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 is considered.

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.