Split Decisions Prove Best for Elbows under Pressure

The simple act of bending the elbow is effortless for many people. But for others, bending and straightening the elbow can cause significant problems. When the elbow bends, the space for the nerves and blood vessels narrows, increasing pressure and strain on both. When decreased circulation and reduced oxygen occur long enough, a condition called cubital tunnel syndrome can develop.

Symptoms of numbness and tingling in the ring and small fingers may develop along with weakness of the hand. If nothing is done to reverse the poor blood supply to the nerves and reduce the pressure, these symptoms can become permanent.

There are several different surgeries to correct this problem. Unfortunately, surgery isn’t always successful. Even when it is, the surgery itself can cause additional problems. Relieving one set of symptoms only to develop another is not a desirable outcome.

For this reason, doctors are looking at the timing of surgery for cubital tunnel syndrome. In the past, if the patient had symptoms but no signs of nerve damage, the surgery was delayed. Studies eventually proved that waiting too long could result in permanent nerve damage that doesn’t improve with surgery.

One group of surgeons tried doing surgery when there were symptoms of numbness and tingling only. Nerve tests showed normal nerve function before surgery. Although the patient group was small (18 elbows), the results were good. This suggests that earlier surgery may be a good idea, even when nerve tests are normal. Seventeen of the 18 elbows regained normal elbow motion and grip strength. Numbness and tingling went away in all cases.

Early treatment for cubital tunnel syndrome is recommended when numbness and tingling in the hand signal possible nerve pressure. Even before nerves test positive for damage or injury, conservative care should be tried. If four to six weeks of physical therapy do not bring relief from symptoms, surgery is suggested. Releasing the pressure on the nerve without disturbing the nerve as it passes through the elbow may be all that is needed.

The goals of early surgery for cubital tunnel syndrome are to relieve symptoms; restore motion, strength, and sensation; and prevent worse symptoms. At least one study has shown that the right timing can accomplish all of these.

Taking a Swing at Tennis Elbow, with or without Surgery

Lateral epicondylitis–commonly known as tennis elbow–is pain along the outside of the elbow that comes from repeatedly twisting or straining tendons in the forearm. This condition can be treated with rest, ice, and physical therapy. But sometimes the pain doesn’t go away. In these cases, patients may need surgery. The purpose of this study was to single out factors that may lead patients to have surgery for tennis elbow.

The participants included 97 patients with elbow pain from repetitive wrist and forearm activity. The patients were half men and half women. Their average age was 46.

Patients were given a specific treatment program. First, they were told to rest and ice their elbows and wear a brace. They also went to physical therapy three times a week for six weeks. In some cases, they took anti-inflammatory medications. If the pain was still severe, they also received steroid injections.

When the pain subsided, patients were taken off anti-inflammatory medications. They continued to do physical therapy, with greater focus on strengthening the wrist and forearm. At this point, patients usually went back to their normal activities.

This treatment was successful for roughly 75 percent of patients. However, the remaining 25 percent went on to have surgery.

Patients who had already tried the elbow treatments used in this study were twice as likely to have surgery. Also, the more steroid injections patients received, the more likely they were to have surgery. Patients who had zero or one injection only had surgery 12 percent of the time. But patients whose pain did not go away after one injection had surgery nearly half of the time. And patients whose pain lasted even after getting two injections had surgery 78 percent of the time.

Overall, most of the patients (92 percent) said their results were good or excellent a few years after treatment. This did not change depending on whether or not they had surgery.

The authors conclude that most patients with tennis elbow respond well to conservative treatment. Steroid injections seem to help up to a point, but the benefits tend to decrease with each injection. In general, when nonoperative treatment doesn’t reduce patients’ pain, it’s unlikely that ongoing treatment of this sort will give patients much additional relief. When this is the case, surgery might become the next best choice.

Elbow Ligaments Hold Tight, Despite Heavy Strains of Athletics

Keep bending a green twig back and forth, and it will eventually break. Keep pitching fast balls at 90 mph, and the shoulder joint will soon become stretched and loose. But what about the elbow joint? Do the ligaments that support the elbow loosen with the repeated elbow strains common to athletes?

A recent study calls into question popular opinion. Until now, it was generally believed that stability in the elbow joint was much like that of the shoulder. Repeated actions in the shoulder tend to cause the shoulder to loosen and become painful over the years, a condition called laxity. Researchers questioned whether players without elbow pain tend to show signs of greater laxity in the elbow joint.

This study compared the elbows of 136 male college athletes. More than one-third played sports that required overhand actions, such as baseball and tennis. The other participants did sports in which the shoulder and elbow were not routinely used in overhand actions, sports such as wrestling and track.

Each athlete had both his elbows tested in a device that pushed against the forearm, angling the elbow outward. This test was used to see how well the ulnar collateral ligament on the inside edge of the elbow held under pressure. Applying stress to a joint causes it to “open” or separate slightly. Healthy ligaments prevent joints from opening too far. The doctor then took an X-ray to tell if the joint had become lax by measuring the separation when stress was applied.

There were no major differences between players, even those doing overhand sports and those who had been playing for many years. Nor was there much difference between each players’ dominant and nondominant elbows. (The dominant elbow is the one on the arm most frequently used–the right elbow on a right-handed person.) Surprisingly, over half the players’ nondominant elbow joints had equal or greater laxity than their dominant elbow joints. These findings led the authors to conclude that extra laxity of the elbow doesn’t occur in athletes who are free of elbow pain.

This is likely because the elbow joint fits together so snugly that the joint is generally stable. This bony stability helps protect the ulnar collateral ligament. However, it also makes it challenging for scientists to specify a cut-off measurement that lets doctors know when a player has developed a loose ulnar collateral ligament.

Beyond Tendonitis

Tendons can be injured all at once, as in an accident, or after long-term repeated use. Many people refer to tendon injuries as tendonitis, but this term really only applies if the tendon is inflamed. Tendinosis is the correct term for the degeneration of the tendon from overuse or other reasons. The difference is important, because the two conditions should be treated somewhat differently.

Tendinosis is not well understood. The goal of this study was to better understand the changes that occur in tendons with this condition. The authors reviewed research on people with tennis elbow, a common form of tendinosis. Medical researchers know that tendinosis seems to cause abnormalities in the tissues and cells of the tendon. They don’t know whether these abnormalities are caused by degeneration or from the way tissues heal.

The authors examined the tendons of nine patients undergoing surgery for tennis elbow. All the patients tried treating their problem for one year using physical therapy, medications, electrical stimulation, ice treatments, and cortisone injections. The authors concluded that the tissue abnormalities found with tendinosis are caused by both tissue degeneration and the way the tissues heal. In either case, they describe tendinosis as “the result of failed tendon healing.”

The authors conclude that promoting healing in tendons is not well treated by anti-inflammatory drugs, steroid injections, or ongoing physical therapy. They recommend:

  • using medications and treatments such as ice, massage, and electrical stimulation to control pain 

  • avoiding cortisone injections, unless the pain is so bad that the patient can’t do exercises

  • keeping the joint moving, because immobilization hurts the tissues’ ability to heal correctly

  • having a doctor put a needle into the tendon to get it to bleed, which helps stimulate the healing response

  • using a special brace

  • designing a short-term therapy program that addresses muscle timing and control, as well as strength, flexibility, and endurance

  • improving the strength of the muscles of the upper back and shoulder

  • adjusting athletes’ form and technique to protect the injured tendon

  • testing the tendon during painful periods.

The authors say that a “handshake test” helps them determine which patients will probably respond best to treatment. They shake patients’ hands with the arm completely outstretched, and then again with the elbow bent at a 90-degree angle. In both cases, they make the patients rotate their arms inward against resistance. If the pain is less when the arm is bent, the patient is more likely to do well with conservative treatment. If the pain is equal in both positions, the patient is more likely to eventually need surgery. 

Tennis Elbow Meets Its Match

Tennis elbow can be caused by injury or overuse of the tendons that attach on the outside of the elbow. The body tries to heal the microscopic tears that form in the tendon. Eventually, scar tissue builds up where the tendon meets the outer bump of the elbow, the lateral epicondyle. The condition causes soreness along the outside of the elbow.

Five to ten percent of patients with tennis elbow don’t respond to conservative treatment. These patients may need surgery to get relief from their symptoms. There are a few ways to go about this surgery. Doctors can do an “open procedure,” meaning they make a large incision in the skin. Or they can operate through the skin using an arthroscope. An arthroscope is a a miniature camera that lets the doctor watch the procedure on a television. This “closed” procedure may reduce some of the risks of the open procedure. But does it get rid of patients’ symptoms?

This study reported on the results of arthroscopy for 16 patients with tennis elbow. All of the patients had tried at least six months of conservative treatment, including cortisone injections, before having surgery. Three-quarters were men. Their average age was 50 years old. Most of the patients had desk jobs. All of them described themselves as recreational athletes.

Doctors used the arthroscope to get in and remove the unhealthy tissue on patients’ elbows. The lesions causing the tennis elbow were of different types and levels of seriousness. Three patients were also found to have other problems associated with tennis elbow.

Twelve of the patients were followed-up for two years. None of the patients had any complications from surgery, and none needed to have further surgery for their symptoms.

Patients were able to resume their normal activities soon after surgery. Notably, they were back to work with no restrictions in an average of only six days. They were all able to return to sports, except one 70-year-old patient whose symptoms had lasted for 20 years.

Patients were very satisfied with the arthroscopic procedure. Ten patients (83 percent) said they felt much better as a result of surgery. No patients said they felt the same or worse after surgery.

Arthroscopy allows doctors to remove unhealthy tissues without hurting the healthy tissues nearby. And it allows doctors to identify other problems that may be adding to patients’ elbow symptoms. All in all, arthroscopy appears to be a safe, reliable way to beat tennis elbow.

Shocking But True: Shockwave Therapy Alone May Be as Good as It Gets

Tennis elbow (also called lateral epicondylitis) can be tough to treat. This is true partly because no one knows exactly what causes the pain. And some cases of tennis elbow don’t get much better with the common treatments of rest, ice, bracing, and anti-inflammatory medication.

In the past 10 years, there has been much research to find better treatments for tennis elbow. Two treatments that seem to be somewhat successful are low-energy shockwave therapy and manual therapy of the cervical spine (the neck). Shockwave therapy involves sending electromagnetic impulses into the elbow. No one knows exactly why it works, but it has been shown to have success rates of about 50% in relieving the pain of tennis elbow. Manual therapy is a specialized form of hands-on treatment used to mobilize one or more joints. Research has shown that up to 80% of people with tennis elbow also have problems in the cervical spine or where the neck and thoracic vertebrae join.

These researchers treated 30 patients with tennis elbow using shockwave therapy followed with manual therapy of the cervical spine. Patients had three shockwave treatments and then 10 manual treatments. The control group was made up of 30 patients who got shockwave therapy only. All patients had tennis elbow that had lasted for at least six months, had gotten at least three steroid injections, and had tried at least six months of conservative treatments. All patients had follow-up physical exams 12 weeks and one year after shockwave treatment began. They also answered questions about their elbow pain and function.

There were no real differences between the groups at the beginning of the study–or after a year. Yet both groups improved significantly over that time. Roughly 60% of the patients in each group reported excellent or good outcomes, which means that they felt–at most–occasional pain in their elbows. These results support the idea that shockwave therapy can be an effective treatment for tennis elbow. However, it appears that manual therapy of the cervical spine may not be of much extra help–shocking, but true.

Getting Hurlers Back in the Game after Elbow Ligament Injuries

Athletes who throw as part of their sport sometimes injure the ligament that crosses the inside edge of their elbow. This ligament is called the ulnar collateral. Its role is to keep the elbow from angling too far outward as the arm picks up speed for the throw. Throwers who injure this ligament face a choice between surgery and non-operative treatments.

This study examined how long it took athletes to return to their sports after non-operative treatment. A total of 31 athletes completed the year-long study. At first, the program involved resting the athletes’ elbows and treatments to control their symptoms. The second part of rehabilitation included strengthening exercises and progressive throwing.
Thirteen athletes (42%) returned to their sport within an average of just under six months. These findings give players a ray of hope about their chances for returning to full-level play. The authors also suggest that the results can help estimate how long it might take a player to get back to throwing sports after non-operative treatment.

The authors also looked at factors that could potentially help predict whether non-operative treatment would let players return to full competition. These factors included the players’ ages, the amount of time between injury and treatment, and whether symptoms were caused by a specific injury or developed gradually. The study found that none of these factors consistently predicted a player’s return to competition.