Arm and elbow pain caused by conditions such as golfer’s elbow and elbow arthritis is treated by Newton Wellesley Orthopedic Associates in Newton and Wellesley, MA.
Conditions Affecting the Arm and Elbow
Newton Wellesley Orthopedic Associates in Newton and Wellesley, MA offers information about tennis elbow including symptoms, treatment and surgical options.
About Tennis Elbow
One of the most common causes of elbow pain in adults is lateral epicondylitis (tennis elbow), a form of elbow tendonitis. Tennis elbow causes pain at the bony point (the epicondyle) on the “outside” of the elbow. Many patients with these conditions do not even play golf or tennis, but often are physically active in other ways, through sports or work. Almost all patients affected by tennis and golfer’s elbow are between 30-60 years old.
Tennis Elbow Symptoms
Tennis elbow affects the extensor carpi radialis brevis (ECRB) tendon where it is attached to the lateral epicondyle of the elbow, and can be considered a form of tendonitis. This tendon is one of the several tendons that work to extend the wrist. Though symptoms often start suddenly or with an injury, the pain is not usually caused by a “tear” or “rupture” of the tendon except in very violent injuries. Whether the tendon is “torn” or “ruptured” does not usually change the course of treatment, in any case.
Patients usually have a very localized pain (i.e. can point at the site of maximum pain with one finger) and the pain may radiate down the back of the forearm. Gripping and grasping and especially lifting anything with an overhand grip (i.e. a handbag, toolbox, etc) aggravates the pain at the elbow and forearm. Though it may hurt to move the elbow, most patients have full elbow range of motion and do not have any mechanical symptoms such as clicking or locking of the joint.
The diagnosis of tennis elbow is almost always made by a simple physical exam. Usually X-rays, MRI, and other tests are unnecessary though the physician may order one if there are atypical symptoms (lack of full motion, mechanical symptoms, pain that is not classic for tennis elbow).
Tennis Elbow Treatment
The most important thing to keep in mind is that tennis elbow is a benign condition. Though it is painful, no harm will come to the arm or elbow by delaying treatment, and eventually the condition will resolve on its own (though this may take quite a long time). In all cases, treatment should start with conservative measures. These include:
- Modification of how the hand is positioned for lifting (i.e. use an underhand grip, not overhand).
Mills stretching exercises.
- Use of a tennis elbow brace (counterforce strap).
- Occasional use of heat and ice packs. Many patients ask if heat or ice is better and there is no agreement on the right answer. Both should be tried, and whichever feels better is the one that should be used.
- Over-the-counter anti-inflammatories such as acetaminophen (e.g. Tylenol) or ibuprofen (e.g. Motrin).
- Physical therapy. This usually involves 1-2 visits per week to a PT over the course of 6-8 weeks. Many different methods of treating the pain are employed, including further stretching/strengthening, manipulation, taping, or even ultrasound/electrical stimulation of the painful area.
Mills Exercise for Tennis Elbow
In some cases, a cortisone injection may be a useful option. This is done in the doctor’s office and involves direct injection of an anti-inflammatory medicine right into the area of pain. A local anesthetic is used to help with the injection site pain. Within a few days, most patients experience significant pain relief and after a few weeks many patients have complete relief of their pain. However, the pain relief is temporary, usually wearing off after about 6 months. There are also limitations to how many injections can be given in an individual’s lifetime and most doctors will not give more than three injections in the same elbow out of concern for weakening of the underlying ligaments of the elbow. A new and promising treatment option is PRP injection, with early studies showing positive results.
If the symptoms of tennis elbow continue to be severe, then surgical treatment of tennis elbow may be the next step. This is done either open (through a 1-2 inch incision at the side of the elbow) or arthroscopically (through two 5-millimeter incisions, one on each side of the elbow). Sutures are removed about a week later and immediate stretching exercises are begun to regain motion. About 85% of patients experience excellent or complete pain relief following surgery (either arthroscopic or open), and return to manual labor and sports is usually possible by 8 weeks postop.
Arthroscopic Surgery for Tennis Elbow
Many patients worry that, left untreated, they will live with elbow pain for the rest of their lives and this is not true. Even with no treatment (i.e. ignoring the problem) many patients with tennis elbow will experience spontaneous disappearance of the pain over time. However, this has been known to take years in some individuals. Therefore, all of the treatment measures for tennis elbow can be considered palliative (i.e. treating pain only).
Golfer’s elbow is often indicated by pain on the inner side of the elbow and forearm. Also called medial epicondylitis, this condition is caused by repetitive stress that damages muscles and tendons that control the wrist and fingers, such as swinging a golf club incorrectly.
The damage is typically related to excess or repetitive stress — especially forceful wrist and finger motions. Improper lifting, throwing or hitting, as well as too little warm-up or poor conditioning, also can contribute to Golfer’s elbow.
Cubital Tunnel Syndrome
Cubital tunnel syndrome refers to chronic compression of the ulnar nerve at the elbow. The ulnar nerve is responsible for providing sensation to the ring and small fingers, as well as one half of the hand. Some of the fine muscles in the hand as well as one of the muscles in the forearm that enable a person to perform power grip are also controlled by the ulnar nerve.
Very frequently, the ulnar nerve is compressed as it courses behind the medial epicondyle of the elbow (see figure to the right) in an area called the cubital tunnel. Rarely, the nerve may be compressed at the wrist, a condition known as ulnar tunnel syndrome. Unlike most major nerves in the arms and legs, the ulnar nerve is the only one to course on the extensor surface of the joint. This means that when the joint is flexed, the nerve becomes significantly stretched. The combination of nerve stretch as well as compression of the nerve in the cubital tunnel is what causes the symptoms of pain, burning, and numbness. With prolonged or advanced compression, muscle atrophy (shrinkage of hand muscles) and weakness with pinch and grip are also seen.
It is rare to see cubital tunnel syndrome in children, but it may be seen in all other age groups including teenagers. Occasionally it is caused by an injury or trauma to the elbow, but most often it is caused by holding the elbow in a prolonged position of flexion. For example, holding a cell phone to the ear for a long time or falling asleep with a hand under the pillow are two positions requiring prolonged elbow flexion, which may bring about ulnar nerve symptoms. Very rarely, it is caused by anatomic abnormalities such as an extra muscle.
Treatment is usually straightforward and involves paying attention to how the hand and elbow are used during the day. Though it is okay to move and flex the elbow, patients should avoid holding the elbow flexed for long periods of time. Hands-free devices for phones may be used, and sitting back away from a keyboard so that the elbows do not have to be tucked in for long periods of time may help. When sleeping, a pillow or rolled towel can be fastened to the front of the arm with rubber bands or tape, to create a quick and cheap splint to prevent elbow flexion at night. A sports elbow pad worn backward (so the thick pad sits in the front of the elbow) also works well. If none of these are comfortable, an occupational therapist can sometimes make a custom molded form fitting splint for the patient.
The majority of patients do well with night splinting and daytime activity modifications. For the few patients who do not get better after a few months of this treatment, or for the patients with advanced nerve compression (muscle atrophy, obvious hand weakness), surgery is the best treatment. This involves surgically decompressing the nerve and in some cases moving the nerve around to the front of the elbow (known as ulnar nerve transposition). These are quick procedures, can be done in fifteen minutes (simple decompression) to an hour (for transposition), and are usually day surgeries.
Immediately after surgery, the elbow may be immobilized in a soft dressing or even a rigid plaster dressing for comfort. Sutures are removed about a week later and patients are encouraged to begin stretching exercises. Almost all patients recover their motion within a month and experience tremendous relief of pain and burning after the surgery. For patients with more severe compression, return of sensation and strength is variable and usually takes months (sometimes years).
What is Elbow Arthritis?
Arthritis of the elbow is usually one of two types – osteoarthritis (e.g. from “wear and tear”) and inflammatory arthritis (such as rheumatoid arthritis). Osteoarthritis most often occurs in manual laborers, heavy weightlifters, or individuals who have had a prior elbow fracture. Rheumatoid arthritis may occur in individuals from any age group and regardless of activity level. No matter what the cause of arthritis, symptoms usually consist of some combination of pain and stiffness.
If there are loose bodies (pieces of bone spurs and cartilage that have broken off and are floating in the joint), patients may have episodes of locking and clicking. History, physical exam, and a simple X-ray are usually all that are necessary to make the diagnosis. In patients where inflammatory arthritis is suspected (and who do not already have this known diagnosis), a panel of blood tests and evaluation by a rheumatologist is necessary.
Thankfully, many individuals with severe arthritis seen on X-ray may have easily manageable symptoms. This may be due to the fact that the elbow is not usually a weightbearing joint (like a hip or knee). Avoidance of heavy lifting with the arm, maintaining motion with stretching exercises, and occasional use of anti-inflammatory medications (acetaminophen or ibuprofen, for example) is the first line of treatment. If symptoms are severe, cortisone injections to the elbow can help but these usually do not provide permanent relief of pain.
Surgical treatment of arthritis mostly consists of either arthroscopy (to remove all loose bodies, bone spurs, and other inflammatory tissues) or total elbow replacement in the most severe of cases. Both treatment methods are very reliable in relieving pain and improving motion.
A 63 year old man with severe pain, clicking, locking, and stiffness in the left elbow. Xrays demonstrated severe arthritis and loose bodies in the elbow. He underwent arthroscopy to remove bone spurs and loose bodies, with significant improvement in his pain, motion, and mechanical symptoms.
A 46 year old truck mechanic with clicking, locking, and pain when flexing the elbow. Despite physical therapy and injections, his pain continued to make work difficult for him. He underwent arthroscopic removal of bone spurs and loose bodies with resultant improvement in motion and pain.
See how this type of arthroscopy is performed in this video.
An 80 year old independently living woman with progressively worsening severe pain in the right elbow. Despite modifications in activity level, multiple pain medicines and multiple cortisone injections to the elbow, the pain continued to be debilitating. She finally underwent a total elbow replacement with complete resolution of her pain.
Elbow instability refers to a rupture or stretching out of one of the main ligaments that keeps the elbow from dislocating or subluxing (“partial dislocation”). This may occur following trauma or as a result of repetitive stress and strain to the ligament. Often, instability is not obvious to the patient but rather manifests as pain or a decrease in athletic performance (such as loss of pitch speed and endurance in a throwing athlete). Rarely, patients are able to actually pop the elbow out of joint, and have had a history of dislocating the elbow in the past. There are several types of elbow instability but the two most commonly treated ones are:
- Posterolateral Rotatory Instability (PLRI)
- Valgus Instability
Posterolateral Rotatory Instability (PLRI)
Posterolateral Rotatory Instability of the elbow (PLRI) is caused by failure of the lateral ulnar collateral ligament (LUCL) of the elbow, resulting in pain in the outer back side of the elbow (posterolateral elbow). This may be caused by a prior elbow fracture or dislocation. Rarely, it may also happen after surgery or too many cortisone injections for tennis elbow. Patients usually feel pain at the posterolateral elbow, and may also have difficulty “locking out” the elbow because of a sense that the elbow may pop out of joint when it is held in a fully straightened position. Very rarely can patients cause the elbow to come out of joint on purpose. Physical exam is not usually reliable in picking up this diagnosis, unless a stress exam of the elbow under anesthesia is performed. Xrays are used to rule out other conditions (fractures, arthritis, loose bone chips in the joint). An MRI may even miss the diagnosis in mild cases.
When the condition is acute (within a few months following an elbow dislocation) it may be treated by keeping the arm in a long cast for about a month, followed by supervised physical/occupational therapy. If the condition has persisted for more than a few months then surgery is almost always required. This is usually in the form of a ligament reconstruction, in which a cadaver tendon or a wrist tendon (the palmaris longus) from the patient is harvested and used to recreate the lost ligament. Elbow arthroscopy is often performed at the same time if other conditions are suspected.
Video: Arthroscopic diagnosis and treatment of an unstable elbow
Following successful ligament reconstruction, the patient will need to be placed into a long arm cast for 3-4 weeks to allow healing of the tendon graft. This is then followed by 6-8 weeks of controlled, protected physical or occupational therapy. By 12 weeks after the surgery patients are allowed full return to activity if they are doing well. The vast majority of patients with PLRI do very well from such a ligament reconstruction.
Injury to the ulnar collateral ligament causes Valgus Instability, making the elbow unstable.
Distal Biceps Tendon Rupture
What Is A Distal Biceps Tendon Rupture?
The biceps muscle is attached by tendons at both ends (the shoulder and the elbow). Either end can be torn as a result of trauma and degenerative change. This page discusses the distal biceps tendon rupture (at the elbow).
Distal biceps tendon ruptures almost always occur in men between age 40-60, though they are becoming increasingly recognized in women. Complete ruptures are fairly dramatic and occur when the elbow is forcibly extended while the patient is trying to keep it flexed (i.e. a heavy weight being placed into the patient’s hand that he or she is unable to carry). Very often the pain is sudden, severe, and an audible “pop” may be heard. This often is followed in the next few days by swelling, bruising, and an abnormal contour to the front of the elbow and arm. Patients may even notice some numbness and tingling running down the forearm. In very lean individuals, this diagnosis is obvious on history and physical examination but in patients with much larger arms or where a partial tear is present, additional testing such as an MRI scan may be required to establish the diagnosis.
Clinical photo of a construction worker with a distal biceps rupture
Sagittal MRI image of a man with distal biceps rupture
The best treatment for a partial distal biceps rupture is several months of rest from heavy lifting. However, if the symptoms do not improve or in the event of a complete distal biceps tendon rupture, the best treatment is surgical reattachment of the ruptured tendon. Repeated studies have shown significantly better arm strength, endurance, and overall functionality in patients who have the tendon repaired compared to patients who do not. The diagnosis of a complete rupture must be made early because the tendon becomes significantly more difficult to repair after a few weeks have passed.
Surgical Repair of Acute Distal Biceps Tendon Rupture
Surgical Repair of Chronic Distal Biceps Tendon Rupture
Bruce Leslie, MD and the physicians at NWOA have performed the largest published series of biceps tendon repairs in the world. Some of Dr. Leslie’s published articles on biceps tendon ruptures are listed below.
Scholarly Articles on Distal Biceps Tendon Tears
Triceps Tendon Rupture at the Elbow
A triceps tendon rupture is an injury to the tendon that connects the elbow to the back of the upper arm.
Triceps Tendon Rupture and Surgical Repair
Repair of Triceps Tendon (warning: may contain graphic material)
Elbow Pain in Young Athletes and Tommy John Surgery
Elbow Pain in Young Athletes
With more widespread and intense participation of young children and teenagers in sports these days, elbow injuries are becoming more and more common. The sports most likely to cause elbow injury are gymnastics and baseball (particularly pitchers and catchers) although athletes of all types and skill level are prone to elbow injury. Learn more about some of these causes of elbow pain in young athletes.
- Osteochondritis Dissecans (OCD) of the Capitellum
- Panner’s Disease
- Medial Ulnar Collateral Ligament Injury and “Tommy John” Surgery
- Valgus-Extension Overload Syndrome
Osteochondritis Dissecans (OCD) of the Capitellum
The capitellum is a bony structure inside of the elbow joint, forming one half of the end of the humerus. It is located on the lateral half of the joint. In teenage athletes who chronically apply compressive loads to the elbow (gymnasts and overhead throwing athletes), osteochondritis dissecans (OCD) may occur in the capitellum. This is a disorder in which a portion of the cartilage overlying the capitellum may soften, fray, and even separate. A variable amount of the underlying bone may separate along with it, resulting in a loose body floating within the elbow joint. No one is entirely sure why this happens but it is thought to occur due to interruption of the blood supply to the separated portion of bone as well as the chronic compressive loads to the joint. In a way this can be thought of as a “stress fracture” of the joint. The pain from an OCD lesion is dull and aching, and feel as if it is coming from deep within the elbow. Very often there is great difficulty straightening the arm. There may also be clicking, clunking, or other mechanical symptoms with attempts at elbow motion if a loose body has formed. Diagnosis is obtained by a physical exam and history, as well as X-rays and in many cases an MRI scan of the elbow.
In its early stages (i.e. before separation and formation of a loose body) this condition is best treated by at least a month of complete rest from the offending sport, possibly even application of a long-arm cast to immobilize the elbow during that time. Physical/occupational therapy may be required following the period of rest, with a gentle and gradual return to play only if pain has improved.
In the late stages (lesion has separated, loose bodies have formed) or if symptoms have not improved after a long period of rest and physical/occupational therapy, surgery may need to be performed. Arthroscopic surgery is now the standard treatment for this condition and may consist of drilling holes in the bone beneath the lesion (to increase blood supply), removing loose bodies, and microfracture (removing the loose lesion and abrading the bone beneath it to stimulate a healing reaction). In extremely rare cases with very large lesions, the loose fragment may actually be fixable using screws, pins, staples or suture.
Video of Arthroscopic Treatment Of OCD Lesion of the Capitellum
Panner’s Disease is similar in almost every way to osteochondritis dissecans of the capitellum. However, unlike OCD of the capitellum (which occurs in teenagers) Panner’s Disease almost always occurs in boys younger than age 9. The prognosis is excellent and, with a period of rest and immobilization (i.e. a brace or cast) the condition almost always resolves on its own.
Medial Ulnar Collateral Ligament Injury and “Tommy John” Surgery
The medial ulnar collateral ligament (MUCL) is a ligament at the medial (“inside”) elbow, which stabilizes the elbow during overhead throwing motion, particularly during the late cocking and acceleration phases. These are the phases during which a pitcher will experience inner elbow pain with a MUCL tear. Inner elbow pain that occurs with follow-through is usually valgus-extension overload syndrome. Other types of overhead throwing athletes (quarterbacks, javelin throwers) are less prone to MUCL injury than pitchers. Underhand throwers (softball pitchers) are at low risk of this type of injury.
The MUCL may rupture with a “pop” and sudden pain, followed by swelling and bruising of the inner arm, or it may stretch and thin out gradually over hundreds and thousands of pitches. Generally, athletes with MUCL injuries do not experience inner elbow pain with regular daily activities. The pain occurs only during overhead throwing, and there will be an accompanying loss of throwing speed and endurance.
For the athlete who is likely to make a career out of pitching, early evaluation by an orthopedic surgeon is best in order to avoid prolonged “down time” and to maximize the odds of return to pre-injury levels of competition. This usually begins with a history, physical examination and often includes X-rays and possibly MRI of the elbow.
Initial treatment should consist of ice, elevation, compression and anti-inflammatory medication. In cases of mild injury or when MRI confirms that no complete ligament rupture has occurred, conservative treatment is highly effective. This consists of avoidance of throwing for 4-6 weeks followed by physical therapy and a graduated throwing program to slowly return to competition, which may take an additional 6-8 weeks. If there is a complete MUCL rupture and the athlete is likely to make a career out of throwing (collegiate or professional), consideration should be given towards reconstruction of the ligament, widely known as “Tommy John Surgery.”
As with any chronic injury, prevention is the best treatment. A serious pitcher should work with a qualified pitching coach to ensure safe pitching mechanics and good general conditioning, particularly of the hips, back, and shoulder. Pitch counts, limitations on days of throwing per week, and a 2-3 month yearly “break” from pitching should all be observed. An excellent summary of these recommendations can be found in the ASMI Position Statement for Youth Baseball Pitchers.
Valgus Extension Overload Syndrome
Valgus Extension Overload Syndrome is also known as pitcher’s elbow and is most often found in athletes due to overhead throwing.
Elbow Fractures and Dislocations
The elbow is a joint that is capable of moving through a very wide arc of motion. Maximum flexion is necessary for a person to bring the hand to the face and head and allow activities such as feeding and hygiene. Extension of the elbow is necessary to allow a person to reach over the head and down well below the waist, to allow for toileting and donning shoes and socks.
Trauma to the elbow such as fractures and dislocations very often cause stiffness and loss of motion of the elbow, which can be very debilitating. Whenever possible, treatment of elbow fracture and dislocations should allow the elbow to continue moving while the injured structures heal. For simple fractures or dislocations, this may involve a brief time in a sling or splint (2 weeks) followed by stretching exercises, which may sometimes need to be done under the supervision of a physical or occupational therapist. For more complex and unstable fractures, surgery is the best option to allow stabilization of all bone and ligament structures while still allowing the patient to begin early range of motion, and therefore a better long-term outcome.
- Elbow Injuries Best Treated without Surgery
- Elbow Injuries Best Treated with Surgery
Nonsurgical Elbow Injuries
Simple Elbow Dislocation
“Simple” elbow dislocations refer to elbow dislocations with no associated bony fractures. These are usually caused by hyperextension (i.e. bending the elbow backward). This may happen when a patient falls from a height, catching all of their weight on the affected hand. Almost always, these are stable once the joint is manipulated back into the correct position under light sedation (i.e. closed reduction) or even a local anesthetic. This usually must be done in an emergency room or operating room. After 2 weeks of immobilization of the elbow in a sling or splint, stretching exercises are begun and most patients do very well, with very few patients having chronic elbow instability. Many patients have slight stiffness of the elbow in the long term, but almost never enough to affect activities of daily living or sports.
Simple Radial Head or Radial Neck Fracture
Radial head and radial neck fractures account for the majority of elbow fractures. Most usually occur from a fall onto the hand, with transmission of force to the elbow, resulting in the fracture. Bruising, swelling, and stiffness are common but subside over the course of several weeks. Most of these fractures are treated by one or two weeks in a sling at most, followed by initiation of stretching exercises as soon as pain allows. Most patients do very well, though it is common to have mild stiffness and occasional discomfort in the elbow for a long time following this injury. In severe fractures (see below) surgery may be required to restore motion and stability to the elbow joint.
Surgical Elbow Injuries
Severe Radial Head or Radial Neck Fractures
Radial head and radial neck fractures account for the majority of elbow fractures. While simple fractures typically heal in a few weeks, severe fractures of this kind may require surgery to restore motion and stability to the elbow joint.
The olecranon is the bony tip of the elbow. In cases where an olecranon fracture is displaced or open, surgery may be required.
Distal Humerus Fractures
The distal humerus is the upper part of the elbow joint. A serious fracture of this bone may need to be repaired surgically.
Elbow Dislocations Combined with a Fracture
Though elbow dislocations are uncommon, when they are coupled with a fracture, surgical repair may be necessary.
Basic Stretching Exercises for the Stiff Elbow
One of the most common difficulties patients encounter following an elbow sprain, fracture or elbow surgery is stiffness of the elbow. In the vast majority of cases these can be resolved with simple exercises, which can be done at home in simple cases or with a physical/occupational therapist in more complex or difficult cases. Pictured below are the basic stretches you may be asked to do to help rehab your elbow following injury or surgery. Please consult with your orthopedic surgeon or physical/occupational therapist before making these exercises a part of your routine.
These exercises should be performed 3 times a day or more, and each position should be held at least 3 minutes.
Gravity-Assisted Elbow Extension Stretch
Gravity-Assisted Elbow Flexion Stretch