Important Information About Four Elbow Conditions

Elbow problems getting you down? Wondering what to do? There are many choices including steroid injections, platelet-rich plasma (blood therapy), physical therapy and even surgery. Perhaps giving the problem some time (the old wait-and-do-nothing approach) might be best.

The information in this review article may be helpful. Two orthopedic surgeons from the Hospital for Special Surgery in New York City bring us up-to-date on four elbow conditions: 1) lateral epicondylitis (tennis elbow), 2) medial epicondylitis (golfer’s elbow), 3) biceps tendon rupture, and 4) triceps tendon rupture.

And there’s one “double whammy” condition of interest to some: biceps or triceps tendon rupture on top of a tendinopathy. Tendinopathy describes a chronic condition present with epicondylitis — there is no active inflammation going on. Microscopic studies have shown us that the area has poorly organized collagen fibers. There is scar tissue and an area where acute inflammation was present in the beginning but just never healed right. Tendinopathy is more of a degenerative condition than one of inflammation.

Causes, natural history (what happens over time), treatment, and outcomes are discussed for each problem. The first thing patients must understand is that these problems take some time to heal (up to a year or more). There’s no quick, easy fix but conservative (nonoperative care) is effective. Time, patience, and consistency are the keys to recovery.

Let’s start with lateral epicondylitis known more commonly as tennis elbow. Repetitive overuse of wrist extension is the most likely cause — and it affects many people, not just tennis players. Men and women are affected equally. Adults between the ages of 35 and 54 who smoke and/or who are obese are at greatest risk for this type of elbow problem.

Once the diagnosis is made (based on patient history and clinical examination and sometimes imaging studies), then treatment can begin. Treatment ranges anywhere from “benign neglect” (just watch and wait) and activity modification to shock therapy. When all else fails, surgery may be done to remove the diseased tissue followed by splinting and postoperative rehab with a physical therapist. Studies are ongoing to find out what works best.

Medial epicondylitis (remember: golfer’s elbow) occurs in anyone who uses wrist flexion over and over. This does include golfers but also anyone in the work force who is required to use this type of repetitive motion. Just like lateral epicondylitis, medial epicondylitis is evaluated and treated in a similar fashion.

In both conditions, steroid injections are known to provide short-term (immediate) pain relief but there’s no long-term benefit. In other words, patients with the same condition who don’t have the injection(s) have the same results three to six months later compared with patients who do have the steroid injection.

Surgery is a bit more problematic with medial epicondylitis because of the potential for nerve damage. Patients with chronic medial epicondylitis may not be able to return to the sport that contributed to the problem in the first place. In fact, studies show that as many as 20 per cent of the adults with medial epicondylitis are unable to return to the recreational sporting activity of their choice.

Now, what about tendon ruptures (either partial or complete) affecting the biceps or triceps? These conditions are much more uncommon when compared with how often epicondylitis develops. Here’s what we know. Anyone who has ever had this type of tendon rupture is at increased risk for the same injury a second time.

Men engaged in lifting activities (sports or occupational) develop tendon ruptures much more often than women. Tobacco use really ups the risk of tendon ruptures. Smokers have 75 times greater risk of tendon rupture than nonsmokers.

Unlike tendinitis that seems to come on more slowly over time, tendon ruptures occur with trauma and load and create immediate symptoms. Patients report a sudden, sharp, painful episode often with a “pop” at the time of the rupture. Weakness, loss of motion, bruising, and a bulge or lump signal tendon injury. An MRI will show the damage clearly and allow the surgeon to evaluate more accurately whether it is a partial or complete rupture.

In cases of tendon rupture (biceps or triceps), surgery is often required to restore full strength and motion. Some patients can get by without surgery, especially if it is a partial tear. Conservative care can always be tried (for partial and complete tears). But the earlier surgery is done, the better the results with less scarring and easier return of the tendon to the place where it belongs.

The biggest challenge in surgical repair is deciding how to reattach the tendon to the bone. Special sutures and surgical buttons have been used with varying results. Triceps ruptures are more likely to require elbow replacement. Most of these injuries occur as a result of acute trauma, which is linked with early development of osteoarthritis and the eventual need for joint replacement.

In summary, whether from acute injuries or overuse, elbow tendinopathy affects many adults. The condition causes chronic pain, loss of motion, and decreased function potentially leading to disability. Finding ways to treat these conditions in the most effective way possible remains the focus of orthopedic surgeons, sports physicians, and physical therapists.

Keeping up-to-date with a review of causes, pathophysiology, evaluation, and treatment such as these authors provide is essential in helping patients accept a realistic view of what to expect. There’s no quick fix to these injuries. But with a careful examination and implementation of the appropriate plan-of-care, most people are able to recover in six to 12 months’ time.

The Docking Procedure for UCL Reconstruction

In this article, orthopedic surgeons from the Rothman Institute in Philadelphia and the Hospital for Special Surgery in New York City team up to instruct other surgeons about the value of the Docking procedure to reconstruct the ulnar collateral ligament (UCL).

The UCL is also known as the medial collateral ligament. 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. Together, these two ligaments (one on each side of the elbow) keep the elbow joint stable and help prevent dislocation during trauma or injury.

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.

The ulnar collateral ligament (UCL) can become stretched, frayed or torn through the stress of repetitive throwing motions. If it does 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.

Professional pitchers have been the athletes treated most often for this problem. Javelin throwers, football players, as well as athletes involved in racquet sports, ice hockey, wrestlers, and water polo players have also been reported to injure the UCL. A fall on an outstretched arm can also lead to UCL rupture (often with elbow dislocation).

Sometimes an injury to the UCL can be treated conservatively (without surgery). The nonoperative approach can work well for patients who have a partially torn but not completely ruptured ligament. The conservative approach may also be recommended for patients who are not athletes and therefore not involved in activities that require overhead throwing.

On the other hand, when there is a complete tear, overhead throwing athletes really are not good candidates for conservative care. Studies have conclusively shown that reconstruction is definitely needed for these athletes if they want to return to full sports play. Of the different surgical procedures that can be done to reconstruct the damaged UCL, as we mentioned, the Docking procedure is the focus of this report.

The surgeons describe and illustrate the operation with color photos taken during the surgery. Type of anesthesia (usually regional) and positioning of the elbow and hand are shown. The technique is done arthroscopically with full details of tunnel positions, type of sutures, care to prevent nerve damage, and ways to split the muscles to gain access to the ligament. The way in which special tools are used (such as the suture passers, burrs of different sizes) is also part of the surgeons’ report.

If a repair procedure is performed, the surgeon reattaches the torn ligament to its original position. But if the ligament is completely ruptured, reconstruction is done with a graft. The graft tissue comes from the patient (usually either the palmaris longus or gracilis tendon is used).

Graft harvest, graft tension, ulnar nerve transpositioning (moving the nerve to a different location), and suturing of the fascia over the muscles are discussed. The ‘docking’ portion of the surgery refers to suturing the graft to the humerus (upper arm bone). A final section on postoperative management with expected results is provided. Athletes can expect to be in a splint for a week after surgery and then transferred to a hinged splint for six more weeks.

Physical therapy is started early and continues until the athlete has advanced through a program aimed at returning to full sports participation. Returning to sports that require overhead throwing is done in stages. Speed of throw and distance are gradually increased over time. When the patient can throw 180 feet without pain, then that person is allowed to resume competitive sports. Usually this takes nine months to a year.

These surgeons say they have had good to excellent results using the Docking reconstructive technique for 100 overhead throwing athletes. Ninety per cent of the group (90 athletes of the 100) were able to return to full sports play. Of the remaining 10 athletes, seven of them were able to play at a lower level.

They concluded that the Docking technique they use is a good choice. It is minimally invasive, reliable, and reduces the risk of nerve injury. Athletes interested in returning to competitive sports play can expect full return with proper rehabilitation. This can take up to a full year. Complications (e.g., numbness, pain) are few and far between and usually temporary. Only a very few athletes must give up their overhead throwing activities.

Clinical Recommendations for Osteochondritis Dissecans of the Elbow

The best way to treat a condition called osteochondritis dissecans (OCD) of the capitellum (elbow bone) when it is unstable has not been determined. That’s the conclusion of orthopedic surgeons specializing in the treatment of this problem. And in this review article, they will tell you why high-level evidence is lacking to support one form of treatment over another.

Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to this odd and troubling elbow condition. In the past, this condition was called Little Leaguer’s elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.

The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. That’s when the condition is referred to as unstable.

Surgery is usually required for unstable OCD. The surgeon has several choices: the fragment can be reattached called fragment fixation. The broken piece can be removed with the remaining bone smoothed over (called debridement). Or osteochondral autograft transfer (OAT) can be done. The autograft transfer involves taking a fresh, healthy piece of bone from the patient’s knee and transferring or “grafting” it into the defective area.

By looking at past studies and reported outcomes, the researchers were able to get an idea of short-, mid-, and long-term results with each of these surgical approaches. They reviewed studies from 1992 to the present. They discovered the data is inconclusive and the studies are not consistent in how they collect and analyze information. There was not enough high-level evidence to support one approach over another.

They were able to glean a few bits of information that might be helpful until better studies are done. For example, debridement is able to get up to 85 per cent of competitive athletes with unstable capitellar OCD back to full sports participation. Debridement can even be used with defects that are large enough to cover more than half of the joint surface. But outcomes are usually worse with debridement in this group compared with debridement of smaller defects.

Osteochondral autograft transfer (OAT) is really used most often for those large, unstable defects. It can also be used as a revision (second) surgery if debridement is unsuccessful in reducing pain and restoring elbow function. Studies have not been done long enough to show whether the donor site (in the knee) develops osteoarthritis years later. That would be an important piece of information to have before recommending the OAT procedure. Poor results with OAT are likely when the defect location is along the edge of the joint where it is difficult for the surgeon to get a graft in there.

Fixation was the other surgical method studied in this review. In fragment fixation, wires or bioabsorbable screws are used to hold the pieces of bone together until healing can occur. With this treatment approach, the player can get back to overhead (throwing) activities about six months after surgery.

Those who have the wires used must have them removed in a second surgery. Outcomes reported with fixation include good resolution (or at least improvement) of pain in 85 per cent of the athletes. X-ray evidence of healing without joint degenerative changes was observed in most cases.

Problems that can occur after surgical correction of OCD include persistent pain, sensation of “catching” in the joint with motion, and an inability to return to full sports participation. In general, the larger the lesion, the poorer the results. And the farther out from the injury and surgery, the less favorable the outcomes reported in the studies available.

In conclusion, the authors call for a long-term study conducted at multiple centers with large numbers of patients. This is the only way surgeons will be able to determine the best, most optimal surgical treatment for athletes who suffer from unstable capitellar OCD defects.

Tennis Elbow Remains a Difficult Problem

Despite over 100 years of study and treatment, lateral epicondylitis, otherwise known as “tennis elbow” remains a difficult problem to treat. Recent research has shown us that partial tears of the extensor carpi radialis brevis (ECRB) tendon just don’t heal right. But the reason for this remains unknown. After the acute injury, repetitive microtrauma results in an area of fibrosis (scarring) rather than inflammation. Finding ways to successfully treat this problem is a challenge health care providers face every day.

To help primary care physicians, orthopedic surgeons, sports medicine physicians, and physical therapists, two orthopedic surgeons from the University of Virginia took the time to research the problem of lateral epicondylitis. They provide us with updated information on this condition starting with the pathology and pathophysiology as it is currently understood. A review of the diagnosis includes clinical presentation, clinical tests, and diagnostic imaging. And finally, there is a discussion of treatment (both conservative and surgical).

The idea that lateral epicondylitis isn’t really an “-itis” (inflammatory) condition at all has been made clear by microscopic studies of the affected tissue. The lack of blood supply to the area (called hypovascular zones) is a key feature of this problem.

Although the radial recurrent artery normally provides blood to the extensor carpi radialis brevis (ECRB), in patients with lateral epicondylitis, there are two areas with decreased blood supply. These two hypovascular zones are located: 1) where the ECRB tendon attaches to the bone and 2) just a little bit (two to three centimeters or about half-an-inch) below the tendon-to-bone attachment.

How does the examiner know for sure the problem is lateral epicondylitis? Caucasian women between the ages of 35 and 50 are affected most often. But those kinds of demographics aren’t enough to make a diagnosis. The clinical presentation is another helpful clue. Pain along the outside of the elbow that goes down the forearm is a telltale sign. There may be tenderness right over the bone. Pain with gripping or lifting is common. And painful symptoms are brought on or increased when the examiner resists the movement of wrist extension.

This collection of symptoms usually directs the physician to consider ordering some imaging studies. X-rays are often ordered but research shows that in the case of lateral epicondylitis, they aren’t really needed or helpful unless the patient fails to improve with conservative (nonoperative) care. MRIs can be more useful but they are also more expensive. An MRI may show areas of tendon thickening, avulsion of the tendon (pulls away from the bone), and severity of damage.

What do the experts have to say about treatment? Well, everyone agrees that conservative care should be first and foremost. But what that should be remains a point of debate and controversy. There are many choices available from the wait-and-see approach, to the use of antiinflammatory medications, steroid or platelet-rich plasma injections, shock-wave therapy, physical therapy, and splinting.

And even within each of those treatment choices, there remains considerable uncertainty about what works best. Stretching, strengthening, soft tissue mobilization, deep friction massage, and electrical stimulation all seem to have some benefit. But is there some way to combine two or more of these approaches for the best results? And if so, which two (or three — or more) work together to produce optimal outcomes? These are questions current research has not been able to answer just yet.

We do know that in up to 90 per cent of all cases, conservative care has the intended effect. Patients report decreased pain, improved strength, and pain free return of full function of hand, wrist, and forearm. It may take up to a full year to get those kinds of results but most patients agree it is worth the time and effort.

For those few people who do not get the hoped for improvements, surgery is a final option. Here again, there are several choices and no real evidence that one approach works better than another. The surgeon may remove the diseased portion of the extensor carpi radialis brevis (ECRB) tendon, perform a tendon repair, or surgically release the tendon.

Percutaneous (through the skin) release has a good track record with decreased pain, improved strength, and return-to-work for many patients. The downside of this surgical approach is that the surgeon is unable to look inside the joint for any other damage or injury that might be part of the problem.

In conclusion, the authors say the current evidence isn’t strong enough to support one treatment over another for lateral epicondylitis except to say: start with conservative care, give it a full year, then re-evaluate. If there hasn’t been enough progress made, then consider surgery as the next available option. There is a need for continued, ongoing study and research to clear up treatment decisions and find the ideal approach that yields the best results.

Can a Biceps Tendon Rupture Heal By Itself?

In this case example, treatment of a distal biceps rupture is discussed. Questions answered include: 1) Can this heal by itself? 2) What happens if no treatment is provided? and 3) When should surgery be done? The optimal timing, best way to operate, and postoperative care are also discussed.

The patient was a 47-year-old man who was lifting something heavy. There was a “pop” sensation along the front of the elbow. Less than 24 hours later, there was swelling and bruising in that area. His job performance was compromised because he didn’t have the strength to turn his hand in the palm up position (called supination).

An MRI showed a complete rupture of the biceps where it attaches to the elbow. For the patient who is self-employed and without insurance or paid time off, the question became: will it heal on its own? The patient wanted to know, “Will I get back to ‘normal'”?

Most orthopedic experts agree that surgery is needed. And the best time to repair a biceps tendon that has retracted (snapped back up into the upper arm) is within the first six weeks after injury. In fact, the best results with fewest complications occur when surgery is done in the first two weeks after injury. After six weeks, reconstruction with a graft (rather than a repair procedure) is more likely.

But back to the question whether surgery restores supination strength. The answer is “Yes.” Without surgical repair, the patient can expect about a 40 per cent loss of supination motion. There can be another 30 per cent loss of strength. And there could still be other complications such as nerve injury, bone fracture, and even re-rupture of the biceps. It’s not likely the arm will get back to normal without intervention.

Surgeons are more concerned than patients about the most effective surgical approach. One decision surgeons face is the best way to reattach the tendon, referred to as the fixation method. There is concern about possible nerve damage and the effect of treatment on the strength of supination and/or flexion.

The surgeon also decides on the number, type, and location of incisions. If an incision technique doesn’t improve overall results, then why use it? Surgeon and patient both keep in mind that any surgery always comes with its own risks and potential for complications.

What happened with this patient? The gentleman was told at the time of his initial exam that he could expect continued weakness whenever trying to turn or twist (supinate) the forearm. This type of motion is important for his job as a self-employed contractor. Easy fatigue of the injured arm was another likely event. Some people can adapt to these changes while others cannot.

The authors did not reveal this patient’s decision or the final outcome. But in the process of presenting the case, they offered their philosophy, approaches, and expected results.

Elbow Stiffness After Injury

Orthopedic surgeons from the Mayo Clinic in Rochester, Minnesota review the concepts and molecular changes that occur with elbow stiffness after elbow trauma or injury.

There are many bone and soft tissue injuries that can contribute to posttraumatic elbow stiffness. It’s not always clear what all the factors are leading to this condition. But animal studies have revealed some new and helpful information that may lead to improved treatment.

It appears there are two major areas of soft tissue damage linked with posttraumatic elbow stiffness. The first area of interest is the joint capsule. The capsule is a group of ligaments and connective tissue that surrounds the entire joint. The second factor that can result in elbow joint stiffness is the increase in number of myofibroblasts (protein in the muscle cells) after injury.

The exact chain of events at the cellular level that lead to capsular and myofibroblast changes are very complex. The author does a good job providing details of the chemical and mechanical signals that occur after elbow injury. Growth factors, collagen expression, and mast cell production are all important in the molecular and cellular events that occur after an injury.

In fact, the discovery that mast cells are released in response to trauma and pain was an important clue. There is some evidence that mast cells may be the missing link between an acute injury that becomes chronic. And that’s where pharmaceutical (drug) treatments could be developed to help prevent posttraumatic stiffness.

There are other factors that might be part of the picture. Female sex hormones, prolonged immobilization right after the injury and genetic predisposition have been identified. Addressing these three risk factors might help physicians predict problems and prevent them. This concept is referred to as selective targeting.

Before treatment begins, imaging with X-rays and CT scans must be done. Imaging shows any fractures, loose fragments of bone or cartilage, or infection. If nothing shows up, loss of motion could be caused by the patient’s apprehension and muscle tension more than a true mechanical problem. It may be necessary to examine the patient under anesthesia to find the true cause of loss of elbow motion.

Treatment is based on whether the stiffness is coming from inside or outside the joint and which specific structures are involved. Treatment ranges from conservative (nonoperative) care to surgery. Various treatment options include physical therapy, bracing, splinting, manipulation under anesthesia, and surgical release of the capsule. For patients who do not respond to any of these approaches, an elbow replacement may be advised.

The authors say there is a need for high-quality research to determine what works best to treat posttraumatic elbow stiffness. The new information presented comes from animal studies but may still help expand pharmaceutical treatment options in the near future. The focus now is on finding ways to prevent this problem from developing whenever possible.

Symptoms After Ulnar Nerve Decompression

Patients suffering from cubital tunnel syndrome may seek relief from painful, disabling symptoms through surgery. But imagine their surprise and disappointment when they have a successful outcome and then the symptoms come back. Are these symptoms the same old (persistent) unchanged symptoms or are they a true recurrence of the previous problem?

That is the question addressed by two hand surgeons from Kaiser Permanente in Los Angeles California and the University of Washington (Seattle). Cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow.

The symptoms are very similar to the pain that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness may develop into pain. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Tapping or bumping the nerve in the cubital tunnel will cause an electric shock sensation down to the little finger. This is called Tinel’s sign. Grip strength may be affected to the point that the person can no longer lift objects or even hold a cup of coffee. This syndrome can be very disabling.

Treatment usually begins with conservative (nonoperative) care. First, it is important to stop doing whatever is causing the pain in the first place. Taking frequent breaks during activities and even modifying job activities is important. Antiinflammatory medications, physical therapy, and splinting are helpful. The therapist will give you tips on how to rest your elbow and how to do your activities without putting extra strain on the elbow.

If the symptoms do not go away with changes in activity and nonsurgical treatments, surgery to stop damage to the ulnar nerve may be recommended. The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. The hope is to reduce pain and other symptoms, possibly to even eliminate all symptoms. But a full recovery is rare. And even those patients who experience a good result at first often experience a return of their former symptoms.

So, again the question becomes — were those symptoms there all along and the patient didn’t realize it? Or are these symptoms a recurrence (the problem got better at first and then worse later)? As the authors of this article point out, the answer to this question is unknown. Certainly it is possible that the patient was so hopeful for improvement that they felt a change in their symptoms even when there was no change in the nerve physiology or function.

And it is possible that another problem is present (e.g., painful neuroma over the nerve) that could be adding to the persistent symptoms. But studies show that removing the neuroma or performing a second surgery to take pressure off the nerve doesn’t seem to help. If anything, patients report worse results after revision surgery.

In fact, it is more often the case that the symptoms of pain or numbness, weakness, and muscle atrophy (wasting) are permanent. It’s possible the first surgery was unlikely to change anything. The authors suggest that there could have been symptoms of nerve dysfunction for a long time before the patients ever noticed them. By the time the problem became obvious, damage to the nerve was permanent.

There are some risk factors to suggest patients who might not be good candidates for surgery to treat cubital tunnel syndrome. These include depression or other mood disorders and/or problems with coping. Dissatisfaction with the results and disability are linked with these psychologic problems and may be the real key to poor outcomes.

There is also the possibility that poor results occur because of the surgery itself. There are different ways to surgically treat cubital tunnel syndrome. Studies are needed to show which technique is the best with the fewest complications. Until the procedure is perfected, the authors suggest that patients should be told what to expect realistically.

Failure to get the desired results may require a second procedure to look for (and remove) any neuromas and to further decompress the nerve (beyond what was done in the first surgery). Follow-up rehab with the hand therapist is essential to ensure full, smooth nerve gliding and prevent scar adhesions from forming.

Best Treatment for Septic Olecranon Bursitis

In this article, surgeons from The Philadelphia Hand Center explore the best treatment for septic olecranon bursitis. Since studies of this problem are limited, evidence-based treatment has not been established. By reviewing the studies that have been done, the authors provide some thoughts on the problem and its treatment.

Olecranon (elbow) bursitis is the inflammation of the bursa at the tip or point of the elbow. A bursa is a sac made of thin, slippery tissue. Bursae (plural) occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts. The olecranon bursa allows the elbow to bend and straighten freely underneath the skin.

This bursa can become irritated and inflamed in a number of ways. Direct impact (a blow or fall) on the elbow can cause bleeding in the bursa. This can cause the bursa to become swollen and tender. Repeated strains on the elbow, such as resting your elbows on a hard surface, can also cause the bursa to become inflamed.

The olecranon bursa can also become infected or septic (the focus of this discussion). This may occur without any warning, or it may be caused by a small injury and infection of the skin over the bursa that spreads down into the bursa. In this the sack fills with pus, and the area around the bursa becomes hot, red, and very tender.

Treatment may depend on what is causing the septic bursitis. The most common approach is the use of antibiotics. A broad spectrum antibiotic is used at first (one that will kill as many different kinds of bacteria as possible). If the fluid in the elbow is aspirated (drawn out), then it can be tested to find out the specific bacteria present. An antibiotic that will target the identified bacteria can be prescribed. With septic olecranon bursitis, it’s usually a staph or strep infection.

Antibiotics and aspiration used together is another common treatment choice. In some cases, the surgeon will put a tube into the bursa and remove fluid while cleansing the area twice a day over a period of three to five days. This type of treatment is called serial aspiration. When the fluid is tested clear and free of infection, then the tube can be taken out and antibiotics discontinued.

Surgery is the final treatment option for septic olecranon bursitis. Although it is not usually the first-line treatment, there are no studies to say this wouldn’t be the best way to go. Most of the time, surgery is reserved for those patients who don’t respond to antibiotics and aspiration. As it stands now, surgeons don’t have hard and fast evidence-based guidelines for determining when surgery is advised.

This group of surgeons suggest surgery is needed when the patient is not getting better after 24 to 48 hours of conservative care and/or when there is a skin infection known as cellulitis. Anyone with a fever, chills, low blood pressure, altered mental status, or other symptoms to suggest a systemic disorder should be treated surgically right away.

The authors conclude that there is plenty of room for research regarding the best treatment for septic olecranon bursitis. Studies are needed comparing each of the treatment choices along with a cost analysis to show which one is the most cost effective. Other areas of research needed include collecting information on complications of treatment (aspiration or surgery), type of dressings used to cover the wound, and ways to support healing.

Myofascial Release Therapy for Elbow Pain Associated with Computer Use

Physical therapists around the world successfully treat elbow pain caused by many hours using a mouse control device at the computer. One of the helpful treatment tools used is a technique called myofascial release therapy (MFT). In this study from researchers in Malaysia and India, evidence to support the value of MFT is provided.

Lateral elbow pain (along the outside of the elbow) is referred to as lateral epicondylitis. When present in computer professionals, it affects the mouse-operating arm and hand most often. Pain and tenderness can be present at rest but are usually made worse by resisted wrist extension with the elbow straight.

Myofascial release is a hands-on technique. The physical therapist applies a low load, long lasting stretch to the myofascial tissue (connective tissue that support and surround muscles and tendons). The therapist holds the stretch for up to five minutes. The desired result is to increase circulation, reduce sensitivity of nerves, and improve elasticity (flexibility and stretch) of the tissues.

In this study, 68 computer professionals with lateral epicondylitis were divided into two groups. Group 1 received 12 myofascial release therapy treatments over a period of four weeks. Group 2 (control group) received a sham ultrasound treatment to or elbow surgery.

Everyone in both groups was tested before treatment began and retested at the end of treatment (four weeks), and three months later as a follow-up. Pain, function, and disability were measured using a specific test called the Patient-Rated Tennis Elbow Evaluation Scale.

Test results showed a consistent and significant value of myofascial release (MFR) for this type of lateral epicondylitis. The MFR group had a 78.7 per cent reduction in symptoms while the control group had only a 6.8 per cent reduction. And that significant difference between the groups was still observed at the end of 12 weeks.

There were no adverse effects from either treatment but a few of the patients in the MFR group noted their pain increased the first week after the first treatment. Painful symptoms went away within a few days and there was no need for pain medications.

The authors concluded that myofascial release (MFR) was much more effective than sham ultrasound therapy in decreasing pain and improving function in computer workers with lateral epicondylitis. The exact mechanism by which MFR is effective isn’t entirely clear. Experts in this area of study believe the technique allows the tendon to heal and restore a more normal soft tissue structure without restrictions. Reorganization of the collagen fibers that make up the connective tissue may be another way in which MFR lengthens the fascia and aids in healing.

More studies are needed to assess the long-term benefits of myofascial release (MFR) therapy. Research to compare MFR to other treatment approaches is also needed. The authors recognize there are different ways to apply myofascial therapy (directly, indirectly, using hands or a special tool designed for this purpose). Each of these methods deserves closer study and comparison as well.

Modern Surgical Concepts for Ligamentous Reconstruction of the Elbow

Ligaments of the elbow are tough and are built to last. But repetitive overuse as in the case of the overhead throwing athlete can result in ligament damage and elbow instability. Chronic load and stress create wear and tear on the ulnar collateral ligament (UCL) in particular.

In this article, surgeons at the Hospital for Special Surgery in New York City provide us with a complete review of ligament reconstruction of the UCL in throwing athletes. They begin with a brief history of this type of injury. Concepts around past treatment are presented along with a discussion of important anatomy and biomechanics needed to understand and the mechanisms of injury. Treatment including nonoperative management and current surgical techniques are presented.

Baseball is usually the first sport that comes to mind when we hear the term “overhead throwing athlete.” But, in fact, the very first throwing injury reported and described was a javelin thrower back in 1946. It wasn’t until almost 30 years later that a well-known surgeon (Dr. Frank Jobe) developed the first surgical technique to address this problem. Up until that time, a UCL injury in an overhead throwing athlete meant the end of a career.

Now, almost 40 years after that first procedure, there are several different ways to surgically reconstruct the elbow. Each one takes into consideration the six stages of the overhead throw and all the mechanics required from start to finish. Load on the soft tissues and bony connections is a key feature in understanding what is needed to fully restore the integrity of the ulnar collateral ligament (UCL).

Nonoperative management is possible for some throwing athletes, especially those who have an acute traumatic injury (rather than a chronic wearing of the ligament). They must follow a carefully prescribed rehabilitation process but can get back into full sports participation again. Newer treatment involving blood injection therapy (called platelet-rich plasma) is being investigated as well.

When it comes to surgical approaches to UCL injuries, the surgeon must evaluate each athlete individually to determine whether repair or full reconstruction is needed. In the case of ligamentous repair, good-to-excellent results have been reported for young athletes with an acute tear of the ligament where it attaches to the bone.

UCL reconstruction is more likely required when there is an old, chronically strained tear in an older athlete. These athletes often subject the UCL to repetitive overloading and experience elbow dislocation because of UCL disruption.

The original Jobe reconstruction used a tendon graft in a figure-eight pattern to replace the UCL ligament. Since that time, modifications to the Jobe technique have been developed. These include the suture anchor method (called the hybrid technique), the interference screw (DANE TJ) technique, the docking technique, and the American Sports Medicine Institute (ASMI) modification.

The authors of this article describe the different reconstruction methods and review research results for each one. Drawings and intraoperative photos provide surgeons with an inside look at each of these surgical techniques. No one individual method stands out as the “best” approach.

Research is ongoing to identify which athlete would respond best to which technique. There are multiple variables to consider including age, activity level and biomechanical stress on the joint, and complications. The most common complications with UCL reconstructive surgery include retear of the ligament, scarring and adhesions resulting in loss of elbow motion, and nerve damage.

Despite the potential for complications, the overall outlook for overhead throwing athletes with UCL damage is good. Modern reconstructive surgery is well-developed and successful. Surgeons have adapted the original Jobe procedure to reduce the amount of muscle and nerve damage that occur with reconstructive techniques. Most athletes are able to return to full competitive sports participation equal to their preinjury status. This is a major advancement in the treatment of UCL injuries that was not possible 30 years ago.

Case Report of Rare Elbow Disease

Physicians from the Rheumatology and Radiology Departments at the Hassan II University Hospital in Morocco present in this report the rare case of elbow pigmented villonodular synovitis (PVNS).

There are only 15 published cases of this condition. The diagnostic process and successful treatment described here may help others recognize and treat future cases.

Pigmented villonodular synovitis (PVNS) is a benign disease of the joint synovium. Benign in this case means that the condition is confined to the area of involvement. It doesn’t spread or travel to other parts of the body. It does not cause death but disability is possible. The synovium is the layer of soft tissue that lines the joint. It has a clear fluid that helps lubricate the joints.

Symptoms usually include joint swelling of a single joint (knee, hip, ankle, shoulder, elbow — in that order) with pain and loss of motion. Pain and loss of motion get worse as the disease progresses. X-rays often show lytic lesions (bone eaten away). In this case, the 32-year-old woman affected had a huge hole in the back of the elbow called a fenestrated fossa.

But lytic lesions of the bone can be caused by cancer so an MRI and biopsy are required to make an accurate diagnosis. In the case of pigmented villonodular synovitis (PVNS), MRI findings are clear. This is because the tissue contains iron deposits called hemosiderin and the MRI signals clearly show these lesions. Synovial fluid removed from the joint was yellow, another clue as to the diagnosis.

The final confirming diagnostic “test” was surgery to open the joint and remove the tissue, a procedure called synovectomy. With open incision, the surgeon could clearly see the condition. Lots of yellow thickened synovial tissue was visible. Tissue samples sent to the lab provided an examination of the cells, called a histology report to further confirm the diagnosis.

By completely removing all diseased tissue, the patient was able to fully move the elbow again without pain. The disease did not come back again despite other reports that the recurrence rate for PVNS after synovectomy is around 46 per cent for the elbow.

The authors believe their success in this case is due to the fact that the joint was carefully and thoroughly cleaned of all diseased tissue (right down to the bone). Radiotherapy (radiation to the area) is sometimes recommended but this patient did not have that additional treatment. No one knows what causes this disease or the best treatment for it. The authors hope by presenting this case, they can add to the knowledge base about pigmented villonodular synovitis (PVNS).

Using Electrodiagnostic Tests to Predict Results of Surgery for Cubital Tunnel Syndrome

Carpal tunnel syndrome (CTS) gets a lot of attention because it affects so many people. But there’s a second type of nerve compression problem that deserves some attention too. And that’s ulnar nerve compression, also known as cubital tunnel syndrome or CuTS.

Just like carpal tunnel syndrome, cubital tunnel syndrome causes pain, sensations of numbness and tingling, and weakness of the hand. But the areas of the forearm and hand affected are different. The symptoms of cubital tunnel syndrome are very similar to the pain that comes from hitting your funny bone.

When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

Numbness on the inside of the hand and in the ring and little fingers is an early sign of cubital tunnel syndrome. The numbness may develop into pain. The numbness is often felt when the elbows are bent for long periods, such as when talking on the phone or while sleeping. The hand and thumb may also become clumsy as the muscles become affected.

Tapping or bumping the nerve in the cubital tunnel (Tinel’s test) will cause an electric shock sensation down to the little finger. This is called Tinel’s sign. Other diagnostic tests that can be done to confirm cubital tunnel syndrome include electrodiagnostic examination. Nerve conduction tests and electromyography to study muscle function are the two main electrodiagnostic tests used for nerve compression.

Treatment for cubital tunnel syndrome (CuTS) is usually conservative. Antiinflammatory medications, changes in activities, a splint, and physical therapy may be helpful. If symptoms are not improved with nonoperative care, then surgery may be recommended to stop damage to the ulnar nerve.

The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel. One surgical treatment is called ulnar nerve transposition. In this procedure, the surgeon forms a completely new tunnel from the flexor muscles of the forearm. The ulnar nerve is then moved (transposed) out of the cubital tunnel and placed in the new tunnel.

Before doing this type of invasive surgery, it would be helpful if the benefit in terms of decreased pain and improved function could be predicted. In this study, a patient-rated tool called the Patient-rated ulnar elbow evaluation (PRUNE) was used to predict change 18 months after ulnar nerve transposition. Electrodiagnostic tests were also used to measure changes in nerve and muscle function. In this way prognosis for functional recovery could be tested and predicted.

One of the specific goals of this study was to see which aspects of the electrodiagnostic tests are the most predictive of pain during daily activities after surgery. By completing the PRUNE questionnaire patients were rated on pain and other symptoms during dressing, household chores, eating, and self-care (e.g., teeth brushing, face washing). Work and recreational activities are also assessed.

Testing took place before surgery (called the baseline) and again 12 to 18 months after anterior ulnar nerve transposition surgery. Seventy-three (73) patients (52 men and 18 women) were included in the study. Almost everyone had sensory changes before surgery and most (85 per cent) had motor changes (muscle action) affecting the hand.

After surgery, half the group still had abnormal sensation but there were still some improvements. Slightly more than one-third of the group experienced a full return to normal sensation. Motor improvement was also present but still not normal in most of the patients. PRUNE scores were significantly better for everyone.

The women in the group seemed to get the best improvements overall. The authors say this can be partly explained by the women’s symptoms and disability being worse than the men’s before surgery. There are other factors at play (e.g., severity of nerve damage, length of time between injury and surgery) but were not evaluated in this study.

The value of this study is to show the benefits of electrophysiological testing before surgery. The test results help confirm the diagnosis of cubital tunnel compression syndrome and provide prognostic information about expected recovery.

The surgeon may even be able to use the information to plan the optimal time for the surgery. For example, when there is slowing of nerve signals but not complete loss of signals, then conservative care may be helpful. Likewise, if there are just isolated spots where nerve transmission is slowed, the patient may respond well to nonoperative care and surgery may not be needed.

The authors conclude that electrodiagnostic testing is a useful tool for cubital tunnel compression syndrome. The testing doesn’t provide all the answers but certainly contributes helpful information in planning treatment. More study is needed to identify clear cut-off points between what is normal and what is considered “abnormal” electrophysiologic values. This is especially true when trying to decide whether or not to have surgery by predicting recovery and outcomes.

Step-By-Step Approach to Elbow Problems in Athletes

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

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

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

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

The examiner often has a pretty good idea what’s wrong with the elbow even before examining it. The list of possible diagnoses can be formulated just based on the patient’s responses to questions. For example, pain on the medial (inside) of the elbow points to the possibility of a ligamentous problem.

On the other hand, symptoms like numbness and tingling down the arm may point more to a problem with nerve compression. There are special tests used to evaluate the status of the three nerves that pass through the elbow and other ligamentous tests to determine how stable the joint is.

Likewise the information collected during the exam guides the examiner in selecting the most appropriate tests to rule in/rule out specific conditions. Are imaging studies needed? Do visual inspection and palpation suggest the necessity of an X-ray, MRI, or CT scan? Will an arthroscopic examination be necessary?

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

The authors provide detailed instructions for various tests (e.g., joint compression tests, pivot-shift test for stability, valgus-varus tests, hook test for biceps tendon rupture) along with photos of each test and fluoroscopic views inside the joint.

Tests are described coming from all four directions around the elbow (anterior or front, posterior or back, medial or side closest to the body, and lateral or side away from the body). And finally, there is a special section on considerations when evaluating the child or teen who has not completed his or her full growth yet.

The authors conclude by saying that a well organized assessment of elbow injuries in throwing athletes will lead to the most appropriate treatment and therefore, faster return-to-sports. By using their suggested step-by-step interview and exam, the examiner can stay focused and produce an accurate diagnosis.

The Truth About Simple Elbow Dislocations

In this report, the incidence of simple elbow dislocations each year in the United States is reported. The authors also provide some demographics (details about age, race, sex, cause of injury) for the patients studied. The goal in understanding more about elbow dislocations is to prevent these injuries from ever happening.

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

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

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

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

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

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

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

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

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

Before summarizing the data, the authors made note of the fact that children younger than 10 were not included in this report. This was due to a technical problem with diagnostic codes used to describe injuries. Thus, injuries from baby walkers and nursemaid elbow (elbow dislocation from lifting the child by the arm) were not included.

In conclusion, the overall incidence of acute, simple elbow dislocations is activity based with high-risk activities being football, wrestling, and basketball for males. Gymnastics and skating (in-line, ice skating, skate boarding, or roller skating) are the high-risk activities for females. With this knowledge, efforts can be made to prevent such injuries. The proper use of protective equipment along with education and training may reduce the incidence of simple elbow dislocations.

Hand Surgeon Presents the Case for Early Tendon or Nerve Transfers in Elbow Injuries

In this article, nerve injuries around the elbow affecting hand function are the focus. The authors walk us through injuries for each of the three major nerves in the elbow, forearm, and hand. These three nerves (radial, ulnar, median) can be cut, pinched, crushed, or stretched in ways that leave the hand useless or less than functional.

Knowing when to repair the problem versus reconstruct the damaged anatomy is a challenge for the hand surgeon. Use of nerve or tendon transfers early is advised with there are signs that motor function won’t occur, rehab will be lengthy, or recovery just isn’t possible.

Nerve transfers as a treatment option aren’t new but recent improvements in the way this surgical procedure is done has made it a more viable option now. Patients gain better and faster improvements when the procedure is done early on after injury. And the recent success with nerve transfers comes without the need for long, extensive retraining afterwards.

The type of injuries discussed in this article includes high-energy, traumatic cuts to the nerves. These injuries are usually the result of accidents with knives, saw blades, or hunting rifles. When planning treatment and considering all the options, the surgeon tests each patient’s sensory (feeling) and motor (movement) function below the level of the nerve injury.

All muscles (and their attached tendons) are tested for loss of function against gravity and against resistance. Grip and pinch strength are measured. Special tests for sensation are carried out. The results of all these tests can serve as a baseline against which treatment results can be compared. The tests are easily repeated anytime along the way.

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

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

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

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

The location of the nerves and anatomy around the nerves are often direct factors in nerve injuries. For example, the radial nerve is close to the bone so any bone fractures near the nerve can end up cutting the nerve. The ulnar nerve is susceptible to scarring because of the thick fascial structures around it. Once damaged and no longer able to move, slide, and glide, the connective tissue can close around the nerve further constricting it.

The authors discuss timing and technique for these transfers for each of the three nerves around the elbow (radial, ulnar, median). They describe which tissues are used to replace these three nerves and tendons affected by them.

Reviewing studies reporting results from using these transfer techniques, they report excellent outcomes with almost normal finger and hand function. Factors that affect outcomes include patient age, time between injury and surgery, and extent (severity) of damage.

The authors conclude by saying that nerve injuries high up around the elbow can cause significant paralysis with loss of sensation and function of the hand. Early nerve and tendon transfers when indicated by testing can provide the return of significant hand and finger function. And that is vitally important for people who require specific hand functions for their jobs or life activities.

Biceps Tendon Ruptures in Both Arms

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

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

So what’s going on for these individuals? Is it a fluke that they tear both biceps muscles? Or is there some reason why they would experience the same type of injury on both sides? By taking a backward look at this large case series (321 patients), the authors of this article may have some new insight to share about this problem.

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

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

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

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

Whatever the cause, this study confirms it’s more than a coincidence that bilateral distal biceps ruptures occur. Patients who have the first biceps tendon rupture may be at increased risk for injury to the other arm. More study is needed to fully identify predictive risk factors that might help with prevention of these injuries.

New Treatment for Tennis Elbow

Steroid injections are no longer routinely recommended for lateral epicondylitis (tennis elbow). Instead, physical therapists offer an alternative treatment in the form of something called iontophoresis.

In this article, the use of steroid injection is compared with iontophoresis delivered in two different ways. Iontophoresis uses a small electric current to drive steroid medication through the skin. It is a noninvasive method of reducing the pain of tennis elbow.

Iontophoresis has traditionally been administered in a hands-on process by the physical therapist. The procedure could take anywhere from 20 minutes up to an hour. But now a new battery powered skin patch has been developed that leaves the therapist free to spend treatment time on other aspects of rehabilitation.

Eighty-two (82) patients participated in this study. Each one had a diagnosis of lateral epicondylitis. They were divided into three groups. Group one had the self-contained skin patch placed over the lateral elbow (side away from the body). The patch was left on for two days.

Group 2 received an injection of the same medication used in group one (10 mg dexamethasone). One injection was given into the extensor tendon-muscle along the lateral elbow. Group 3 received a 10 mg injection of a steroid (triamcinolone) to the same extensor area of tendon-muscle.

Steroid injection has fallen out of favor for the treatment of lateral epicondylitis but is still used by some physicians. The disadvantages of steroid injection include only short-term pain relief and disruption of the body’s natural healing process.

Steroid injections do not change the underlying pathology. And in the case of degenerative rather than inflammatory epicondylitis, steroids can actually delay healing. Since iontophoresis and steroid injections are all antiinflammatories, the question has been raised: why use them if there’s only a short-term benefit with potential drawbacks?

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

It is also possible that it’s not the medication itself that is the problem but rather the method of delivery. That’s what makes this study valuable: comparing three different delivery methods of the same or similar medication.

Results showed that the two groups treated with iontophoresis got better faster than the steroid injection group. The best clinical outcomes were in the skin patch iontophoresis delivery. But at the end of six months, pain relief, grip strength, and hand function were the same for all three groups.

There were some treatment failures but they were evenly distributed in all three groups. The patients in the iontophoresis group received by skin patch were able to return-to-work sooner and with fewer restrictions compared with the other two groups. Overall, battery delivered iontophoresis provided faster results than the injection groups. This may be evidence that the method of drug delivery is an important factor as suspected.

Future studies are needed to compare patients who receive no treatment with those who are given a placebo iontophoresis treatment. It’s important to sort out the real reason(s) why some patients improve while others don’t (or improve at a slower rate).

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

Treatment of Nerve Injuries Follows the “Rule of 18”

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

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

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

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

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

For every month surgery is delayed, one inch of restored motor function may be lost. In other words, say the repair is done six months after the injury. Motor recovery is possible up to 12 inches from the level of the injury. When making the decision when to do surgery, the surgeon also takes into account the type of injury, the patient’s age, and the nerve(s) involved.

Bone fractures of the forearm are most likely to cut into the radial nerve. Sometimes surgery to repair the fracture is actually the cause of the nerve injury (e.g., a pin or screw used to hold the bone fragments together pierce the nerve).

The ulnar nerve is close to the surface of the skin and most likely to be damaged due to direct injury. This is the nerve that causes pain when you hit your “funny bone” (the bony bump of the elbow closest to the body). Damage to this nerve often requires a procedure called nerve transposition. The surgeon has to move the nerve away from the bone where it is being bumped or compressed.

Thumb function depends on the median nerve. Surgery to perform a nerve or tendon transfer is advised if the median nerve has been damaged high up by the elbow or if the injury is severe enough to compromise thumb movement. The median nerve also provides sensation to most of the hand so full recovery is not complete until 18 months at the earliest. Continued sensory recovery can take two years or more after nerve repair.

Any one of these nerves can be sewn back together if it is damaged by a clean laceration (cut) through the nerve. This is called an end-to-end repair. Nerve grafting is more likely when there has been a crush injury to the nerve. The area crushed is removed and a piece of donor nerve is used to replace the crushed portion.

Nerve transfers are used when it’s clear that the sensory and/or motor function to the hand isn’t going to be restored. Certain extra branches of nerves can be separated and divided to be used in place of the lost nerve without losing motor function at the site of harvest.

Some surgeons suggest early surgical treatment is better. Instead of waiting to see what kind of recovery occurs spontaneously, the surgeon performs a tendon transfer to improve hand function. Maintaining hand movement during the period between injury and recovery may yield better results compared with the wait-and-see (sometimes until it is too late) approach.

The authors conclude by saying that planning treatment for nerve injuries can be a complex and challenging process. The surgeon must take into consideration which nerve was injured, the location and severity of the lesion, the patient’s age, and the rule of 18. They agree that tendon or nerve transfers should be done sooner than later if the surgeon’s assessment is that recovery will be significantly delayed or not occur at all.

Options for the Middle-Aged with Elbow Arthritis

Middle-aged adults with elbow pain, loss of motion, and stiffness from osteoarthritis are too young for a joint replacement. Where does that leave them? In this article, hand surgeons from the Hospital for Special Surgery in New York City review the evidence for various surgical procedures to address this problem.

They use the case of a 46-year-old man with osteoarthritis of the elbow to discuss surgical treatment options for the middle-aged adult. This particular patient had obvious arthritic changes of the elbow as seen on X-rays. Although he can bend the elbow, extension is very limited making for some difficulty with daily activities and self-care.

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

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

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

The hand surgeons who authored this article tell their patients to expect “modest” and “unpredictable” improvements. They are honest and forthright in saying the osteoarthritis won’t go away but will get worse over time. For these reasons, they encourage further research to find better ways to treat this problem. Understanding the underlying cause and pathology of the disease might help scientists find a way to prevent the disease in the first place or at least stop the progression of disease once it starts.

For now, they advise open release and debridement with special care to avoid damage to the ulnar nerve. Without enough evidence to show that results are better with arthroscopic techniques, they prefer the ability to see and protect the nerve using the open approach.

First Study to Report Long-Term Results of OAT Treatment for the Elbow

Athletes involved in lifting heavy weights, repetitive elbow motions, or overhead activities are at risk for a condition called osteochondral lesions. Osteochondral lesions refer to damage or defects to the joint cartilage (chondral) that go all the way down to the first layers of bone (osteo). Holes in the osteochondral layer and/or loose fragments of bone and cartilage in the joint can cause pain, locking of the joint, and eventually osteoarthritis.

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

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

That’s why the surgeons from Germany who published this study are still pursuing a new approach called osteochondral autograft transfer. They have studied and written about the short- and mid-term results of this treatment for a group of eight patients. This is a continuation of those studies with follow-up eight to 14 years after surgery.

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

The group being studied and followed long-term consisted of four men and four women between the ages of 15 and 21. All were athletes engaged in competitive sports including volleyball, soccer, gymnastics, tennis, basketball, and skiing. All had “failed” six months or more of conservative care. Failure of nonoperative care means despite all efforts, pain, decreased elbow motion, and loss of function persisted.

As with the other surgical techniques to treat this problem, there is concern that degenerative changes will occur years later causing painful and debilitating osteoarthritis. In this study, the patients were followed at regular intervals to measure and observe results. X-rays, MRIs, pain analysis, and the American Shoulder and Elbow Surgeons (ASES) score were used to assess condition of the damaged elbow joint, pain levels, range of motion, and function.

Results were considered excellent. MRIs showed good coverage of the defects with full incorporation of the graft. Some slight changes were seen with mild bone edema (swelling) in one patient and bone cysts in two others. But the joint space was open and free for each patient and only two patients had any signs (all mild) of osteoarthritis 10-years later.

All eight patients were pleased enough with the procedure they said they would have the same surgery again if given the choice. They were all able to return to sports without any limitations. The biggest problem reported was knee pain from the donor graft site but this wasn’t enough to stop them from doing what they wanted to do in terms of daily activities or sports participation.

The surgeons concluded that the use of osteochondral autograft transplantation (OAT) is a successful treatment option for severe osteochondral lesions of the elbow. The overall long-term results were better for this treatment than results reported for other treatment approaches (e.g., microdrilling, debridement).

This treatment is also an option for patients who have tried other surgical treatments that failed to bring satisfying results. The goal of returning to full participation in sports was met. Those patients who changed sports activities or level of participation did so because of age or work requirements, not because of the previous elbow injury.

The authors make note of the fact that their study did not include baseball players engaged in repetitive throwing motions. Since osteochondral elbow lesions are fairly common in this group of athletes, a similar study is needed to see if the results would be equally good in that patient population.