Anatomy of the Elbow
The elbow is a hinge joint made up of the humerus, ulna and radius.
The unique positioning and interaction of the bones in the joint allows
for a small amount of rotation as well as hinge action. This rotation
is easily noticed during activities such as hand-to-mouth eating motions.
The primary stability of the elbow is provided by the ulnar collateral
ligament, on the medial (inner) side of the elbow. However, one of the
most common injuries to the elbow occurs on the lateral, or outer, side
of the elbow -- it is called Lateral Epicondylitis, or Tennis Elbow.
Tennis Elbow (Lateral Epicondylitis)
Tennis elbow, or lateral epicondylitis, is one of the most common elbow
problems seen by an orthopedic surgeon.
It is actually a tendinitis of the muscle called the extensor carpi radialis
brevis which attaches to the lateral epicondyle of the humerus. It may
be caused by a sudden injury or by repetitive use of the arm.
Many doctors feel that micro tears in the tendon lead to a hyper-vascular
phenomenon resulting in pain. The pain is usually worse with strong gripping
with the elbow in an extended position, as in a tennis back hand stroke,
but this problem can occur in golf and other sports as well as with repetitive
use of tools.
Before surgery is considered a trial of at least six months of conservative
treatment is indicated and may consist of a properly placed forearm brace
and modification of elbow activities, anti-inflammatory medication and
physical therapy. If the above treatment is not helpful, a cortisone injection
can be beneficial but no more than three injections are recommended in
any one location in a year.
Conservative treatment is in two phases and after Phase I (Pain relief)
has been successful, Phase II (Prevention of recurrence) is equally as
important and involves stretching and then later strengthening exercises,
so the micro tears will not occur in the future.
When conservative treatment has failed, then surgery is indicated. Many
procedures have been described. Procedures as simple as percutaneous release
of the tendon off of the bone have been described and more recently arthroscopic
procedures or other procedures involving the joint and resection of a
ligament as well have been described.
The most popular procedure today is a simple excision of diseased tissue
from within the tendon, shaving down the bone and re-attachment of the
tendon. This can be performed as an outpatient procedure with regional
anesthesia (where only the arm goes to sleep) and through a relatively
small incision of approximately 3” long. 85-90% of patients with
this technique are typically able to perform full activities without pain
after a recuperation of two to three months. Approximately 10-12% of patients
have improvement but with some pain during aggressive activities and only
2-3% of patients have no improvement.
Golfer's Elbow (Medial Epicondylitis)
Medial epicondylitis is inflammation of the tendon attachment of the flexor
pronator muscles in the forearm. Usually this begins as microscopic tears
in the tissue which leads to an inflammatory or hypervascular process.
This occurs when stiff, underused tendons are suddenly overused or this
may occur from an acute injury. The treatment includes three treatment
options, no treatment, conservative and surgery.
Surgery is a last resort and involves cleaning up the tendon from diseased
tissue, shaving down the bone and re-attachment of the tendon. This is
necessary in 10-15% of the patients. Conservative treatment is in two
phases, Phase I is to get rid of the pain and Phase II is to prevent it
from coming back with stretching and strengthening exercises. To reduce
the pain, using the elbow in a flexed position and the use of an elbow
strap counterforce brace is usually the first line of treatment. If the
patient has persistent symptoms a cortisone injection may be considered.
No more than three injections are recommended per year and if the patient
still has persistent symptoms despite conservative treatment, surgery
Cubital Tunnel Syndrome
Cubital tunnel syndrome is a pinched nerve at the elbow commonly known
as the "funny bone". This might be caused by trauma or repetitive
use of the elbow and may be caused by continuous use of the elbow in a
flexed position. This causes the nerve to become stretched and irritated
as opposed to when the arm is extended and the nerve is in a relaxed position.
The diagnosis can be confirmed with electrodiagnostic testing including
nerve conduction velocity and the electromyogram. Nerve conduction velocity
studies, the speed of the nerve across the elbow, will be slowed when
there is nerve compression and electromyogram studies, the innervation
of the muscles, might be affected by the pinched nerve.
For this problem there are three modes of treatment; no treatment, conservative,
and surgical. Unfortunately with conservative treatment, only splinting
with the arm in an extended position has been found to be helpful. Night
time splinting is achieved with a custom made long arm splint that the
patient will wear at night time and as often as possible during the day.
Unfortunately it is cumbersome to keep the arm out straight all the time
and therefore this is usually used only at night.
If the patient has persistent complaints despite conservative treatment
surgery would be recommended. There are three types of procedures, one
is to cut the medial epicondyle which is the bone pinching the nerve or
the other two operations are to actually move the nerve out of the cubital
tunnel either above or below the muscles of the forearm. This can be performed
as an outpatient procedure with an axillary block where only the arm is
put to sleep and it has a high success rate.