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Elbow and Forearm Conditions

ANTERIOR INTEROSSEOUS NERVE SYNDROME

What is anterior interosseous nerve syndrome?

Anterior interosseous nerve syndrome is a nerve disorder in the elbow and upper arm that causes pain and weakness in the hand. Muscles or ligament-like tissues compress a branch of the median nerve in the forearm. It may decrease athletic performance in sports that require pinching of the thumb and index fingers. This nerve does not supply sensation to the skin; as a result, there is no numbness associated with it.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

What causes anterior interosseous nerve syndrome?

  • Pressure on the anterior interosseous nerve at the forearm caused by swollen, inflamed, or scarred tissue, ligament-like tissue, or pressure between muscles of the forearm
  • Possibly, a virus causing inflammation and dysfunction of the nerve

What increases the risk of developing this condition?

  • Sports or occupations that require repetitive and strenuous forearm and wrist movements (rowing, weightlifting, body building, tennis, squash, racquetball, carpentry), particularly rotation of the wrist and hand
  • Poor physical conditioning (strength and flexibility)
  • Inadequate warm-up before practice or play
  • Diabetes mellitus
  • Hypothyroidism (underactive thyroid gland)

What are the symptoms of anterior interosseous nerve syndrome?

  • Pain in the upper forearm, usually vague
  • Inability to pinch your thumb to index finger tip to tip (make the OK sign)
  • Thumb weakness, particularly bending the thumb, or weakness of the index finger
  • Frequent dropping of objects and difficulty writing
  • Weakness when turning the palm down against resistance

How is this condition diagnosed?

Anterior interosseous nerve syndrome is diagnosed by an appropriate history and physical examination and often confirmed with a nerve test A

What are the treatment options for anterior interosseous nerve syndrome?

  • Non-surgical treatment: Initial treatment consists of rest from the painful activity and medications and ice to help reduce inflammation. Stretching and strengthening exercises of the muscles of the forearm and elbow are important. Referral to physical therapy or an athletic trainer may be necessary for treatment.
  • Surgical treatment: Surgery is sometimes necessary to free the pinched nerve. Surgery is generally an outpatient procedure (you go home the same day) and provides almost complete relief in most patients. We may recommend surgery eight weeks to one year after the onset of symptoms.

When can you return to your sport/activity?

With appropriate treatment, this condition is usually curable, although resolution may occur spontaneously. Spontaneous recovery has been noted from three weeks to 18 months after the onset of symptoms.

How can anterior interosseous nerve syndrome be prevented?

  • Appropriately warm up and stretch before practice or competition
  • Maintain appropriate conditioning:
    • Wrist, forearm, and elbow flexibility
    • Muscle strength and endurance
    • Cardiovascular fitness
  • Use proper technique and have a coach correct improper technique

 

BICEPS TENDON RUPTURE OF THE ELBOW

What is a biceps tendon disruption?

When the biceps tendon ruptures at the elbow, it is torn from where the elbow meets the radius. The radius juts out slightly at the point where the biceps tendon joints, known as the radial tuberosity. Although the tendon usually pulls completely away from the bone insertion, some tendon tears are incomplete.

Biceps tendon rupture usually causes some degree of impairment because the biceps muscle is important for both bending the elbow (called elbow flexion) and turning the palm face up (called forearm supination).  Studies have shown that distal tendon rupture of this structure may result in about a 30 percent loss of elbow bending strength and about a 40 percent loss of strength in turning the palm up.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does biceps tendon disruption occur?

  • The elbow is subjected to a sudden force while lifting or holding something, exceeding the inherent tensile strength of the muscle-tendon unit.
  • It typically occurs in middle-aged athletes lifting something very heavy.

What increases the risk of developing biceps tendon disruption?

  • Weightlifting and bodybuilding
  • Heavy labor
  • Poor physical conditioning (inadequate strength, poor flexibility)
  • Inadequate warm-up before practice or play

What are the symptoms of biceps tendon rupture?

  • Acute pain in the front of the elbow, accompanied by a pop or tearing sensation at the time of injury
  • Visible deformity or bulge is often noted above the elbow crease
  • Pain exacerbated by elbow flexion against resistance
  • Pain and weakness on attempting forearm supination against resistance
  • Evolution of ecchymosis (bruising) in the elbow or forearm

How is biceps tendon rupture diagnosed?

Physical exam is reliable in the vast majority of cases with a visible deformity above the elbow crease, tenderness along the course of the tendons’ attachment to its radial insertion and weakness with forearm supination against resistance.

Are there any special tests?

  • X-rays
  • MRI is the definitive test to confirm suspected distal biceps tendon rupture.

How is biceps tendon rupture treated?

Initial treatment consists of medication and ice to relieve the pain, and a sling may be recommended for comfort.

Historically, surgical treatment was unusual because it was believed that long-term function of the tendon was not compromised when it was left alone. But more recent studies have revealed that some patients continue to suffer from significant deficits in strength, particularly in movements requiring forearm supination (e.g., opening doors, opening jars, using screwdrivers, etc.)  Non-operative treatment may be preferable for those patients whose affected arm is their non-dominant one, who want to avoid surgery or who are less active.

Most patients are candidates for surgical reattachment of the biceps tendon. Surgery is usually recommended as soon as is reasonable after the injury, ideally within 3 weeks, to minimize retraction of the torn tendon and to take advantage of the healing environment. Delay in surgery may result in inability to re-attach the tendon due to muscle retraction. Operative treatment requires re-attachment of the tendon to its normal insertion on the radial tuberosity.

  • The surgery for a ruptured biceps tendon cannot be done laparoscopically. Current techniques require open exploration to identify the torn tendon end, which is then debrided (surgically excising the unhealthy degenerative tendon tissue through which the tear occurred). Suture material is weaved throughout the tendon remnant so that it can be used to pull it into a tunnel created at its original attachment site. Several techniques are used to secure the tendon.
  • The historic practice for repairing the tendon has been a “two incision” technique, making one incision in the front of the elbow (within the elbow crease) to retrieve the torn tendon, and another on the dorsum (back part) of the forearm near the elbow to help secure reattachment to bone.
  • The advent of newer surgical fixation devices have led to the development of a “single incision” approach, in which the only incision necessary is that anteriorly in the antecubital fossa (skin crease in the front of the elbow). Surgical retrieval, debridement, suturing, and insertion of sutured tendon into the radial tuberosity bone tunnel are all achievable.
  • Once the tendon has been introduced into the tunnel, fixation can be achieved using a “button” (known as a Retro or Endo button), in which a small metal button is flipped against the opposite side of the tunnel, securing like a molly bolt the tendon within the tunnel. An alternative technique, used by itself or in conjunction with the button, is an “interference screw,” in which a bioabsorbable screw is seated within the tunnel against the tendon, thereby securing it against the tunnel wall, much like a cork fit into a champagne bottle. Regardless of which fixation technique is used, tendon to bone healing appears to occur within about 6 weeks.
  • Post-operative treatment requires immobilization in a sling, followed by exercises to restore motion and, eventually, strength. The pace of return to activity and rehabilitation depends upon a number of factors and is individually determined at the time of surgery. These factors include the tendon quality and quantity (amount of quality tissue remaining after debridement of the torn end), security of fixation, and patient considerations (their “handedness,” demands, reliability).

What are the potential complications from treatment?

Possible complications of non-operative treatment include:

  • Weakness, especially with activities involving supination (turning forearm/palm “up”)
  • Mild elbow flexion weakness (typically not significant with daily activities because the brachialis, the muscle beneath the biceps, is a strong flexor of the elbow)

Possible complications of operative treatment include:

  • Surgical complications not specifically associated with the distal biceps tendon repair, such as pain, bleeding (uncommon), infection (<1 percent), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.
  • Complications specific to surgical treatment of this condition include repair failure, persistent pain and restriction in motion. Repair failure is attributed to the security of fixation and compliance with post-operative requirements. Pain is an uncommon problem. Restriction in motion can occur if there is insufficient tendon length or if there is protracted immobilization post-operatively.

When can you return to your sport/activity?

  • With current fixation techniques, most patients will be able to resume daily activities within a few weeks of surgery. This means dressing, hygiene, typing and returning to non-physically demanding jobs. Lifting anything heavier than a cup of coffee requires minimum of 6 weeks, until the tendon has had a preliminary chance to begin healing. At 3 months, the tendon is secure enough to tolerate beginning resistance exercises, including resistance tubing and lifting weights. These should advance progressively and be modified as necessary. These serve as guidelines rather than an obligatory timetable.
  • Return to sports depends on the type of sport and position.
  • Full elbow and wrist motion and strength are necessary before returning to sports.
  • Four to eight months are necessary for complete healing before a return to sports or heavy lifting.

How can a biceps tendon disruption be prevented?

  • Appropriately warm up and stretch before practice or competition
  • Avoid overloading with excessive weights, which is typically how this tear occurs
  • Allow time for rest and recovery between practices and/or competition
  • Use proper technique

 

BICEPS TENDON TENDONITIS OF THE ELBOW

What is biceps tendon tendonitis?

Distal biceps tendon tendonitis is characterized by pain in the front of the elbow, presumably due to inflammation of the biceps tendon. However, most tendon conditions do not actually demonstrate true inflammatory tissue changes, and in fact, are considered “tendinosis,” a word reflecting pathologic changes within the tendon itself, usually from degeneration.

Most patients with anterior elbow pain have an element of tendinosis, usually at the insertion of the biceps tendon on the radial tuberosity (the site of attachment of the distal biceps tendon is on a small tubercle of the radius, or forearm bone). Disease or injury to the distal biceps tendon is important because it can cause symptoms and impairment with elbow flexion and when turning the forearm with the palm up (supination).

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does biceps tendon tendonitis occur?

Tendonitis of the biceps is caused by strain from sudden increase in amount or intensity of activity or from overuse or repetitive elbow bending or wrist rotation, particularly with supination (when turning the palm up, such as when using a screwdriver).

What increases the risk?

  • Sports that involve heavy use of the elbow, such as gymnastics, weightlifting, bodybuilding or rock climbing
  • Heavy labor
  • Poor physical conditioning (strength and flexibility)
  • Inadequate warm-up before practice or play

What are the symptoms of biceps tendon tendonitis?

Pain or discomfort at the front of the elbow is the major symptom. Pain is exacerbated with elbow flexion (bending) and supination (turning the palm up).

How is biceps tendon tendonitis diagnosed?

A history of elbow pain in the antecubital fossa (front crease of the elbow) associated with tenderness along the course of the tendon towards its insertion on the radial tuberosity is an indicator of this condition, along with pain and/or weakness with supination of the forearm (turning the palm up) against resistance.

Are there any special tests?

  • X-rays
  • MRI is helpful in cases where there is sufficient tendonosis or partial tearing of the tendon, usually near or at its attachment site. Occasionally, fluid is seen around the tendon, an indirect indication of tendon involvement.

How is biceps tendonitis treated?

Initially, distal biceps tendonosis is treated non-operatively. This includes activity modification and avoidance of provocative activities, as well as pain medication and use of ice at the site of discomfort. Gentle stretching and subsequent strengthening have been advocated as helpful strategies to restore function as pain subsides.

Injections

Although cortisone injections have value in certain conditions, such as tennis elbow or rotator cuff tendon problems, there is no role for their use in treating distal biceps tendon problems. The distal biceps tendon is surrounded by important vessels and nerves, which preclude safe targeting.

Operative treatment is considered for those whose persistent symptoms have failed to respond to non-operative treatment. Surgery consists of an open incision of the anterior (front of) elbow and examination of the distal biceps tendon. In the vast majority of cases, degenerative changes with partial tearing are appreciated near the insertion site. The tendon is completed and released at the normal insertion site, the degenerative intervening tissue is debrided (surgically trimmed), and the tendon reinserted into its normal attachment site on the radius. A number of surgical techniques have been described for reattachment. The current most commonly performed procedure combines strong fixation with a minimally invasive approach to permit rapid restoration of normal use and return to activities.

What are the complications of treatment?

Possible complications of non-operative treatment include:

  • Persistent pain and impairment
  • Possible progression to complete tear

Possible complications of operative treatment include:

  • Surgical complications not specifically associated with exploration/reattachment, such as pain, bleeding, infection, nerve injury, stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity
  • Complications specific to surgical exploration include the possibility that the tendon will in fact appear normal (rare), possible loss of motion (usually in pronation/supination or rotation of the forearm), and possible formation of bone in the soft tissues (known as heterotopic ossification)
  • Repair failure, with re-rupture or detachment of the tendon, is very uncommon.

When can you return to your sport/activity?

This condition may remit within a period of six weeks of non-operative treatment, though varies considerably depending upon the severity, hand dominance, activity level, etc.

Most patients can resume activities of daily living within two weeks of surgery (using current surgical techniques). However, tendon integration into the bone requires three months, which is the basis of avoiding any lifting or carrying anything heavier than a cup of coffee during this period. Strengthening begins at the three-month mark. The ability to return to previous level of activity depends upon a number of factors, but is within the three to six months range.

How can biceps tendon tendonitis be prevented?

Because most distal biceps tendon pathology is consequent to degeneration, prevention is not realistic. However, attention to symptoms early on may preclude progression or abrupt failure.

Activities that may facilitate prevention include:

  • Avoid provocative activities that precipitate or exacerbate symptoms
  • Perform appropriate warm up and stretch before practice or competition
  • Allow of time for adequate rest and recovery between practices and competition
  • Maintain of appropriate conditioning:
    • Elbow flexibility
    • Muscle strength and endurance
    • Cardiovascular fitness
  • Use of proper technique

 

ULNAR NEURITIS (CUBITAL TUNNEL SYNDROME)

What is cubital tunnel syndrome?

Cubital tunnel syndrome is a condition in which the ulnar nerve, under the medial (inside) aspect of the elbow (the “funny bone”) becomes irritable, causing symptoms of pain, numbness tingling and, sometimes, weakness into the ulnar (little finger aspect) side of the hand.

It is known as cubital tunnel syndrome because it occurs due to compression or entrapment or irritation of the nerve within the confines of a space called the cubital tunnel, just behind the bony prominence on the inside (medial aspect) of the elbow. It is also known as ulnar neuritis, derived from neur-, meaning nerve, and –itis, reflecting inflammation. Ulnar nerve dysfunction or inflammation may greatly decrease athletic performance in sports that require strong hand or wrist actions.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does cubital tunnel syndrome occur?

Most commonly, neuritis is due to some irritation, compression or stretching of the ulnar nerve within the relatively restricted confines of the cubital tunnel through which it travels. The nerve is vulnerable within this space for a number of reasons:

  • The space itself is relatively confined, with little room to accommodate any soft tissue swelling
  • The surrounding soft tissue envelope provides little protection and is thus at risk from trauma such as a direct blow during contact sports (like football or rugby)
  • In some cases (up to 17 percent) of the population, the nerve can actual be “unstable,” i.e., the nerve can actually move back and forth across the medial side of the elbow (the medial epicondyle), leading to repetitive stresses within the nerve. In an athlete performing repetitive overhead activity (baseball pitcher, tennis player, weight lifter), this can lead to neuritis as well.
  • Laxity of the elbow’s medial (inside) ligament can also result in increased forces on the ulnar nerve, causing symptoms

Some patients have insidious onset of symptoms without identifiable cause.

What increases the risk?

  • Athletic activities involving forceful and usually repetitive “overhead” type of motions, such as the baseball pitch, javelin throw or tennis serve
  • Contact and collision sports, particularly those in which the elbow is insufficiently padded (such as football and rugby)
  • Failure to properly warm-up, stretch or be appropriately conditioned, and subjecting the elbow to considerable demands

What are the symptoms of cubital tunnel syndrome?

  • Sense of numbness, tingling or radiating discomfort down the ulnar side (inside aspect) of the forearm or into the little and ring fingers
  • Occasional pain, discomfort or aching within the area of the cubital tunnel itself
  • Sense of hand weakness or clumsiness
  • Loss of normal sense of finger dexterity, grip strength and control
  • Compromised athletic performance (decreased throwing or serving velocity or accuracy, decreased weight-lifting ability)

How is cubital tunnel syndrome diagnosed?

Diagnosis is based on history and physical exam, occasionally complemented by a nerve study known as an EMG. Important components of the history are the symptoms listed above, most commonly discomfort, burning along the inside of the elbow and/or numbness and tingling in the little and ring fingers, particularly associated with provocative athletic activities (such as throwing for a baseball pitcher or serving for a tennis player)

Typical physical exam findings include:

  • Discomfort or tenderness to palpation (touch) over the cubital tunnel
  • A positive “Tinel’s” sign, in which light tapping over the course of the nerve within the tunnel elicits (and typically reproduces) the patients’ symptoms of referred pain, numbness and tingling, often in the little and ring fingers
  • Decreased sensation to light touch in the distribution of the nerve (little and ring fingers)
  • Possible “instability” of the ulnar nerve, in which the nerve can actually be felt to “move” back and forth over the medial (inside) aspect of the elbow bone (medial epicondyle)
  • A weak grip, especially power grip, and a weak pinch

Are there any special tests?

  • The most common tests are nerve diagnostic tests known as EMG/NCV.
  • An EMG stands for Electromyography. Very much like an EKG (electrocardiograph), an EMG measures the electrical activity in muscles of the upper extremity. In cases of significant neuritis, the muscles to which the nerves travel can demonstrate “irritability, confirming the likely problem within the nerve itself. EMG changes are uncommon in ulnar neuritis, since most patients have this condition occur only during activity, rather than at rest.
  • A more commonly performed diagnostic test is the NCV, or Nerve Conduction Velocity test. The NCV measures the speed of nerve conduction along the course of the nerve and is compared to known normals and the opposite elbow.

How is cubital tunnel syndrome treated?

Non-operative treatment

Initial treatment consists of avoiding provocative activities that precipitate symptoms. Anti-inflammatory medication and ice as necessary may be of value. Leaning on the elbow should be avoided. The use of an elbow pad or elbow splinting (usually only at night) may be recommended to prevent full bending of the elbow. Stretching and strengthening exercises of the muscles of the forearm and elbow are important. Referral to a physical therapist or an athletic trainer may be recommended for treatment.

Operative treatment

Failure of non-operative treatment may justify surgical intervention. Surgery involves decompression of the nerve by incising over the nerve’s sheath and releasing any adhesions or compression along the course of the nerve. If the nerve is “unstable”, it is usually transferred anteriorly (in front of) the medial epicondyle (inside elbow bone) and positioned either subcutaneously (under the skin) or sub-muscular (under the muscle).

What are the complications of treatment?

Possible complications of non-operative treatment include:

  • Persistent symptoms, impairment of athletic activity (such as in overhead athletes)

Possible complications of operative treatment include:

  • Numbness, tingling, persistent symptoms

When can you return to your sport/activity?

Return to activity is permitted as soon as symptoms have resolved. Activity modification may be necessary if the symptoms do not resolve with standard non-operative treatment. Return after surgical intervention may require three to four months depending upon whether the nerve required transposition (moving it anteriorly in front of the elbow) and the nature of the sport.

How can cubital tunnel syndrome be prevented?

  • Appropriately warm up and stretch before practice or competition
  • Maintain appropriate conditioning:
    • Wrist, forearm and elbow flexibility
    • Muscle strength and endurance
  • Wear proper protective equipment, including elbow pads
  • Use proper throwing techniques

 

TENNIS ELBOW (EPICONDYLITIS, LATERAL)

What is tennis elbow?

Tennis elbow (lateral epicondylitis) is the most common painful condition of the elbow. Pain occurs on the outside of the elbow at the bony prominence known as the epicondyle, where the muscle-tendons of the forearm and wrist attach. Movements associated with tennis--repetitive stresses with forearm supination (turning the forearm over with the palm up) and wrist extension--gave this condition its nickname, although many patients with tennis elbow do not in fact play tennis.

Furthermore, the word “tendonitis” refers to inflammation (“itis”) of the tendon, when in fact there is no real inflammatory component. The true pathology is what is now referred to as “tendinosis,” referring to degenerative changes in the tendon at the attachment site. Although the “itis” of epicondylitis refers to inflammation of the tendon, there is no real inflammatory component; this condition is rather “tendinosis,” the degenerative changes in the tendon at the elbow.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

What causes tennis elbow?

  • Chronic repetitive stress and strain to muscle-tendons of the forearm and wrist
  • Sudden increase in activity level or intensity
  • In tennis and other racquet sports, an inappropriately sized grip, racquet or string tension
  • Incorrect hitting position or technique (usually backhand; leading with the elbow)

What increases my risk?

  • Sports or jobs requiring repetitive and strenuous forearm and wrist movements (tennis, squash, racquetball, carpentry)
  • Sports that require strenuous or repetitive forearm movement (tennis, racquetball, “lead arm” in golf)
  • Poor physical conditioning (strength and flexibility)
  • Inadequate warm-up before practice or play
  • Resumption of activity before healing and rehabilitation and conditioning are complete

What are the symptoms of tennis elbow?

  • Pain and tenderness on the outer side of the elbow
  • Pain or weakness with gripping activities
  • Pain  upon twisting the wrist (playing tennis, using a screwdriver, opening a door or a jar)
  • Pain upon  lifting objects, even light things such as a coffee cup

How is tennis elbow diagnosed?

  • Diagnosis is established by the history pain on the outside of the elbow , focal tenderness over the bony prominence (epicondyle)
  • Pain with wrist extension against resistance
  • Pain with forearm supination against resistance

Are special tests required to diagnose tennis elbow?

  • X-rays are typically ordered by your doctor
  • MRI is unnecessary except in cases that are atypical ( e.g., history of prior surgery, significant trauma, swelling, difficulty with elbow motion)

How will my doctor treat tennis elbow?

Non-operative treatment is effective for most patients. Initial treatment consists of refraining from activities that cause the elbow pain. Ice and anti-inflammatory medications may help.

Brace or splint

Your physician may recommend using a “counterforce,” in the form of a tennis elbow brace (also called a tennis elbow strap), worn to splint the muscle-tendon unit just below where it attaches to the elbow. Gentle stretching and strengthening is helpful as the symptoms subside. Persistent symptoms may justify referral to physical therapy for further evaluation and treatment. Persistent symptoms are often treated with cortisone injection, which is effective for most patients, but may need to be repeated.

Operative treatment

Most patients respond to non-operative treatment, but surgery is indicated for those whose symptoms do not respond to physical therapy or cortisone injections.  Surgical treatment can be performed by either open or arthroscopic techniques. Both involve removal of the abnormal tissue responsible for causing pain. The success rate with surgical treatment is better than 90 percent.

What are potential complications from treatment?

Possible complications of non-operative treatment include:

  • Persistent symptoms of pain and impairment in daily activities, vocation and/or athletics

Possible complications of operative treatment include:

  • Persistent symptoms of pain/impairment
  • Risks associated with any surgery, such as infection, stiffness and inability to return to previous level of pre-injury activity

When can you return to your sport or activity?

  • In cases that have been present for a short period of time, improvement with simple measures may be effective quickly
  • Chronic cases may require three to six months to resolve and may require referral to a physical therapist or athletic trainer

How can tennis elbow” be prevented?

  • Appropriately warm up and stretching before practice or competition
  • Maintain:
    • Wrist and forearm flexibility
    • Muscle strength and endurance
  • Ensure proper equipment fit (i.e., racquet size/weight and grip)
  • Maintain proper technique and have a coach correct improper technique.
  • Wear a tennis elbow (counterforce) brace

 

GOLFERS' ELBOW (EPICONDYLITIS, MEDIAL)

What is “golfers’ elbow”?

Medial epicondylitis (golfers’ elbow) is less common that its counterpart on the lateral (outside) and occurs more frequently in sports that place stresses on the medial aspect of the elbow. Affected structures include the muscle-tendon structures at and just below the attachment site on the medial epicondyle (bony prominence on the inside of the elbow). These muscles are responsible for flexing your wrist and pronating (turning the palm down) your forearm. This condition occurs not only in golfers, but also in anyone who performs repeated resisted motions of the wrist.

Examples include golf, tennis and bowling. Despite its name “tendonitis,” which literally refers to inflammation (“itis”) of the tendon, there is no inflammatory component. The true pathology is what is now referred to as “tendinosis,” referring to degenerative changes in the tendon at the attachment site.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does golfers’ elbow occur?

Chronic, repetitive stress and strain to the muscles and tendons of the wrist and forearm to the elbow may cause this condition; alternatively, a sudden strain on the forearm, including wrist snap when serving balls with racket sports or throwing a baseball

What increases the risk?

  • Sports or jobs that require repetitive and/or strenuous forearm and wrist movements (tennis, squash, racquetball, carpentry)
  • Poor physical conditioning (strength and flexibility)
  • Inadequate warm-up before practice or play
  • Resumption of activity before healing and rehabilitation and conditioning are complete

What are the symptoms of golfers’ elbow?

  • Pain and tenderness on the inside of the elbow
  • Pain or weakness with gripping activities
  • Pain with twisting motions of the wrist (playing golf, using a screwdriver, or bowling)

How is golfers’ elbow diagnosed?

Diagnosis is established by the history of medial elbow pain, focal tenderness over the bony prominence on the inside of the elbow (the medial epicondyle). There may be pain with wrist flexion (bending wrist towards the palm) against resistance or pain with forearm pronation (turning palm down) against resistance.

Are there any special tests?

  • X-rays are usually normal
  • MRI is unnecessary except in cases that are atypical (i.e., history of prior surgery, significant trauma, swelling, difficulty with elbow motion).

How is golfers’ elbow treated?

Non-operative treatment is effective for most patients. Initial treatment consists of activity modification to minimize provocative activities that cause the pain. Anti-inflammatory medications and ice may be of value.

Brace or splint

Use of a “counterforce” (tennis elbow brace splints the muscle-tendon unit just distal to (below) the site of attachment) may be recommended. Gentle stretching and strengthening is helpful as the symptoms subside. Persistent symptoms may justify referral to physical therapy for further evaluation and treatment. Persistent symptoms are often treated with cortisone injection, which is effective for most patients, but may need to be repeated.

Operative treatment

Most patients respond to non-operative treatment, but for those who have persistent symptoms, surgery is indicated. Surgical treatment is open and involves surgical excision of the pathologic abnormal tissue responsible for the symptoms. The success rate with surgical treatment is better than 90 percent.

What are the complications of treatment?

Possible complications of non-operative treatment include:

  • Persistent symptoms of pain and impairment in daily activities, vocation and/or athletics

Possible complications of operative treatment include:

  • Persistent symptoms of pain/impairment
  • Risks associated with any surgery, such as infection, stiffness, and inability to return to previous level of pre-injury activity

When can you return to your sport or activity?

In cases that have been present for a short period, improvement with simple measures may be effective quickly. Chronic cases may require three to six months to resolve, and may require referral to a physical therapist or athletic trainer.

How can “golfers’ elbow” be prevented?

  • Appropriately warm up and stretch before practice or competition
  • Maintain:
    • Wrist and forearm flexibility
    • Muscle strength and endurance
  • Ensure proper equipment fit (e.g., racquet size/weight and grip)
  • Maintain proper technique and have a coach correct improper technique
  • Wear a tennis elbow (counterforce) brace

 

VALGUS EXTENSION OVERLOAD

What is valgus extension overload?

Valgus extension overload (VEO) syndrome is a condition seen in throwing athletes, in which repetitive stresses of throwing lead to progressive changes within the elbow joint, which cause pain and athletic impairment.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does VEO occur?

In the throwing motion, a substantial amount of force is generated over the medial (inside) aspect of the elbow. Over time, such stresses can lead to breakdown of the cartilage on the olecranon (the bony tip of the elbow that engages the distal humerus (end of the arm bone).

Eventual breakdown of the cartilage can lead to unstable body formation, development of bony osteophytes (spurs) and, in many cases, loss of normal elbow extension. Forces can also compromise the most important restraint on the medial side of the elbow, the ulnar collateral ligament (UCL). Injury to the UCL can precipitate or exacerbate VEO due to increased loading of the aticular surfaces.

What increases the risk?

  • Overhead throwing activities, especially those performed with sudden and forceful elbow extension (most commonly pitching though it can be any baseball position player   also the motions of  the javelin, hockey slap shot, tennis serve and volleyball serve/spike)
  • Improper mechanics
  • Inadequate physical conditioning (strength and flexibility)

What are the symptoms of VEO?

  • Pain and tenderness around the elbow (inner, outer or back of the elbow), especially when trying to throw or straighten the elbow
  • Occasionally, locking or catching of the elbow
  • Swelling within the elbow joint
  • Loss of normal extension (ability to straighten the elbow)
  • Inability to throw at full speed; loss of ball control
  • Occasionally, there is associated stress on the ulnar nerve (the funny bone), which is vulnerable to the same stresses and overload that lead to VEO. This can present as numbness or tingling in the ring and little fingers, with clumsiness and weakness in gripping.

How is VEO diagnosed?

Diagnosis is made by history and physical exam. X-rays are important to demonstrate the ostephytes (bone spurs) and, when present, loose bodies within the elbow.

Are there any special tests?

MRI is often indicated to evaluate integrity of the UCL, as well as document the extent of the ostephytes and any other pathology within the elbow.

How is VEO treated?

Non-operative treatment is appropriate in early stages. Rest, anti-inflammatory medication, gentle stretching and gradual return to throwing (or other sport) is effective for many patients. At a more elite level, presentation of a locked elbow that doesn’t straighten, and is accompanied by X-rays showing loose bodies, operative treatment is often warranted.

Operative treatment is indicated for those refractory to non-operative management and those with restricted motion and loose bodies. Arthroscopic surgery, in which a small camera is introduced into the elbow joint, permits removal of loose bodies and debris and shaving of any bone spurs that have formed.

The most important consideration in surgical intervention is identifying those individuals whose UCL also may require operative treatment to reconstruct the damaged ligament. If symptoms persist, or if there is locking and catching, which are due to loose bone fragments within the joint, arthroscopic surgery is recommended. Surgery is performed to remove bone spurs, bone fragments and loose cartilage.

What are the complications of treatment?

Possible complications of non-operative treatment include:

  • Persistent symptoms upon return to athletic activity, particularly amongst those with UCL pathology
  • Athletic impairment, such as inability to throw at full speed or distance, pain with throwing, and loss of ball control, especially if activity is resumed too quickly after injury
  • Inability to return to the same level of sports
  • Injury to other structures of the elbow, including medial epicondylitis and strain of the muscle-tendon of the muscles that bend the wrist
  • Prolonged disability
  • Elbow stiffness (loss of elbow motion)
  • Arthritis of the elbow

Possible complications of operative treatment include:

  • Recurrent symptoms upon return to athletic activity, particularly amongst those with UCL pathology
  • Athletic impairment, such as inability to throw at full speed or distance, pain with throwing, and loss of ball control, especially if activity is resumed too quickly after injury
  • Persistent elbow stiffness (loss of elbow motion)
  • Arthritis of the elbow
  • Surgical complications not specifically associated with VEO, such as pain, bleeding (uncommon), infection (<1%), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity-

When can you return to your sport or activity?

Resolution of symptoms and recovery of motion permit resumption of a throwing (or other activity, as appropriate) program. Return following surgery may be as early as 4 weeks, but requires resolution of pain, swelling, restoration of motion and ability to tolerate resumption of athletic activity.

How can VEO be prevented?

  • Appropriately warm up and stretch before practice and competition
  • Maintain appropriate conditioning:
    • Arm, forearm, and wrist flexibility
    • Muscle strength and endurance
  • Use proper technique when throwing, serving or hitting a puck

 

PRONATOR SYNDROME

What is pronator syndrome?

Pronator syndrome is a nerve disorder in the elbow and upper arm that causes pain, hand weakness and loss of feeling, often in the thumb and first three fingers. It involves compression of the median nerve in the forearm by muscles or ligament-like tissues. It may greatly decrease athletic performance in sports that require strong hand or wrist action.

How our elbow experts can help

Our elbow and arm experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does pronator syndrome occur?

Pressure affects the median nerve at the forearm. It is caused by swollen, inflamed or scarred tissue ligament-like tissue or between muscles of the forearm. A virus may cause inflammation of the nerve.

What increases risk?

  • Sports or occupations that require repetitive and strenuous forearm and wrist movements (tennis, squash, racquetball, carpentry), particularly rotation of the wrist and hand
  • Sports that require strenuous or repetitive forearm movement (tennis, racquetball, golf)
  • Poor physical conditioning (strength and flexibility)
  • Inadequate warm-up before practice or play
  • Diabetes mellitus
  • Hypothyroidism (underactive thyroid gland)

What are the symptoms or pronator syndrome?

  • Tingling, numbness or burning in part of the hand or fingers that may awaken you at night
  • Sharp pains that may shoot from the elbow to the wrist and hand, especially at night
  • Morning stiffness or cramping of the hand
  • Thumb weakness, particularly when bending the thumb; frequent dropping of objects; and inability to make a fist
  • Shiny, dry skin on the hand
  • Easy forearm fatigue and activity related forearm discomfort that may radiate up into the arm
  • Reduced performance in sports requiring strong grip

How is pronator syndrome treated?

Non-operative treatment: Initial treatment consists of rest from the offending activity and medications and ice to help reduce inflammation. Discomfort often improves by shaking your hand or dangling your arm. Stretching and strengthening exercises of the muscles of the forearm and elbow are important. Referral to a physical therapist or an athletic trainer may be necessary for treatment.

Operative treatment

Surgery may be necessary to free the pinched nerve. Surgery may be performed on an outpatient basis (you go home the same day), or you may be admitted for overnight stay. Surgery provides almost complete relief in most patients.

What are the complications of treatment?

Possible complications of non-operative treatment include:

  • Persistent symptoms
  • There is no evidence that ongoing compression will lead to permanent injury in most cases

Possible complications of operative treatment include:

  • Surgical complications not specifically associated with the forearm, such as pain, bleeding (uncommon), infection (<1%), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity-level.
  • Complications specific to surgical treatment of this condition include ongoing pain, nerve irritation and/or compression, and possible inability to return to previous level of activity.

When can you return to your sport/activity?

This condition is usually curable with appropriate treatment, and sometimes it heals spontaneously. Occasionally, surgery is necessary. Surgery is usually needed if muscle wasting (atrophy) or nerve changes have developed.

How can pronator syndrome be prevented?

  • Appropriately warm up and stretch before practice or competition
  • Maintain appropriate conditioning:
    • Wrist, forearm, and elbow flexibility
    • Muscle strength and endurance
    • Cardiovascular fitness
  • Ensure proper equipment fit
  • Use proper technique and have a coach correct improper technique

 

RADIAL TUNNEL SYNDROME (Radial [Posterior Interosseous] Nerve)

What is radial tunnel syndrome?

Radial tunnel syndrome is a nerve disorder in the elbow and upper arm that causes pain and hand and wrist weakness. It involves compression of the radial nerve (particularly the posterior interosseous branch) at the elbow or forearm by muscles or ligament-like tissues. That nerve has no sensory component; thus, there is no numbness associated with it.

Because its symptoms are similar in type and location to lateral epicondylitis (tennis elbow), it is often known as “resistant tennis elbow.” Posterior interosseous nerve dysfunction may decrease athletic performance in sports that require strong hand or wrist action.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does radial tunnel syndrome occur?

Radial tunnel syndrome is caused by pressure on the radial nerve at the elbow or in the forearm, caused by pressure under one of the forearm muscles or swollen, inflamed, or scarred tissue, ligament-like tissue, or an artery pressing on the nerve. It may also occur due to a direct blow to the nerve at the back of the upper arm.

What increases the risk?

  • Sports or occupations that require repetitive and strenuous rotation motions of the wrist
  • Contact sports, such as football, soccer and rugby
  • Poor physical conditioning (strength and flexibility)
  • Inadequate warm-up before practice or play
  • Diabetes mellitus
  • Hypothyroidism (underactive thyroid gland)

What are the symptoms of radial tunnel syndrome?

  • Vague, activity-related pain in the outer elbow that may shoot down the forearm
  • Sharp pains that may shoot from the elbow to the wrist and hand
  • Wrist and finger weakness
  • Tenderness of the outer elbow
  • Pain or weakness with gripping activities
  • Pain with twisting motions of the wrist, such as when playing tennis, using a screwdriver, or opening a door or a jar; also, with resistance, turning the palm up or passively turning the palm down.

How is radial tunnel syndrome treated?

Non-operative treatment: Initial treatment consists of rest from the offending activity and medications and ice to help reduce inflammation. Elbow splinting may be recommended. Stretching and strengthening exercises of the muscles of the forearm and elbow are important. Referral to physical therapy or an athletic trainer may be recommended for treatment.

Operative treatment

If this treatment is not successful within three to six months, surgery may be necessary to free the pinched nerve.

What are the complications of treatment?

Possible complications of operative treatment include:

  • Surgical complications not specifically associated with elbow repair/reconstruction, such as pain, bleeding (uncommon), infection (<1%), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.

When can you return to your sport/activity?

This condition is usually curable with appropriate treatment, and sometimes it heals spontaneously. Uncommonly, surgery is necessary. Surgery is usually needed if muscle wasting (atrophy) or nerve changes have developed.

How can radial tunnel syndrome be prevented?

  • Appropriately warm up and stretch before practice or competition
  • Maintain appropriate conditioning:
    • Cardiovascular fitness
    • Wrist, forearm, and elbow flexibility
    • Muscle strength and endurance
  • Wear proper protective equipment, including elbow pads

 

ULNAR COLLATERAL LIGAMENT INJURY OF THE ELBOW

What is an Ulnar Collateral Ligament Injury of the Elbow?

Ulnar collateral ligament injury of the elbow is a sprain (tear) of one of the ligaments on the inner side of the elbow. The ulnar collateral ligament (UCL) is a structure that helps keep the normal relationship of the humerus (arm bone) and the ulna (one of the forearm bones). This ligament is injured in throwing types of sports or after elbow dislocation or surgery. It may occur as a sudden tear or may gradually stretch out over time with repetitive injury. This ligament is rarely stressed in daily activities. It prevents the elbow from gapping apart on the inner side. When torn, this ligament usually does not heal or may heal in a lengthened position (loose).

Sprains are classified into three grades. In a first-degree sprain, the ligament is not lengthened but is painful. With a second-degree sprain, the ligament is stretched but still functions. With a third-degree sprain, the ligament is torn and does not function.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

How does ulnar collateral ligament injury occur?

A force that exceeds the strength of the ligament causes ulnar collateral ligament injury. This injury usually is the result of throwing repetitively or particularly hard. It may occur with an elbow dislocation or because of surgery.

What increases the risk?

Most injuries to the UCL occur in the arms of overhead throwers, particularly baseball pitchers. The injury usually occurs because of repetitive stresses in which the ligament ultimately compromised. Other risk factors include:

  • Contact sports (football, rugby) and sports in which falling on an outstretched hand results in an elbow dislocation
  • Throwing sports, such as baseball and javelin
  • Overhead sports, such as volleyball and tennis
  • Poor physical conditioning (strength and flexibility)
  • Improper throwing mechanics

What are the symptoms of ulnar collateral ligament injury?

  • Pain and tenderness on the inner side of the elbow, especially when trying to throw
  • A pop, tearing or pulling sensation noted at the time of injury
  • Swelling and bruising (after 24 hours) at the site of injury at the inner elbow and upper forearm if there is an acute tear
  • Inability to throw at full speed; loss of ball control
  • Elbow stiffness; inability to straighten the elbow
  • Numbness or tingling in the ring and little fingers and hand
  • Clumsiness and weakness of hand grip

How is ulnar collateral ligament injury diagnosed?

Pain over the medial aspect of the elbow, tenderness directly over the course of the UCL and special physical exam tests that reproduce the stress over the ligament are all helpful in confirming the diagnosis. The special physical exam tests include the “moving valgus stress test,” in which a force is applied to elbow as it is put through a range of motion. This may be the most sensitive and specific physical exam test.

Are there any special tests?

An MRI is the best test for visualizing the soft tissue structures of the elbow. When Gadolineum dye is instilled into the elbow prior to the MRI, small tears on the underside (deep portion) of the ligament can be detected, which may otherwise go unrecognized.

How is ulnar collateral ligament injury treated?

A mild injury may resolve on its own.

Non-operative treatment is indicated for most patients, who are able to successfully resume all pre-injury activities.

Non-operative treatment: Initial treatment consists of medications and ice to relieve pain and reduce the swelling of the elbow. You must stop participating in the sport that caused the injury. Occasionally a splint, brace or cast may be recommended while the acute phase subsides.

Medication may include:

  • Non-steroidal anti-inflammatory medications, such as aspirin and ibuprofen (do not take within seven days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician. Contact your physician immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.
  • Your physician may prescribe stronger pain relievers as necessary. Use only as directed.

Operative treatment is usually reserved for the small number of patients with complete traumatic injuries or those with persistent pain and impairment and evidence of a compromised ligament. This is most common in baseball pitchers.

“Tommy John” procedure

For those who have an acute rupture of the ligament or those who have failed therapy and wish to continue throwing competitively, surgical reconstruction (rebuilding the ligament using other tissue) is usually recommended. This procedure is known as the “Tommy John” procedure, named for the player whose career was saved when the ligament was reconstructed by Dr. Frank Jobe.

The ligament reconstruction can be performed using a variety of soft tissue grafts obtained from the patient, but is most commonly carried out using the palmaris longus tendon from the forearm. Because this tendon provides biomechanical characteristics that are similar to those of the native ligament, and because there are no consequences from its absence, it makes an ideal ligament substitute. Some patients do not have a palmaris longus tendon and therefore require an alternative graft for reconstruction, such as one of the toe extensors.

What are treatment complications?

Possible complications of non-operative treatment include:

  • Inability to return to previous level of throwing
  • Frequent recurrence of symptoms, such as an inability to throw at full speed or distance, pain with throwing, and loss of ball control, especially if activity is resumed too soon after injury
  • Injury to other structures of the elbow, including the cartilage of the outer elbow; loose body formation; injury to the ulnar nerve of the hand; medial epicondylitis and strain of the muscle-tendon of the muscles that bend the wrist
  • Injury to articular cartilage, resulting in arthritis of the elbow
  • Elbow stiffness (loss of elbow motion)
  • Ulnar nerve symptoms

Possible complications of operative treatment include:

  • Surgical complications not specifically associated with this procedure, such as pain, bleeding (uncommon), infection (<1%), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity

Complications specific to surgical treatment of this condition:

  • Failure to restore normal stability
  • Inability to return to previous level of activity (~10-20 percent failure rate)
  • Ulnar nerve injury
  • Irritation of cutaneous (skin) branches related to harvesting of palmaris longus tendon graft

When can I return to my sport or activity?

  • The UCL usually does not heal sufficiently on its own with non-operative treatment. To return to throwing, surgery is often necessary. Return to sports after injury without surgery may take three to six months and may take nine to 18 months following surgery.
  • Rehabilitation to improve strength endurance and proper throwing mechanics is initiated. This may be carried out at home, although usually referral to a physical therapist or athletic trainer is recommended.

How can an ulnar collateral ligament injury of the elbow be prevented?

  • Appropriately warm up and stretch before practice and competition
  • Maintain appropriate conditioning:
    • Arm, forearm and wrist flexibility
    • Muscle strength and endurance
  • Use proper protective technique when falling and throwing
  • Functional braces may be effective in preventing injury, especially re-injury, in contact sports


ULNAR NERVE CONTUSION

What is an ulnar nerve contusion?

Ulnar nerve contusion is a bruising injury to the ulnar nerve, close to the skin’s surface at the elbow, from a direct blow. Contusions cause bleeding from ruptured capillaries that allow blood to infiltrate the nerve. Direct injury to the nerve causes damage even if bleeding of capillaries is not a factor. The contusion causes pain, hand weakness, and loss of feeling, often in the fourth and fifth fingers. Ulnar nerve dysfunction or inflammation may greatly decrease athletic performance in sports that require strong hand or wrist action.

How our elbow experts can help

Our elbow experts will diagnose and treat your condition using the latest advances in orthopaedic technology. To request an appointment with our physicians, please call 202-787-5601.

What increases the risk of developing ulnar nerve contusion?

  • Ulnar nerve contusion occurs via a direct blow to the nerve at the elbow or falling on the elbow.
  • Risk for this kind of injury increases with contact sports such as football, soccer or rugby
  • Bleeding disorder or medications that thin the blood (such as warfarin [Coumadin], aspirin, and nonsteroidal anti-inflammatory medications)
  • Diabetes mellitus
  • Hypothyroidism (underactive thyroid gland)

What are the symptoms of ulnar nerve contusion?

  • Tingling, numbness or burning in part of the hand or fingers
  • Sharp pains that may shoot from the elbow to the wrist and hand
  • Hand weakness, clumsiness and heaviness
  • Poor dexterity (fine hand function)
  • Weak grip, especially power grip, and weak pinch
  • Swelling in the elbow
  • Tenderness of the inner elbow
  • Atrophy of muscles of the hand
  • Reduced performance in any sport requiring a strong grip

How is ulnar nerve contusion treated?

Non-operative treatment is indicated for most patients, who are able to successfully resume all pre-injury activities.

Non-operative treatment: Initial treatment consists of rest from the activity that causes pain and medications and ice to help reduce pain and inflammation. Your physician may recommend elbow splinting (usually only at night). Stretching and strengthening exercises of the muscles of the forearm and elbow are important. You may receive a referral to physical therapy or an athletic trainer.

Medication may include:

  • Nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen (do not take within seven days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician. Contact your physician immediately if any bleeding, stomach upset or signs of an allergic reaction occur.
  • Your physician may prescribe pain relievers as necessary. Use only as directed and only as much as you need.

Operative treatment is usually reserved for the small number of patients. If the non-surgical treatment is not successful, surgery may be necessary to free the pinched nerve, but this is rare.

What are the treatment complications?

Possible complications of non-operative treatment include:

  • Persistent symptoms of pain and impairment
  • Occasionally, muscle atrophy

Possible complications of operative treatment include:

  • Surgical complications not specifically associated with the elbow, such as pain, bleeding, infection, nerve injury, stiffness, problems with anesthesia and inability to return to previous level of pre-injury activity. Some of these complications are uncommon.
  • Complications specific to surgical treatment of this condition include injury to the ulnar nerve, with numbing, tingling and possible weakness of the muscles innervated by this nerve.

Possible complications of either treatment include:

  • Permanent numbness and weakness of the ring and little fingers
  • Weak grip
  • Permanent paralysis of some of the hand and finger muscles
  • Prolonged healing time if usual activities are resumed too soon

When can I return to my sport or activity?

This condition is usually curable with appropriate treatment and often heals spontaneously. Complete healing may take up to six weeks, depending on the extent of injury. Rarely, symptoms may be permanent.

How can an ulnar nerve contusion be prevented?

Wear proper protective equipment, including elbow pads, while engaging in contact sports.

 

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