Elbow Conditions

Mechanical Elbow Pathology

Cause: As with other joints the cause of arthritis is unknown but fortunately the elbow only rarely becomes arthritic to such an extent that surgery is required. The exception is in patients with Inflammatory Arthritis, but fortunately the more recent “disease-modifying” drugs have made the need for elbow replacement very rare. Most mechanical elbow symptoms are caused by loose chips of cartilage jamming the joint or by incongruences of the joint surfaces; possible the result of previous trauma.

Presentation: Most common are symptoms of locking or jamming; as if the elbow gets stuck and has to be eased back to movements. Other symptoms may be a rasping sensation on bending or rotating the joint, or a loss of movement (i.e. reduced flexion or an inability to straighten the elbow fully). There may be a history of previous trauma such as a fracture to the head of the radius.

Treatment: Most elbow symptoms settle down following a period of rest, followed by mobilising exercises possibly supervised by a physiotherapist. If the symptoms persist X-rays may be indicated to assess the status of the joint. Occasionally an MRI scan is helpful, but if mechanical symptoms persist an elbow arthroscopy (key-hole procedure) should be performed or, depending on the problem, an arthrotomy (opening the joint via a small lateral incision). Any loose bodies can be removed, bony irregularities possibly trimmed. If the head of the Radius is arthritic or irregular of shape causing symptoms this may be excised.

Occasionally bone prominences (osteophytes) need to be excised and it may be necessary to open up the back of the elbow.

Only in the severely arthritic elbow may elbow replacement be an option. This is very rare following osteoarthritis, may be necessary after severe fractures in the elderly patient but otherwise the procedure is mainly done in patients with inflammatory arthritis. I do 40-50 hip replacements per year, 35-40 shoulder replacements and only 1 or 2 elbow replacements. I have in total done more than 45 elbow replacements but, as stated above, the present medical treatment has almost completely removed the need for joint replacements. Most elbow surgery is done during a one-day admission, occasionally with the need for an overnight stay. In most cases early movements and use of the arm is encouraged.

Surgical risks: All surgery is associated with risks. The main risk in connection with elbow surgery is post-operative stiffness and some loss of movement. Other risks are nerve damage (often temporary), infection, bleeding and postoperative pain. In patients suffering from inflammatory arthritis the infection risk is higher as they are often treated with immuno suppressing drugs.

Night-time splintage. Steroid injections into or close to the Carpal Tunnel. Surgery: Transecting the Carpal Ligament relieves the pressure on the nerve and generally results in almost full symptomatic relief. But if the nerve has been severely and permanently damaged before surgery the aim of surgery is to prevent further damage and possibly obtain some relief. Surgery may be associated with complications such as infection, delayed wound healing, finger and wrist stiffness, nerve damage, tenderness corresponding to the scar, and Regional Pain Syndrome.

Tennis Elbow

Cause: Tennis Elbow is caused by micro tears to the soft tissues at their attachment to Lateral Humeral Epicondyle (the prominent bone just above the elbow joint). Repetitive activities or excessive strains to the muscles used for straightening the wrist may result in small tears to the area where the muscle blends into the membrane covering the bone (the Periosteum). Tennis Elbow is rarely associated with tennis but often with other wrist straining activities in connection with gardening, manual work, keyboard activities etc. It may also be associated with sports – racket sports or throwing disciplines.

Presentation: Pain of the outside of the elbow (or in the Case of Golfer’s Elbow the inside), The pain may radiate down towards the wrist. It is often brought on by activities requiring the wrist to be bend backwards (extended) or requiring the wrist to be held still (in an isometric position). The pain may become severe causing sleep disturbances.

Treatment: Generally Tennis Elbow settles down with time – in particular if the causative activities can be avoided – or in case of sports changes to technique introduced. Rest, anti-inflammatory medication, wearing an Elbow Brace (Epicondylitis Brace), Physiotherapy or Acupuncture may all result in a cure.

If the symptoms persist a steroid injection may give relief but one should only give one or two injections as side effects may be seen.

If non-operative treatment is unsuccessful surgery in the form of partial release of the muscle attachment to the outside of the elbow is often successful. In most cases this can be done in a local anaesthetic trough a minimal incision. It should be followed by a period of rest before strenuous or repetitive activities should be taken up again.

As always surgery may be associated with the risk of complications.