the outside bump of the elbow, the lateral epicondyle. As you have discoverred, this condition is not limited to tennis players.

Many other types of repetitive activities can also lead to tennis elbow including typing and filing. Just the act of pinching the fingers around the top of a file folder and pulling it up out of a file drawer over and over can lead to pain and dysfunction. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow.

Rest and activity modification are the first two suggestions made for recovery from tennis elbow. But if you have a job that isn’t easily modified, then you may need some additional help. A physical therapist can show you some exercises to help reduce the stress and tension on the tendons as well as some alternate ways to use the hands whenever possible. This can help save wear and tear on the soft tissues around the elbow. Some specific stretching and strengthening exercises may prove to be just what you need.

If that doesn’t help, your doctor can inject the area with cortisone, an antinflammatory to aid in pain relief. Acupuncture has been used successfully by some patients. A combination of physical therapy, massage, and acupuncture may be even better. But if all else fails and it’s been months and months without pain relief, then some patients benefit from surgery.

There are many ways to surgically approach this problem. Sometimes the surgeon just smooths away any frayed edges of tendon, shaves off any bone spurs, or possibly releases one or more tendons from around the elbow. The tendon retracts a short distance away from the bone and reattaches to nearby soft tissues. By taking the pressure off the bone, painful symptoms can be relieved without losing function.

Treatment for rheumatoid arthritis is divided into two types: conservative (nonoperative) and surgery. Nonsurgical treatment usually begins with medications to control symptoms and prevent damage to the joint. For some patients, the use of antiinflammatory drugs and disease modifying anti-rheumatic drugs (DMARDs) can completely eliminate all signs and symptoms of rheumatoid arthritis.

It sounds like your daughter has been treated with medications. But if she is still having problems, she should go back to her rheumatologist for a follow-up visit. It is often possible to make changes in medications that can help.

No matter what the cause of the problem is, activity modification, rest, and physical therapy are often recommended. Sometimes splinting is advised to help protect, support, and mobilize (move) the joint. If after three to six months of conservative care, there is no improvement (or the symptoms are worse), then surgery may be an option.

There are various types of surgical procedures to consider. Which one is selected depends on the patient’s age, diagnosis, job demands, or sports participation. The selection of surgical procedures also takes into account the areas of the joint affected most (e.g., joint surface, capsule, synovium). The surgeon does everything possible to preserve the dynamic nature of the joint — both stability and mobility needed for upper extremity function.

Elbow fusion is a possibility but the patient faces loss of motion and some function. At 33, she’s still too young for a joint replacement. One procedure that is being used with good results in younger patients is the interposition arthroplasty.

This surgical technique shaves away the joint surface, removing any bone spurs and loose fragments of bone or cartilage in the joint. A piece of tendon used as a graft is placed where the surfaces of the elbow joint are rubbing together. The main goal of interposition surgery is to ease pain by using the soft tissue graft to form a spacer separating the surfaces of the joint. The patient can still lift more than the 10-pound lifting limit imposed on total elbow replacements.

Your therapist may actually have some alternate ideas to share with you. Don’t hesitate to let him or her know of your painful response to the splint. That’s not an uncommon reaction but it is one that needs to be corrected. Without some form of holding device, your elbow will only get stiffer.

There are different kinds of splints. Some are more dynamic than others — meaning, they have more elasticity or give to them. It’s possible that with a static (hold in one place) kind of splint, your muscles on either side of the joint are contracting at the same time. This sets up a pain-spasm cycle that is counter productive.

Your therapist will know if there is a different kind of splint (or way to adapt your current splint) to take the painful pressure off but still get the job done. In some cases, serial casting is used to replace splinting. The elbow is moved to the farthest point of motion and a cast is placed around the elbow and forearm. Gradually, the muscles will relax and your elbow will move farther. The cast is removed weekly, the elbow moved to the new end range and then recast. This process is repeated for several weeks.

Another option is the use of Botulinum Toxin A (BOTOX). The BOTOX is injected into the muscles that are contracted. It acts as a paralyzing agent to prevent muscle contraction of the muscles injected. Splinting continues but with much less pain and more five in the muscles.

Conservative (nonoperative) care is the best approach. But if all measure fail, then surgery may be a consideration. Before you go that far, work with your therapist and your surgeon to find successful alternatives.

The elbow is a hinge-type joint allowing open and close motion. But it really has three separate articulations (joints) to make forearm rotation possible (palm up, palm down). The capsule and surrounding ligaments help hold and support the elbow giving you stability. The muscles give strength. Together, the soft tissues and bone structure of the elbow complex provide mobility.

Anything that disrupts the musculoskeletal components of the elbow can result in scarring, fibrotic tissue, and loss of motion. After injury or surgery, bone cells can form in the muscles causing a problem called heterotopic ossification. Elbow stiffness is a side effect of ossification.

Scientists aren’t really sure all the steps in the formation of elbow stiffness. The inflammation and swelling that accompanies any injury (or arthritis) contributes to this problem. But it’s likely there’s more to it than that.

A key focus of treatment for any elbow problem is to prevent stiffness. Once it develops, rehab can be a long, slow process. If you have not gone back to your surgeon, a follow-up visit is advised. You may need to see a hand therapist for some special one-on-one help. Regaining elbow motion is essential for upper extremity function.

Total elbow arthroplasty (replacement) can be helpful for the older adult (65 years or older) who has severe pain and loss of elbow motion and function. The cause of the elbow problems may be from rheumatoid arthritis, osteoarthritis, or years later after a traumatic injury.

Conservative care is always recommended before surgery. If after at least six months of trying activity modifications, medications, and hand therapy, there has not been any (or enough) improvement, then surgery may be considered. It is true that there are some activity restrictions — primarily you must not engage in any activities that require lifting more than 10 pounds.

That may seem like it’s no problem. But if you have grandchildren, it means not trying to lift them up no matter what the circumstances. You’ll have to be careful when grocery shopping, gardening, or other activities that involve placing a load on the elbow.

Today’s improved elbow implants do a better job of reproducing normal elbow motion than earlier designs. The newer prostheses allow for side-to-side and rotational motions needed for full elbow motion. Various implant systems are available now (e.g., constrained, unconstrained, convertible, fixed).

Each new generation of implant designs try to improve elbow stability while still allowing mobility at the same time preserving bone and soft tissue structures. Patients who have arthritis compounded by fractures and/or loss of bone mineral density may need one of these newer implants. Older adults seem to do better with elbow implants than younger patients. They have far fewer problems and are much less likely to need a second (or third) surgery.

Companies designing and making elbow implants continue to look for better materials that won’t wear loosen, or break. Preventing mechanical failure of the implant will improve long-term results for patients with various kinds of elbow problems. There is still a need to find an implant that will hold up with active use for younger patients who have debilitating elbow arthritis.