News Category: Elbow

Believe it or not, a wait-and-see approach is still the best way to treat lateral epicondylitis, more commonly known as tennis elbow. What? You say you’ve had acupuncture and it worked fine? Or maybe you saw a physical therapist and recovered nicely. Some people swear by steroid injections. Others have tried laser therapy.

But what’s the evidence that any of these outperform the others? Or that anything works better than letting nature take its course over time? Dr. R.M. Szabo, Professor of Orthopaedics and Plastic Surgery at the University of California, Davis, School of Medicine took the time to research various treatment approaches to lateral epicondylitis and present a summary in this review article.

After looking at all the evidence around each of these modalities, Dr. Szabo’s found that the wait-and-see approach still has merit. Tennis elbow will go away on its own with time and activity modification. Most people get annoyed that this condition gets in the way of the things they want to do (golf, fish, play tennis). They would rather have a quick fix (e.g., steroid injection) than wait around.

But the evidence suggests that lateral epicondylitis is common in adults in their 40s and 50s. Steroid injections may actually delay tissue healing, thus prolonging the course of recovery. And until research can show one treatment works better than any others, the cost of intervention may not be justified.

You may ask: what about some of these newer treatments like laser, BOTOX, or shockwave therapy? Aren’t they supposed to use today’s technology to get the physiology back on track for healing? Yes, but — results from high-quality studies has been inconsistent. When compared with placebo treatment, some patients get better, others don’t.

Other studies have compared shockwave therapy to steroid injections. Shockwave therapy stimulates the release of growth factors to get a healing response at the local tendon. Steroid injections bathe the disrupted tissue with a numbing agent and an antiinflammatory. Steroid treatment is less expensive than shockwave therapy and more successful, but there is still the downside of steroids to consider. Besides the potential for delayed healing with steroids, post-injection pain is reported as worse than preinjection pain for half the patients studied.

Acupuncture for back pain has gotten a lot of press lately as being effective. How well does it work for tennis elbow? After analyzing all the data currently available, it looks like acupuncture provides short-term relief of pain. It certainly works better for pain control than doing nothing. But there isn’t enough proof that the results last more than 24 hours. So making it a top choice for treatment isn’t advised.

Similar results were found using botulinum toxin type A (BOTOX). This agent temporarily paralyzes the troublesome tendon (common extensor tendon). A single injection gives short-term pain relief but doesn’t change the long-term outcomes. Pain, weakness, and reduced activity are still reported as equal in results when compared to other treatments such as steroid injections or surgery.

So, where does that leave us? Back where we started: letting the condition run its full course until the body heals itself. How long does that take? Well, scientists understanding that this is the situation is fairly new. Studies looking at the natural history of lateral epicondylitis suggest perhaps as much as a full year may be required for complete resolution of the problem.

Physician may be tempted to give in to their patients’ demands for injections, but the evidence just isn’t there to support this idea. Patient education and support may not be a popular approach, but until clear or consistent evidence to suggest otherwise is available, that’s the current guideline for best practice.

The authors say this is the first clinical study of the results of surgery for repair of a biceps tendon rupture allowing early elbow motion. Why is that so important? Most rehab protocols require a week or more of immobilization before allowing a gradual increase in active motion. The thinking behind the conservative approach is that the body needs time to allow tendon ingrowth into the bone. Too much stress too soon could disrupt the surgical site.

But surgeons have noticed that patients who don’t follow their instructions and return to aggressive activities earlier than they should, seem to do just fine. In fact, no matter how the injury is treated in the postoperative rehab program, everyone seems to have the same results. And rerupture is rare.

So, what if they protect the repaired tendon for one or two days and then start moving it? That’s the approach two surgeons at the Mayo Clinic in Rochester, Minnesota took with 21 (male) patients. Everyone in the study had a complete acute distal biceps rupture. Distal means the biceps tendon pulled away from the bone where it inserts at the radius (forearm or elbow) bone. Rupture at the opposite end (up at the shoulder) would be considered a proximal rupture. Acute for this study meant the injury happened within the last six weeks before surgery.

The surgical repair done was a 2-incision suture repair reattaching the retracted biceps tendon with transosseous sutures. Transosseous means through the bone, specifically the radial tuberosity. The radial tuberosity is a bump on the radius where the distal end of the biceps normally attaches.

Since the surgeon can’t just glue the tendon back where it belongs, the end of the tendon is attached to a suture, the needle is pushed through the radius, and out the skin on the other side. The suture is then tied over a button outside the skin. Transosseous sutures have been shown to be stronger than suture anchors. Using this type of suture allows for more aggressive early motion and an early return to full motion.

In this study, patients discontinued using the sling after the second day and started moving the elbow and forearm. They were allowed to actively flex and extend the elbow as far as they could comfortably. They were instructed to try and regain as much flexion as possible. Forearm rotations (supination/palm up and pronation/palm down) were restricted to passive range of motion at first. They gradually progressed to active movement.

There was a one-pound weight restriction (i.e., don’t lift or pick anything up that weighs more than 16 ounces or one pound). Otherwise, daily activities were only limited according to what the patient could tolerate or felt comfortable doing. After six weeks, they were allowed to lift two-pounds with a gradual increase in weight lifted. By the end of three months, full strength was expected with unrestricted lifting.

Everyone was followed for at least two years. Some patients were seen for as long as seven years. Results were measured using range-of-motion, strength, and function. Strength was tested in various ways — with the elbow in 90 degrees of flexion and neutral forearm rotation, using isometric muscle contractions, and using isotonic contractions.

The surgeon also checked for biceps integrity using a special clinical test called the hook test. This test is done with the patient’s forearm in supination (palm up) and the elbow flexed 90-degrees. The examiner tries to hook his or her index finger under the biceps tendon from the lateral side (out side of the elbow, away from the body). With an abnormal hook test (indicating distal avulsion of the biceps tendon), there is no cord-like structure under which the examiner may hook a finger.

The patients were also asked to rate the success of the surgery. It was a satisfactory result if the elbow was better than before surgery and/or if they would have the same surgery again. Everyone was satisfied with the results and returned to work with no problems. Some patients were white-collar workers with desk jobs. Most were employed in jobs requiring heavy use of their arms. More than half were involved in sports before the injury.

Full strength was regained in elbow flexion but not forearm supination. It didn’t seem to matter whether the involved arm was the dominant or nondominant hand. Supination strength was affected equally in either case.

One of the variables the authors discussed in this article involved the one-incision versus the two-incision approach to this surgery. Although their study did not include or compare the one-incision method, they noted that there are no real guidelines for rehab and recovery after each procedure.

Most of the time, there is a long period of immobilization (up to six weeks). Concern that the elbow will get stiff without enough movement is one reason surgeons are looking at the effect of introducing movement early on after surgery. The use of immediate active motion in this study is considered fairly aggressive. But patients did well regaining motion and strength without losing function, rerupturing the healing tendon, or gaining a stiff elbow.

The inability to restore full strength in supination remains a mystery. Several theories have been put forth based on altered biomechanics of the repaired tendon, but nothing has been proven yet. For now, it looks like this modified mini-2 incision distal biceps repair is maintained even with early elbow range of motion. Patients like it because they can get back to their regular activities faster with less inconvenience from an immobilized arm.

Debate has been ongoing since as far back as 1756 about the role of the brachioradialis muscle in movement. Some say that it just flexes (bends) the elbow. Others insist it helps rotate the forearm to turn the hand palm up (supination) or palm down (pronation). The results of this study may put the arguments to rest.

The brachioradialis muscle goes from the lateral (outside) part of the lower humerus (upper arm) down to the wrist. At the wrist it attaches to the lateral aspect of the radius (one of the two bones in the forearm).

This study was done in a musculoskeletal laboratory at the University of Kentucky. Ten normal, healthy volunteers were recruited. None of the subjects had any prior health problems or forearm injuries of any kind. No one had a previous history of surgery or known arthritis of the elbow. Everyone was willing to have needle electromyography (EMG) testing done.

Once the fine-wire needle electrodes were implanted, testing was done. Each person performed a series of elbow movements while hooked up the EMG. The EMG was connected to a computer software program. In addition to measuring electrical impulses of the muscles, the data collected was able to show the percentage of maximal muscle activation and time of maximal activation during each task.

Testing was done with elbow flexion and rotation. Flexion was done with the forearm in one of three different starting positions (pronated, supinated, and neutral). Neutral means the hand was in a thumbs up position with the elbow bent to 90 degrees at the subject’s side.

Rotation was measured in two phases: supination to neutral and pronation to neutral. All motions were tested and measured with four different loads. The various loads were designed to mimic daily activities (e.g., lifting a gallon jug of milk or a bag of groceries). Heavier loads could be used during elbow flexion compared to forearm rotation.

The subjects went through five repetitions for each position and load. A metronome (device used to set a beat) was used to help each person keep a steady pace throughout all the movements. The speed was set so that movement occurred at 130 degrees of flexion per second. Frequent, regular rest breaks were built into the test protocol to avoid over fatiguing the muscles.

The scientists set out to test four things: 1) difference between pronation, supination, and neutral forearm positions during elbow flexion, 2) difference in EMG amplitudes during different phases of muscle contraction during elbow flexion, 3) when the brachioradialis is activated the most, and 4) determine the primary (main) role of the brachioradialis and any secondary role present.

Here’s what they found out. The main role of the brachioradialis muscle is to flex the elbow (starting from an extended position). This movement is called concentric elbow flexion. In addition, the brachioradialis does indeed, work as a forearm rotator.

In particular, it assists in concentric forearm pronation. It also has an eccentric role moving the forearm from a neutral position back to a supinated (palm up) position. Moving to a palm up position is an eccentric movement. This means the brachioradialis works to slow down (control) the movement. These results actually confirm the first hypothesis about the function of the brachioradialis first suggested by a man named W. Cheseden in 1756.

Why does it even matter what the brachioradialis do? There have been an increasing number of brachioradialis injuries lately. Rock climbers seem to be at greatest risk. But anyone doing any lifting with the elbow flexed and rotated can be affected. Less often, there are cases where injuries of other muscles result in weak elbow flexion. Surgeons looking for a muscle they can transfer to do the work of the main elbow flexor (biceps muscle) may want to consider using the brachioradialis.

Studies like this help surgeons understand what functions might be affected if the brachioradialis is used to replace another muscle/tendon unit. Analyzing the patient’s activities and needs for movement, strength, and function can help guide the decision in tendon transfer procedures.

Athletes involved in overhead throwing sports are at risk for a problem at the elbow called osteochondritis dissecans (OCD). Baseball pitchers and racket-sport players are affected most often. Sometimes gymnasts who put weight through the arms develop this condition, too. It can be very disabling. Treatment that enables them to return to full participation in their sport is a challenge.

The forceful and repeated actions of these sports can strain the surface of the elbow. Specifically, the capitellum is affected. The capitellum is a knob at the end of the humerus (upper arm bone). It forms the upper part of the elbow that fits into the cup-shaped depression on the head (top) of the radius bone. The radius runs from the outer edge of the elbow down the forearm to the thumb-side of the wrist. The joint formed by the connection of these two bones is called the humeroradial joint.

With repetitive shearing and compressive force on the capitellum, the bone under the joint surface weakens and becomes injured. This, in turn, 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. The result is osteochondritis dissecans (OCD).

If the condition isn’t treated or if treatment fails, the humeroradial joint can become unstable. The articular surface of the radial head is made of stiffer cartilage than the cartilage of the capitellum. Some experts say that’s why the capitellum side of the joint is affected rather than the radial head side. However, as the capitellum breaks down, the humeroradial joint can shift and even dislocate.

The two main goals in treatment are to regain pain free elbow motion and function (short-term goal) and prevent osteoarthritis from developing later (long-term goal). Conservative (nonoperative) care isn’t always successful meeting the first goal. Despite a long period of rest from throwing or weight-bearing, very few patients make it back to their sports activities.

And even with surgery to remove or reattach the broken pieces, very few athletes are able to return to full sports participation. For this reason, newer methods of treatment are being explored. Autologous osteochondral mosaicplasty is one approach that may help athlete regain full function again.

In the mosaicplasty procedure, the surgeon takes plugs of bone and cartilage from the patient’s knee and transfers it to the elbow. The word autologous refers to the fact that the graft comes from the patient (not from a donor). This method sounds good in theory. But there are some questions about using cartilage from one joint to help heal cartilage in another joint. Is the knee cartilage the same stiffness as the elbow cartilage? Will it hold up under repetitive force?

In this study, ultrasound is used to assess the tissue quality of the plugs before and after grafting. This may be the first study evaluating the material properties of autologous osteochondral plugs transplanted in humans (a fairly uncommon procedure). Material properties refer to stiffness or roughness of the cartilage.

The advantage of ultrasound imaging is that it can measure cartilage stiffness, roughness, and thickness. Degeneration of the articular cartilage can be determined from the signal intensity, duration, and interval. For example, decreased signal intensity and prolonged signal duration are two indicators of cartilage degeneration.

Ten young (ages 10-19) male baseball players were tested. They all had been diagnosed with osteochondritis dissecans and treated with autologous osteochondral mosaicplasty. Various ultrasound measures of cartilage were taken. The researchers tested the healthy cartilage of the capitellum, the OCD lesion, the radial head, the donor site in the knee, and the osteochondral plug after grafting.

Here’s what they found:

When someone dislocates their elbow, it can be classified as simple or complex. The difference is whether there are any fractures around the elbow or not. If there aren’t any fractures, usually the elbow is treated conservatively, without surgery. Most often surgery is only done if the elbow can’t be reduced (put back into place) or if the elbow is very unstable.

The elbow is a complicated joint. It moves up and down and side to side. The radial head, where one of the forearm bones meets the elbow, is used to stabilize stress and force that is placed on the elbow. It also helps distribute the weight load. The ligament in the elbow helps hold the bones together and keep them stable. It allows the elbow to bend and straighten out again. If the ligament is torn, it can cause pain and instability in the joint, making it difficult to move. The muscles around the elbow stabilize it, but needs the ligaments to hold the elbow together first. Injury can force the muscle away from the elbow, leading to more destabilization.

When doctors assess a patient for a dislocated elbow, they must do so quickly because timing is important. If an elbow is dislocated, it could be pressing on blood vessels or nerves in the area and if this left too long, could cause further damage. Therefore, if there is any sign of this (numbness, inability to move the fingers) and the elbow is dislocated, it should be reduced as quickly as possible.

X-rays need to be done to rule out any other damage to the bones around the elbow and if there is no further injury, then the elbow can be reduced with the patient under a general anesthetic. After the elbow has been reduced, the doctor will move the elbow around to see if it will dislocate again or if there is a difficulty with moving it. If the elbow can’t be stabilized or there seems to be a problem with the range of motion, then surgery will still be needed.

Not many studies have been done comparing the outcomes between patients who had surgery and those who didn’t. One done by Josefsson and colleagues didn’t find a significant difference although there were a few patients who had surgery who had some trouble straightening out their arm completely and some patients who didn’t have surgery who had pain in the elbow for quite a while after.

The author of this article suggested that some patients who wouldn’t normally be referred for surgery may do better with surgery than conservative treatment. This would include patients who also tore the stabilizing ligament when injuring the elbow. This allows the surgeon to reconstruct the ligament and provide stability to the elbow. Of course, elbows with fractures do require surgery.

In conclusion, the author writes that even if the elbow has been reduced without surgery, it is important to do a close follow up to ensure the elbow is stable.

Athletes who put a tremendous amount of pressure on the elbow in a throwing movement, such as baseball and softball pitchers, javelin throwers, tennis players, and wrestlers, are at risk of an injury of the ulnar collateral ligament, a ligament in the elbow. This type of injury can be career ending but in the early 1970s, a surgeon, Dr. Frank Jobe, saved the career of baseball pitcher Tommy John, by reconstructing the damaged ligament. The surgery has been called Tommy John surgery ever since. Over the years it been adapted and improved to help many more athletes regain use of their elbow.

There three sections to the ulnar ligament, the posterior bundle, the anterior bundle, and the transverse bundle (the front, the back and across). When a pitcher throws the ball, there is an intense force placed on the ligament each time. As well as the stress on the ligament, there is also a great stress on the joint itself, which is caused valgus extension overload syndrome.

In order to diagnose the ligament injury, the surgeon needs to review the patient’s history, when the pain started, when it happens the most, and whether the pain is only when throwing or if it occurs during other activities too. The typical complaint with ulnar ligament damage is complaints of pain when the arm is cocked, ready to throw, and as the arm picks up speed before throwing the ball. Patients can also complain of numbness in the hand and fingers or radiating pain down the forearm.

Testing can include palpating, pressing, over the ligament with the elbow bent between 50 and 70 degrees. If this causes pain or is tender, this is a sign of ligament damage. To surgeon also tests for elbow stability. X-rays are also important to see if there are any abnormalities in the bone. A stress x-ray should be done as well but of both x-rays so the surgeon can compare the two.

To treat this type of injury, if the tear is only partial, the usual treatment is resting the elbow from the stressful activity, usually between two and six weeks. Ice is used to help reduce inflammation as are anti-inflammatory medications. The patient shouldn’t use a throwing motion at all during this healing period. If the patient is pain-free after the rest, he or she can begin throwing again provided the strength and range of motion are there. Sometimes, complete ligament tears are treated without surgery too, but this is only for patients who will not return to the previous sport or activity that will place the stress on the elbow.

If surgery is needed after rest and nonsurgical treatment don’t eliminate the pain, it used to be that surgeons just repaired the ligament. However, this wasn’t very effective and surgeons began reconstructing the ligament using grafts. This was a much more successful approach and allowed many (over 80 percent) athletes to return to their sport.

There is a newer surgical treatment that is being tested. It involves a docking technique with a screwed down graft. This technique seems to provide a more natural rebuilding of the ligament and has been showing some good results in clinical trials.

Research is continuing in an attempt to prevent these injuries in the first place. One finding is that if children don’t throw curveballs, they limit their risk of injuring the elbow. As well, in many children’s baseball leagues, the pitchers are only allowed to pitch a maximum number of pitches and must not pitch a certain number of games within a specific time period.

The authors of this article have found that an athlete who pitches or forces his or her elbow to perform sudden and forceful movements is at high risk for a ligament injury, but surgery for rebuilding the ligament has seen good results with over 80 percent of athletes returning to their level of play or even higher.

When someone develops a stiff elbow that’s stiff enough to interfere with range-of-motion and functioning, treatment is usually needed. Some people may not bother seeing a doctor because elbows often don’t have to have full range of motion to be used effectively. Most activities require the elbow to bend between 30 degrees and 130 degrees – neither full bend or full extension usually. However, depending on the activities you do, you may need the full extension or flexion (bending).

The elbow has three distinct sections called the single synovial capsule, the ulnotrochlear joint, and the proximal radioulnar joint. These are what allow the elbow to make the movements it can.

When an elbow is stiff, it could be caused by any one of a number of reasons that are intrinsic or extrinsic (from inside or outside forces). Extrinsic factors can include contractures (tightening of the tissues that normally allow your to open and close your elbow angle, by issues with the bones, such as bones not healing after a fracture, (nonunion), or even the skin that can scar badly after a burn, for example, causing the elbow to contract. Intrinsic causes include illnesses like arthritis or something internal that changes the structure of the joint.

A stiff elbow isn’t necessarily painful, but if there is pain, when it occurs is an important clue to determining why it’s stiff. For example, if the pain is only present when the elbow is actually bending, this may tell the doctor that the problem is an intrinsic one. The doctor will need to know information such as the patient’s general health, if there was any trauma at all, even the slightest one can be significant if the patient has an illness such as diabetes.

X-rays will help see if there is any damage to the joint and stress x-rays may help the doctor see if the elbow is stable and a CT scan (computed tomography imaging) may also be helpful. Occasionally, an MRI (magnetic resonance imaging scan) will be done to check for soft tissue damage that can’t be seen on an x-ray. Another issue doctors must check in to is infection. This is a possibility of the elbow is quite painful, even at rest.

Treatment of a stiff elbow depends on what the cause is. If a patient has osteoarthritis of the elbow, the so-called wear-and-tear arthritis, the doctor knows that the joint is still intact and can work with that. On the other hand, if the cause is due to pieces of bone breaking off and lodging in the joint, surgery will be needed to remove those pieces. Surgery may also be needed to release contractures or to remove tissue that may be pressing on the ulnar nerve, the nerve that passes down through the elbow.

If it’s decided that a nonsurgical approach will be taken, one study, done by Doornberg and colleagues, found that progressive splinting of the elbow helped increase the elbow’s ability to bend, but the trick seemed to be that the splinting had to be done as soon as possible after the splinting rather than after an old injury.

When treating children, doctors are concerned about poor and unpredictable results. Researchers Madel and colleagues did perform surgery on the elbow in teens and, although the surgery itself was complicated, the results seemed to be promising.

The advent of arthroscopic surgery, where tiny incisions are made and surgery is done with long instruments that reach inside the incisions, has been good for elbow surgery. This allows surgeons to remove tissue from the elbow without making large incisions. If the elbow is stiff because of a trauma or injury, the results were best if the surgery was done within one year of the injury.

Finally, Botox may also be a form of treatment for stiff elbow. By injecting Botox into a severely contracted elbow, the elbow may relax.

This article’s author suggests that the focus needs to be on preventing stiff elbow to begin with. If a patient presents with an elbow injury, there is an increased risk of developing a stiff elbow if the problem was caused by major elbow trauma or burns, for example.

You may have heard of (or even seen) the Popeye deformity that occurs when the biceps tendon ruptures or pulls away from the inside of the elbow. The tendon retracts (coils away) from the bone, leaving the muscle bunched up and looking like Popeye’s big bicep in his skinny arm. Popeye was a famous cartoon character (a sailor) shown on television in the 1950s and early 60s.

Distal biceps rupture isn’t rare, but it doesn’t happen very often. Middle-aged men lifting weight beyond their strength are affected most often. Tobacco use seems to be a major risk factor. Besides the obvious Popeye deformity, the patient reports elbow pain with activity, weakness, and loss of motion.

The mechanism of injury is usually a violent, eccentric contraction. An eccentric contraction occurs when an already fully contracted muscle starts to lengthen. With a biceps tendon rupture, this means the biceps tendon was contracted putting the elbow in a position of flexion. Then as the elbow extended, the biceps lengthened. Sudden extension, especially with a weight in the hand can result in this type of biceps rupture.

This type of injury usually requires surgery right away. The surgeon finds the retracted tendon, pulls it back down, and reattaches it to the radial tuberosity. The radial tuberosity is the bony bump on the radius bone of the forearm where it meets the humerus (upper arm bone) to form the elbow. That’s the site of the original distal biceps insertion.

This procedure is considered an anatomical repair because it restores the tendon to its original site. If the surgery is delayed for a long period of time (18 months or more), then an anatomical repair may not be possible. The tendon retracts too far and then gets bound down in scar tissue.

In chronic cases of this type, the surgeon performs reconstructive surgery. A graft is used to make up the distance between the stump (end) of the retracted tendon and the elbow where it is reattached. The surgeon must carefully remove scar tissue from around the tendon and nerve in the forearm, and then gently stretch the tendon as far as it will go before attaching the graft. The graft comes from the hamstring or Achilles tendon. It can be an autograft (taken from the patient’s own body) or an allograft (someone else’s tissue from a donor bank).

In this article, surgeons specializing in sports injuries report on one case of a distal biceps reconstruction performed four years after the injury. The patient was in his late 30s and injured himself lifting weights.

He didn’t have the surgery at first because he wasn’t bothered by the injury. But over time, the pain with daily activities and loss of function, strength, and endurance brought him in to see the sports specialists.

The surgeons described their findings and surgical technique. A single S-shaped incision was used. They found a mass of scar tissue around the retracted biceps tendon and next to the lateral antebrachial cutaneous nerve (nerve along the front and side of the elbow). The surgeons harvested a hamstrings graft from the patient, wove it in with the biceps stump, and used an EndoButton to hold the graft in place. Fluoroscopy (a special type of imaging) showed that the EndoButton fixation was in the right place for optimal results.

The outcome was so good, the patient opted to have the other arm repaired as well. He was pain free, regained his strength, and improved his motion (especially elbow flexion) to normal. At the end of one year, his biceps strength for elbow flexion and forearm supination (palm up motion) was about 86 to 87 per cent of normal.

There have been other reports of delayed surgery for this type of injury. But this was the first published so long after the initial injury (four years). The surgeons conclude that although there are many different ways to perform this operation, the reconstructive technique described here is very successful and therefore recommended.

Only 25 cases of chronic exertional compartment syndrome (CECS) have ever been reported. This is number 26 reporting on CECS affecting the volar side of the forearm. Volar refers to the flexor under side of the forearm.

Compartment syndrome is an acute medical problem. Pressure within the compartments of the forearm builds up and cuts off the blood supply to the muscles. The increased pressure occurs as a result of inflammation after an injury, surgery, or in most cases, repetitive overuse of the muscles.

There are six known compartments in the forearm. Three on the extensor (back) side and three on the volar (flexor or under) side. In the forearm, the volar compartment is affected more often than the extensor compartment.

Fascia (sheaths of connective tissue) separate the compartments. It’s these bands of fibrous tissue that constrict the space. Inflammation in the confined space (fascial compartment) takes up any extra space. Muscles cannot contract and expand. Increasing pressure keeps the cycle of pressure – restriction – blood loss – inflammation – pressure going.

Without prompt treatment, nerve damage and muscle death can occur. This condition is seen most often in the lower leg, but can affect the arm as well. In this report, the case of a 27-year-old Olympic flatwater kayaker was presented. His symptoms started out as left forearm pain and weakness that went away with rest and got worse with activity.

Over time, symptoms started developing even when he wasn’t kayaking or training. Eventually, he was no longer able to train and compete. He was evaluated at the Rush University Medical Center (Division of Sports Medicine) in Chicago. A history and physical exam led to the diagnosis of exertional compartment syndrome.

Surgery was performed to release the restricting fascial bands. The procedure is called a fasciotomy. The surgeon had the patient perform resisted forearm exercises right before surgery. Exercising right before the fasciotomy made it easier for the surgeons to identify what compartments and soft tissues were affected most.

Tight, restrictive fibrous bands were released until there was no fascial restriction and no tense muscular swelling. The patient experienced immediate relief of symptoms. Once the stitches were taken out, a rehab program was started. The athlete slowly regained flexibility and strength through stretching and strengthening exercises. He was able to return to training by the end of six weeks.

A follow-up check two years after surgery showed the patient was completely recovered and involved in Olympic trials and training. There was no concern that the condition might return. The surgeons noted that the compartment syndrome probably developed late in this athlete’s career because of a pre-existing injury. It looked like a previous forearm injury resulted in the formation of the fibrous bands. Over time and with training to strengthen the forearm muscles, these bands eventually restricted forearm muscles leading to the compartment syndrome.

Most patients with compartment syndrome have been engaged in activities requiring significant demand on the muscles of the forearm. In the previous 25 cases of forearm chronic exertional compartment syndrome reported, patients have included manual laborers, rock climbers, tennis players, and weight lifters.

Because of the potential seriousness of the condition, anyone working with athletes (and athletes themselves) must be aware of the symptoms of compartment syndrome. Seeking medical attention sooner than later can result in early intervention, potentially preventing damage and long-term consequences. This patient was able to return to elite-level training and competition. A wonderful success story.

Pressure on a nerve can cause entrapment leading to symptoms such as pain, numbness, and/or weakness. Two of the most common nerve entrapment syndromes are carpal tunnel syndrome and cubital tunnel syndrome. A new diagnostic test for these conditions is now available.

Carpal tunnel syndrome is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of carpal tunnel syndrome.

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.

Making the diagnosis for either of these nerve entrapments can be difficult. The physician relies on the patient’s history, clinical presentation, and results of specific tests. Most of the tests depend on the patient’s subjective response to provocative tests. The examiner taps over the nerve or places the arm, wrist, and/or hand in a position that makes the symptoms better or worse. These tests are provocative because they can irritate an already compromised nerve and confirm that there is a problem.

Electrodiagnostic tests can also help make the diagnosis. Electrical energy passed through the nerve is measured. A lag time in nerve messages sent to the skin (sensory) or to the muscles (motor) is a sign that the nerve isn’t functioning properly. But nerve conduction tests of this sort aren’t always accurate enough.

With all of these tests, patient responses can vary widely. Studies of test sensitivity and specificity have not found one test that is both sensitive and specific. Sensitivity means the test shows a true positive when there’s a problem. Specificity refers to the ability of the test to also show a true negative (the person doesn’t have the problem). If a test isn’t sensitive enough, patients who have the problem will be missed. If the test isn’t specific enough, patients who don’t have the problem won’t be eliminated.

To overcome low sensitivity and/or low specificity, the examiner must use more than one test. After all the tests are done, then the results are compared. The physician looks for a pattern to confirm or rule out nerve entrapment. What physicians really need is one test that is both specific and sensitive to replace the whole battery of other tests.

The authors of this study suggest that the scratch collapse test may be that test. The test is done by first resisting the patient’s forearms as he or she tries to move the forearms away from the body. At the start of the test, the patient is sitting facing the examiner. The elbows are at the sides and bent 90 degrees. The palms of the hands are facing each other.

After the resistance, the examiner scratches the patient’s skin over the area of the affected nerve. For cubital tunnel syndrome, this would be along the inside of the forearm at the level of the elbow. For carpal tunnel syndrome, the skin is scratched over the palm-side of the wrist. The resistance test is repeated. A positive response for nerve entrapment is a sudden (but temporary) weakness of the forearm.

To test the scratch collapse test, the researchers compared two groups of people. One group had a nerve entrapment (either carpal tunnel syndrome or cubital tunnel syndrome). The other (control) group had no symptoms of either condition. Although electrodiagnostic tests were positive for everyone in group one, these tests were not done on the control group. Provocative tests (e.g., Tinel’s test, flexion/compression test) were done on everyone in both groups.

The scratch collapse test was also done on everyone in both groups. Sensitivity and specificity was compared for all three clinical tests (Tinel’s, flexion/compression, scratch collapse). The scratch collapse test had higher sensitivity than the other two tests for both types of nerve entrapment. Overall accuracy for diagnosing nerve entrapment was 82 per cent for carpal tunnel syndrome and 89 per cent for cubital tunnel syndrome.

Other benefits of the test include its ease of use and repeatability. The test can be done more than once without a rest. Patients don’t seem to get fatigued, so the test can be repeated to verify results. Mild-to-severe entrapment can be assessed by how severe the weakness is. The test can be used to sort out patients who might be seeking secondary gain (a money settlement) for their injury.

The authors conclude that the scratch collapse test is sensitive and specific enough to be reliable. They showed that it was also reproducible. This means the test was reliable no matter who performed it (so long as the examiner was trained to do the test). And since the results don’t depend on the patient reporting on results, it is considered a more objective clinical test. A video of this test is available at www.jhandsurg.org.

Lateral epicondylitis, commonly known as tennis elbow, is not limited to tennis players. Any activities that repeatedly stress the same forearm muscles can cause symptoms of tennis elbow. For example, painting with a brush or roller, running a chain saw, and using many types of hand tools. Reaching across the computer keyboard to use the mouse is one of the more common causes of this problem today.

Symptoms that last more than the expected time for healing can result in chronic epicondylitis. It’s not completely clear what is happening in the healing process of chronic tennis elbow. Finding out if there is bone involvement might be helpful in planning the best treatment program. In this study, bone scintigraphy is investigated as a possible diagnostic tool for chronic epicondylitis.

Bone scintigraphy looks at the distribution of blood flow and active bone. It helps show blood flow to and through the bone and shows places throughout the skeletal system where the bone is actively metabolizing. A radioactive dye (99mTc-HDP) is injected into the blood stream. Areas of high bone metabolism show a larger bone uptake of the dye. A three-phase bone scintigraphy test shows blood flow, blood pooling, and bone metabolism.

The advantage of bone scintigraphy is that changes in bone metabolism show up on the bone scan before structural changes would appear on an X-ray. Conditions such as fractures, infections, tumors, and arthritis can be recognized with a bone scan long before they can be seen with plain radiographs.

In the case of epicondylitis, bone scintigraphy can show whether or not there is a reparative process started. The test results don’t explain what is causing the problem. They just show the specific areas of bone where local bone responses are occurring.

Patients included in this study had failed to respond to conservative care including cast immobilization, oral and topical medications, heat or electrical stimulation, and steroid injections.

Everyone was seen by a physician who took a detailed medical history and completed a physical exam. Height, weight, health status, pain assessment, arm and grip strength, and motion were measured and recorded. Special tests for epicondylitis were performed to confirm the diagnosis.

Patients were asked to answer questions about their pain, how the pain affected regular activities, and time spent in leisure or recreational activities. Many other types of information were also gathered such as past elbow injuries, treatment tried so far, tobacco use, and work history/sick leave. One of the goals of the study was to see if pain intensity (or any of these other factors) correlated with the results of the bone scintigraphy in any way.

The study did not show any difference in scintigraphy results among patients based on pain intensity or duration. Men had higher uptake values than women suggesting faster and better healing responses. The longer the symptoms were present, the lower the scintigraphy rating (indicating poor healing). Patients who had steroid injections into the elbow were also more likely to have a poor bone healing response.

Patients with higher bone uptake on the scintigraphy had greater strength, less functional loss, and better ability to return to work. Patients with abnormal blood flow, blood pooled in the area, and low bone uptake of 99mTc-HDP had the worst results with poor recovery and more relapses.

The authors suggest that although bone scintigraph is not routinely ordered, it has a place in the diagnosis of chronic epicondylitis. It does not replace standard X-rays and medical examination. But it offers additional information about the underlying healing or inflammatory process present. This type of advanced imaging shows when there is a healing response in the bone tissue and may help guide patients in making treatment, rehab, and return-to-work decisions.

An elbow fracture in someone with rheumatoid arthritis (RA) is a bad break. Surgery is often needed. There are two basic choices: open reduction and internal fixation (ORIF) or total elbow replacement (TER). ORIF involves using a metal plate, wires, and/or screws to hold the broken bone(s) together. Plates and screws are referred to as instrumentation.

Which one of these two treatment approaches has the best results? Can one be recommended over the other? That’s the subject of this study.

Three orthopedic surgeons from Mayo Clinic in Rochester, Minnesota put together a series of 16 cases of elbow fracture in patients with rheumatoid arthritis. Using X-ray results and the Mayo Elbow Performance Score (MEPS), they analyze the outcomes and report on them.

The Mayo Elbow Performance Score (MEPS) gives points (up to a total of 100 points) for pain, joint motion, stability, and function. A total score of 90 points or more is considered excellent. A rating of good means the patient scored between 75 and 90 points. Fair is 60 to 74 points. And poor is a total score less than 60 points.

Each category also had a range of scores to identify the specific area(s) of problem or deficiency. For example, pain was rated as none and given a score of 45 points, mild (30 points), moderate (15 points), or severe (zero points). Motion was given points based on degrees of joint motion present.

Stability (stable to unstable) was graded from 10 points for stable down to zero points for unstable. And points were assigned for function based on daily activities of combing the hair, eating, dressing, and personal hygiene. Looking at the points given in each category gives the surgeon an idea of which area might be the most problematic.

X-rays were used to classify the fractures according to type and severity. The AO classification system was used along with Mayo’s own classification system. The AO method (named for the Swiss group that set it up) uses two numbers and a letter to label each fracture. The first number specifies which bone in the body was broken. The second number indicates the exact location of the fracture within that bone. And the letter identifies the number of bone fragments involved (a measure of fracture severity).

The authors note that elbow deformity caused by the arthritis and age-related osteoporosis of the bones make surgical management difficult. They found that ORIF works well for patients with mild arthritis. But joint replacement is usually needed for patients with severe arthritis. How did they come to these conclusions?

They reviewed the charts of 14 patients with 16 distal humeral (elbow) fractures. Two patients had bilateral (both) elbow fractures. The humerus is the upper arm bone. The distal portion of the bone refers to the bottom of the upper arm where it meets the bones of the forearm at the elbow. Besides looking at before and after X-rays, they also assessed the effect of age, fracture type, and severity of arthritis at the elbow joint.

The fractures occurred as a result of a fall in all patients. Everyone in the study had arthritis for at least 20 years (some as long as 55 years). They were all treated surgically within 10 days of the injury. They either had an ORIF or an elbow replacement.

The decision as to which procedure to use was based on X-ray findings, strength of the bone, and patient preferences. Whenever possible, the surgeons tried to use ORIF because it preserves the joint and is a less invasive procedure. Everyone was followed for at least two years. Post-operative X-rays were used to look at the fracture site for signs of healing and signs of implant or instrumentation loosening.

After analyzing all the data, looking at the X-rays, and reviewing the MEPS scores, the authors were able to see that age and type of fracture did not make a difference in results between the two groups. The less involved ORIF surgery was recommended for younger adults whenever possible. Severity of arthritis did seem to make a difference. Fractures treated with ORIF healed well with no problems. Total elbow joint replacement was reserved for patients with severe rheumatoid arthritis (even for younger patients).

This was the first study ever published to compare the results of treatment for elbow fracture in patients with rheumatoid arthritis. The authors looked for the best treatment approach based on patient personal factors, extent of injury, and severity of arthritis. In summary, they found that the degree of joint involvement was a more important factor than the type of elbow fracture when treating arthritic patients.

In the case of cubital tunnel syndrome, one treatment does not fit all. So say surgeons from the Hand and Upper Extremity Surgery at the University of Pittsburgh after reviewing recent studies on the topic. They found that there are a number of different surgical approaches that all have good results.

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. That’s where 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.

Pressure on the nerve over time can also lead to muscle weakness and loss of forearm function. Imagine not being able to make a fist to hold a spoon or pick up a simple object like a cup of coffee. That can happen when cubital tunnel syndrome causes pain, numbness, and weakness.

Pressure or traction on the nerve can come from a variety of places. Part of the problem may lie in the way the elbow works. The ulnar nerve actually stretches several millimeters when the elbow is bent. Sometimes the nerve will shift or even snap over the bony medial epicondyle. (The medial epicondyle is the bony point on the inside edge of the elbow). Over time, this can cause irritation of the nerve.

Bending the elbow over and over, such as pulling levers, reaching, or lifting can lead to cubital tunnel syndrome. Constant direct pressure on the elbow over time may also contribute to the problem. For example, the nerve can be irritated from leaning on the elbow while you sit at a desk or from using the elbow rest during a long drive.

The ulnar nerve can also be damaged from a blow to the cubital tunnel. Other possible causes include an extra slip of muscle that crosses the nerve, a ganglion cyst, or a bone spur. Any of these extra anatomical structures can cause enough pressure to compress the neural tissue. Sometimes it’s not even possible to tell what’s causing the problem. These cases are called idiopathic, which means unknown.

A careful history and evaluation of the patient’s symptoms can help the surgeon make an accurate diagnosis. A loss of sensation can be measured using special wires called monofilaments. The monofilaments are pressed against the skin with a certain amount of pressure. The patient reports whether or not the pinpoints of pressure are felt.

Muscle and nerve testing are also done. Tapping over the nerve can reproduce the symptoms. This is called the Tinel’s sign. But a more accurate test is the elbow flexion test. The elbow is held in a position of elbow flexion for 60 seconds. This position compresses and irritates the nerve and sets off the symptoms. Applying pressure to the bent elbow increases the sensitivity of this test. Studies show that not pressing long enough or applying pressure for too long can result in false negative or false positive tests.

Imaging studies such as ultrasound or MRIs have their place in the diagnostic process. Ultrasound pictures can show the presence of tumors, extra muscle tissue, or nerve subluxation (nerve slips out of its tunnel). MRIs can show when the nerve (or a section of the nerve) is enlarged. Tumors, cysts, infection, or other lesions are also clearly seen on MRIs.

Once the diagnosis has been made, then the task of determining the best treatment approach begins. Nonoperative care may include antiinflammatory drugs, activity modification, and rest. It is important to stop doing whatever is causing the pain in the first place. Limiting elbow flexion is a key factor.

If the symptoms are worse at night, a lightweight plastic arm splint or athletic elbow pad may be worn while sleeping. This will help limit movement and prolonged periods of time with the elbow bent, thus easing nerve irritation. The elbow pad can be worn during the day to protect the nerve from the direct pressure of leaning.

Doctors commonly have their patients with cubital tunnel syndrome work with a physical or occupational therapist. Therapist gives patients tips on how to rest the elbow and perform activities without putting extra strain on the elbow. Nerve gliding exercises can be done to keep the nerve moving smoothly and reduce pressure from adhesions or soft tissue obstructions. Exercises are used to gradually stretch and strengthen the forearm muscles.

When conservative treatment fails to give patients the relief needed, then surgery may be considered. Almost 100 years of research on this topic has yielded the following results:

The elbow is where you find your “funny bone.” If you hit this spot in just the right place, your lower arm goes numb and you have a tingly feeling for a few seconds to a couple of minutes. While it’s not painful, it’s not comfortable either. What you’re hitting isn’t really a bone, but a nerve, called the ulnar nerve. The ulnar nerve reaches from the collarbone down to the lower arm through the inside of the elbow, through the cubital tunnel.

Ulnar nerve compression is a very common injury and is caused when the ulnar nerve is pressed upon in the elbow by either a mass or cyst that shouldn’t be there, swelling, bone spurs, or older bone breaks that didn’t heal quite right. Although doctors don’t have an exact number, they estimate that about 1 percent of people in the United States have ulnar nerve compression.

People who frequently lean on their elbows on a desk, for example, are at higher risk of developing nerve compression, as are people who work at jobs or activities that make them bend and relax their elbow often, especially if there is a force at the same time, such as while playing tennis.

Usual treatment for ulnar nerve compression at the elbow is to splint the elbow so the patient can’t bend it, giving the elbow a rest from the bending motion. However, that is a difficult treatment to follow through because splinting an arm so it can’t be bend is very uncomfortable and inconvenient for most people. So, if the nerve compression is severe enough for treatment, surgery is an option for many patients. The actual procedure though, is often debated among surgeons as to which is the best approach.

One procedure involves decompression of the nerve, which simple removes the cause of the pressure. This is considered a good, safe approach because of the limited risk of affecting nerves and blood supply to the area. However, the drawback is that the actual problem, what caused the pressure in the first place and the tension on the nerves aren’t fixed and may make it necessary for repeat surgeries.

A modified procedure is called decompression with transposition, whereby the surgeon moves the nerve to a new area of the elbow that has less trauma or scarring, so the nerve can’t catch on it as the elbow is bent and relaxed. This also stretches the nerve a bit. Of course, like all procedures, this one has a drawback as well. In this case, the drawback is that the blood supply to the area is interrupted and not as much blood as is necessary may reach the area. Surgeons are also concerned about what the long-term effect of moving the nerve is and that this may just move the problem to another section of the elbow as more scarring occurs.

As far as can be told, there are no randomized controlled trials that compared the two procedures, but some neurosurgeons in Europe and Australia have performed trials comparing the decompression with transposition alone. One researcher, Nabhan and colleagues, studied 32 patients who had decompression alone and 34 who had a procedure called anterior transposition procedure. The researchers found that there was no difference between the two groups when they assessed the patients three and nine months after surgery. Another small trial with the same procedures, done by Gervasio and colleagues, studied 70 patients, half who had decompression and half who had the transposition. This group of researchers found that the simple decompression group rated the results as: 54 percent excellent, 26 percent good, 20 percent fair. In the transposition group, the results were 51 percent excellent, 31 percent good, and 18 percent fair.

Finally, a third smaller study by Biggs and colleagues looked at 23 patients who had decompression and 21 who had transposition. They also had similar findings to the two earlier studies. The interesting finding in this study, though, was that three patients who had transposition experienced deep wound infections and the decompression group had no reported infections.

Other researchers looked at reviews of studies and also came to the same conclusion: there was not much difference between the findings between the two procedures. Therefore, most recommend that the easier of the two procedures, the decompression, be done. That being said, none of the studies that were found were of “high” quality. The three studies mentioned above were quite small, which doesn’t give a good representation of statistics. The two reviews were also problematic because the studies were of poor or low quality.

The author of this article wrote that further studies are needed and they should be larger, multi-center designed studies for researchers to begin seeing any significant differences between the surgeries.

There are an estimated 600,000 to 1.2 million football-related injuries per year among young adults in the United States. If the injuries are severe enough, they can put athletic careers in peril, limiting the athletes’ ability to follow their dreams. Much attention has been placed on injuries of the leg, such as the knee and ankle, but upper extremity injuries (hand and arm) appear to be much more common than any other type of injury, including concussions. Up to 30 percent of injuries involve the arm or shoulder.

Research on these injuries that is available is old, so researchers aren’t aware of any particular patterns to the injuries, nor information on the most common locations for arm injuries or the risk factors. This type of information is important because it allows pre-emptive action, to avoid the injuries in the first place. The authors of this article wanted to review how the injuries occurred, how often they occurred, and the resulting time lost from playing.

Researchers did a 10-year retrospective (looking back) review of the National Football League (NFL) Sports Injury Monitoring System. Injuries entered into the system where considered to be significant if they caused the player to stop participating early in at least one practice or game, or training. Delayed injuries, ones that were treated later, were also in the database. The injuries were divided into eight classifications: general trauma, overuse, muscle/tendon injuries, fractures, ligament or joint instability, cartilage injury, nonspecific joint injury, and miscellaneous.

The researchers found 24,432 injuries in all and 859 (4 percent) involved wrist, forearm, or elbow. The most common arm injury involved the stability of a joint, the elbow (51 percent of the time) and the wrist (72 percent) of the time. Fractures were the most common injury of the forearm (78 percent), with the fractures of the wrist coming in (17 percent). With regard to sprains, the wrist was the most commonly injured joint although the elbow was a very frequently injured joint as well. Elbow hyperextension (bending the elbow the wrong way) occurred in 24 percent of elbow injuries, but if the wrist and forearm injuries were combined, hyperextension made up 14 percent of all the injuries.

Looking at when the injuries occurred, during practices or games, was important. The researchers found that the injuries occurred much more often during actual games (74 percent) than in practices, despite the fact that the players spend much more time in practices than on the game field.

Among the athletes who had elbow injuries, there was an average of 22 days lost per injury, although this did range from one to 340 days, depending on the injury and the athlete. Of the forearm injuries, there was an average of 42 days lost (ranging from zero to 114 days). Wrist injuries resulted in an average of 27 days lost (zero to 260 days). What was interesting was the types if injuries that didn’t take as long to recover compared with those that took longer. Traumas were the quickest injuries to come back from (average of six days), while injuries caused by overuse or inflammation followed closely at 10 days, although wrist inflammations took longer for recovery than did elbow inflammations. Ligament injuries and/or joint instability caused an average of 18 days lost, fractures 47 days, and dislocations 56 days.

The injuries were most often caused while tackling (24 percent) or blocking (23 percent), with the elbow being the most common injury there: 53 percent from tackling and 63 percent from blocking. Being on the receiving end of the tackle or block also caused elbow injuries, with 52 percent occurring while being tackled and 67 percent while being blocked.

The position played also had a role in the injuries. Offensive and defensive linemen had the highest (20 percent) number of injuries, and the elbow was the most commonly injured area of all, except for wide receivers. Seventy six percent of injuries affected offensive linemen and 74 percent affected defensive linemen. They sustained more wrist injuries. Quarterbacks had fewer arm injuries (only 4 percent). In fact, quarterbacks had the lowest arm injury rate overall, at 6 percent. Cornerbacks and safeties had the highest number of arm injuries.

The results of the study show that the way to prevent injuries is to be able to recognize which injuries occur most often and in what way. It’s important that the those responsible for sports and safety identify these injuries and the risks, and implement processes that help reduce them. This may mean changing some rules, modifying equipment, and altering training routines. The authors pointed out that there was a dramatic reduction in head and neck injuries when changes were brought in in 1976, so it is possible to alter the course of injuries.

When looking at the number of injuries that occur on the football field, the authors do acknowledge that part of the increase is due to more players in the league, due to expansion and the addition of more teams. Nevertheless, there still are more elbow injuries now, overall, than there were a few decades ago. Because of this, the authors feel that this area needs more research.

In conclusion, the authors did note that there were some flaws to the study, as there are in all studies. These included that the study was retrospective and was based on collecting data, without any opportunity to standardize diagnosis or coaching decisions as to whether the players should return to play or sit out a longer period. As well, there was no information in the database regarding treatments nor if there was an injury that occurred in training but was aggravated or returned while playing a game.

While most people have heard of carpal tunnel syndrome, a condition in which the nerves going through the carpal tunnel in the wrist are pinched, another condition called cubital tunnel syndrome also exists. With cubital tunnel syndrome, the pressure is on the back of the elbow onto the ulnar nerve – where your “funny bone” is. It can cause pain, weakness, or numbness of the hand. It can also cause numbness or a pins-and-needles sensation on the ring finger or small finger (pinky).

Cubital tunnel syndrome can be caused by a few things, with the most common cause being repetitive bending and straightening of the elbow, such as reaching for something and pulling down. Other people develop it by leaning on their elbow either at their desk, in the car, or elsewhere. Other causes include something that is in the elbow that shouldn’t be, like a cyst, that takes up space and puts pressure on the nerve. Of course, like with striking your “funny bone,” if you hit the ulnar nerve hard enough to cause an injury, it could also result in cubital tunnel syndrome.

Diagnosis of cubital tunnel syndrome includes patient history of pain or numbness in the fourth (ring) finger and small finger. Some patients may have weakness in their hand as well as a duller sensation compared to the other hand. Studies have found that 40 percent of patients with cubital tunnel syndrome also have atrophy, or wasting away of muscles, in the hand.

When examining the hand, the doctor will check for the sensation on the tip of each finger, as well as strength in the fingers. The doctor may also apply pressure to the ulnar nerve, check the patient’s ability to bend the elbow, and performing the Tinel’s sign, which involves lightly tapping over the nerve to see if the tapping causes tingling.

In one study, performed by Novak and colleagues, of 32 patients with cubital tunnel syndrome and 33 control patients who didn’t have an elbow problem, researchers found that the elbow bending test was twice as effective (sensitive) if it was done for 60 seconds when compared to only 30 seconds. The problems with such tests is the margin of error that exists – if they are done correctly and for a long enough period. The authors of this article wrote that using electrodiagnostic tests, tests that use electrical currents, may be more effective and help avoid the subjective nature of tests like the elbow test. However, some doctors don’t care to use electrodiagnostic tests because they, too, have given false negative results.

Other tests that can be done are ultrasounds and magnetic resonance imaging (MRI). Ultrasounds use sound waves to make an image on a screen. This can help find if there are any cysts, tumors or other masses in the elbow that may be causing the problem, as well as tell if there are any abnormalities. MRIs, which make images using magnets, can show if the nerve has become larger than it should be and it can also tell if there are any masses in the elbow space.

Treatment for cubital tunnel syndrome varies according to the doctor. Surgery has been a common treatment, but the type of surgery may differ. Some surgeons decompress the area so there is no more pressure on the nerve, while others move the nerve so that it’s not so vulnerable to pressure. Studies have shown that there doesn’t seem to be a difference between the two techniques in how successful the surgery is. And, because there is no difference in outcome, researchers recommend that surgeons choose to do the decompression because it’s less invasive than the other.

Following surgery, it’s possible that the patients still feel pain in the elbow. This may be caused by damage to the nerve during surgery. The solution for this could be injection of an anesthetic directly to the painful area.

In conclusion, the authors wrote that researchers are still trying to determine the best way to treat cubital tunnel syndrome. In order to be more exact, however, more trials will need to be done on larger patient populations.

Elbow dislocations are a common arm injury and although shoulder dislocations are more common in adults, dislocated elbows come a close second. They occur in about six to eight people out of 100,000. The most frequent cause is a fall onto an outstretched hand, although the elbow can be dislocated in other ways as well.

The injury is classified in one of four ways, depending on the direction of the dislocation: anterior, which means to the front, posterior, which means to the back, lateral, which means to the side, or divergent, which means that the bones moved apart from one another. The most common one, however, is the posterior one, with both the radius and the ulna (both bones in the forearm) becoming dislocated from the humerus, the upper arm bone. In 10 percent to 15 percent of cases, there can be other injuries, such as injury to the shoulder, to the arm bones themselves, and to the wrist bones.

The elbow is supported by “pulley” type system, called a trochia and this stabilizes the joint. The ligaments, tough tissue that hold bone together also help stabilize the elbow.

When an elbow is dislocated, usually it’s treated by manipulating it back into place. The patient would normally receive only a local anesthetic, unless the reduction is complicated. After the elbow is put back into place, treatment can vary from the patient being encouraged to use the arm and elbow right away, to casting or bracing. The elbow is well protected, so repeat dislocations aren’t usually a worry and that is also why surgery is usually not needed.

The authors of this article wrote about a 56-year-old woman who complained of a swollen and painful right elbow, with her forearm turning inwards toward her body. This happened after she fell and broke her fall by holding out her arm and landing on it as it was stretched out. When the doctor examined the patient, they saw on the x-ray that there was an unusual form of twisting at the elbow – the radius was twisted at a right angle (90 degrees) and the ulna at 180 degrees.

Treatment was to set it so the patient received a local anesthetic to the elbow and the doctor, along with an assistant, moved her arm back into place. Her arm was then casted in to place with the elbow bent at 90 degrees for three days. After that, the cast was replaced with a brace to remain on for three more weeks.

When the patient returned for follow up after three weeks, the doctors found that the patient was able to bend her arm quite a bit but had difficulty turning her wrist in towards her body and away from it. The doctors recommended exercises to regain that ability and the patient returned again two weeks later. at that point, there was no more pain in the elbow and she was able to move it completely in any direction.

Surgical treatment for elbows affected by arthritis differs between patients because of the type of arthritis, how severe it is, and how old the patient is. The authors of this article reviewed the different types of surgery available for treatment of arthritic elbows.

The elbow, unlike other joints, is more prone to being stiff when it is damaged, like with arthritis, making treatment to return use and motion a priority. Also, unlike arthritis in the hip, knee or shoulders, the elbow doesn’t usually deteriorate from primary osteoarthritis. The elbow usually deteriorates from rheumatoid arthritis, trauma (injury), or other types of arthritis. Patients with deterioration in the elbow from osteoarthritis tend to fall into certain categories, such as heavy-machine operators, weight lifters, and professional overhead athletes – people who regularly put a lot of force on their elbows.

When evaluating the elbow, the patient will complain of pain and inability to fully extend the elbow (the range of motion). After a while, the pain becomes more frequent and occurs whenever the elbow is bent or straightened out. At this point, the surgeon must take into account the patient’s job and what the effects of surgery will have before deciding on what type of surgery to perform. The examples used in the article are that of a baseball pitcher and a jackhammer operator. If the athlete has surgery to remove the bony growth that has formed on his or her elbow, this could cause the elbow to become unstable and cause further damage. On the other hand, if a jackhammer operator was to have an elbow replacement, the vibration from the jackhammer could destabilize the new joint and cause loosening.

Another issue to be considered is the health of the arm above and below the elbow. Is the bone strong enough to tolerate a replacement, is there enough healthy soft tissue, where is the nerve located, and has there already been surgery are just a few of the questions that need to be asked.

If the patient has rheumatoid arthritis, only about 5 percent of patients end up with an elbow problem alone that needs to be fixed with surgery. Most often, the shoulder and wrist are affected as well. Therefore, any treatment done to the elbow has to take into consideration how it will affect the wrist and shoulder.

When examining a patient, the surgeon should evaluate the patient completely with particular attention on not just the elbow, but joints nearby. The patient should be questioned about previous treatments, including medications and splinting. The condition of the patient’s skin around the elbow is important to know to see if it would heal well following elbow surgery. The range of motion should be checked and the strength of being able to bend at the elbow.

X-rays can show if there has been narrowing in the joint and if there are any bony growths. If necessary, the surgeon can get a computed tomography image (CT scan) and/or magnetic resonance imaging (MRI) to see more clearly around the elbow. If there is a question with the nerves in the elbow, further testing can also be done. If the surgeon has any reason to suspect an infection, blood tests and even withdrawing some fluid from the elbow for testing can be ordered.

Once it’s been decided that surgery is needed, the surgeon has to decide what approach. The least invasive is the arthroscopic debridement, which is done for mild to moderate cases of arthritis that haven’t responded to non-surgical treatment. Arthroscopic surgery needs just a few tiny incisions for the instruments and a camera to enter the elbow. For patients with rheumatoid arthritis, the surgery is done to remove inflamed tissue that is causing pain and destruction in the joint. For people with osteoarthritis, the procedure is done to remove bony bits or loose pieces of tissue or bone that are affecting elbow movement.

The results of arthroscopic debridement show 85 to 90 percent success for short-term improvement in pain and function, but there long-term results are not well known and some studies show only about 50 percent improvement. Complications from the procedure can include injury within the joint caused by the instruments.

Another procedure, ulnohumeral arthroplasty, or a partial bone replacement, is another option that can be done in several different ways depending on surgeon preference and the reason for the surgery. This surgery is usually done for patients who have extreme pain and inability to move their elbow from mild to moderate arthritis. It is usually only done with patients who have osteoarthritis as it would not be beneficial for patients with rheumatoid arthritis or other types of arthritis.

The results of the surgery show that it is fairly successful if used in patients with mild to moderate joint degeneration, at about 75 percent success rate. This drops over time and to approximately 50 percent after around 12 years following surgery. Complications include further degeneration and some nerve injury.

The oldest procedure done on the elbow is the interpositional arthroplasty, which is another type of replacement or insertion of a graft. This procedure is done for patients who have advanced arthritis but are considered to be too young for a total elbow replacement. The deciding factors for this surgery is that the patient have incapacitating pain, considerable loss of elbow range of motion, and/or be younger than 30 years old if the surgery is for rheumatoid arthritis and younger than 60 years old if the surgery is for another type of arthritis.

Even if a patient meets the requirements, there are some issues that would cause the surgeon not to choose this procedure. They include if there was a history of infection in the elbow, if the bone around the elbow is not strong enough, if the patient is a heavy laborer, or if the patient has an unstable elbow.

The results of this surgery are generally good with a success rate at 5 years of at least 70 percent. There are, however, high rates of complications, regardless of the surgeon’s experience. There was a reported rate of 27 percent of complications in one small study of 27 patients. Complications are many but include problems with the pin site, deep infections, and surgery failure.

The total elbow arthroplasty, or full replacement, is done for patients who have moderate to severe arthritis, causing pain, limited range of motion, and is affecting function. The type of arthritis and the effect it has had will be the deciding factor as to which of three different types of arthroplasty is used. There are some types of patients who surgeons must weight the pros and cons before attempting this surgery. These include patients who have had infections in the elbow, if there are multiple scars around the elbow, if patients may not be motivated to follow up with proper rehabilitation, or those who may not be able to live within the limitations of the replacement, such as not being able to lift more than 10 pounds or lifting 2 pounds repetitively. These issues are important to consider to reduce the chance of complications or replacement failure.

In assessing the effectiveness of the total elbow arthroplasty, researchers found an average of 50 percent success after 10 to 14 years after surgery. This drops, however, to 25 percent after 15 to 19 years, and longer. Complications include infection, which happen in about 2 to 11 percent of cases. The next most common complication is loosening of the implant.

The authors concluded that the choice of procedures to improve the function and reduce pain in the elbow depends on many pre-operative issues, functional requirements of the elbow for each patient, as well as how well the patient is expected to cooperate in terms of rehabilitation and respecting limitations of the repaired elbow.

This is the first article in a two-part series on elbow instability injuries. Dislocation and joint laxity (looseness) on either side of the elbow are common with elbow instability. Proper diagnosis is needed in order to plan the best treatment approach. In this article, elbow anatomy and biomechanics are reviewed to help with the diagnostic process.

The elbow is a complex hinge joint. Three bones come together at the elbow to create elbow flexion and extension. There are ligaments, muscles, and other soft tissue restraints holding the joint together. Traumatic or overuse injuries that disrupt any of those structures can result in elbow instability.

The structures around the elbow must provide a stable position of the joint no matter what position it’s in. Forces exerted on the elbow during a dislocation can result in significant loss of stability. The medial collateral ligament (MCL) on the inside of the elbow (closest to the body) and the lateral collateral ligament along the outside of the elbow create a capsule around the joint.

Both of these ligaments are made up of several bundles or bands of tissue that resist stress through the joint. If enough force is exerted on the ligaments, dislocation can occur. After elbow dislocation, the surgeon must evaluate the strength and integrity of these two ligaments.

Special stress tests can be performed. Testing procedures for each of these ligaments are presented. Symptoms of medial instability for the MCL and lateral instability for the LCL are also reviewed.

The most common symptoms are pain and tenderness along the inside (or outside) of the elbow. Symptoms occur with overhead throwing activities. Pressure on the nerves through the elbow can also result in numbness and tingling down the arm or into the hand and fingers. With lateral instability, there may be a painful clicking, catching, or snapping sensation. It feels as if the elbow is slipping in and out of the joint.

Stress radiographs (X-rays) can be used to show gaps in the joint. This is a sign that the soft tissues are insufficient. This means they aren’t strong enough to hold the joint and prevent future instability. MRIs with an injected dye are used to make the diagnosis of a partially torn or completely ruptured ligament.

Elbow dislocation doesn’t always mean surgery is needed. Once the physician identifies the soft tissue structures that were damaged, a specific treatment plan can be determined. Part-two of this article series will provide more details on conservative (nonoperative) and surgical care of this problem.

The medial collateral ligament (MCL) can become stretched, frayed, or torn through the stress of repetitive throwing motions. Professional pitchers have been the athletes treated most often for this problem. The word medial means it’s on the inside of the elbow (closest to the body). Sometimes it’s also referred to as the ulnar collateral ligament (UCL).

Treatment for a torn or ruptured ligament is surgery to repair or reconstruct the ligament. The procedure works well. Many athletes are able to return to play even better than before. But in a small number of pitchers, the ligament tears again. A revision (second) surgery may be needed.

In this study, the results are presented for 15 male ball players who had revision surgery for reinjury of the medial (ulnar) collateral ligament. The authors report a high rate of complications after the second surgery. Scarring and adhesions were much more common than after the first procedure.

The number of athletes able to return to play was much lower after a revision operation. There was a high rate of complications due to technical difficulties during the procedure. Bone fractures, nerve pain, and failure of the tendon graft used to replace the ligament occurred in 40 per cent of the athletes in this study.

Some players may not be willing to go through the long and difficult rehab required after a second operation. This is especially true when the outcome is unpredictable. Sometimes it’s difficult to advise the player about what to do. There’s no way to know in advance if the operation will be successful. More studies are needed to help in this decision-making process.