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About Orthopaedic Surgery

Elbow

Anatomy | Lateral Epicondylitis | Medial Epicondylitis
Radial Tunnel Syndrome | Cubital Tunnel Syndrome
Olecranon Bursitis

Anatomy
The elbow is a very complex joint, with three bones, the humerus, radius, and ulna, coming together to move in flexion, extension, and rotation. The structures most often of clinical significance are the radial head (fracture), the ulnar nerve, the tendinous origin of the extensor muscles, the radial nerve, and the olecranon bursa. top

Lateral Epicondylitis (Tennis Elbow)
Tennis elbow (lateral epicondylitis) is a painful inflammation of the tendon on the lateral aspect of the elbow, caused by the pull of the muscles which extend the wrist and fingers. It can be caused by acute or repetitive injury. In tennis, it is caused by excessive forces on the elbow with the backhand shot.

The diagnosis is made by physical examination. Treatment includes the use of tennis elbow straps, judicious use of cortisone injections, physiotherapy (especially strengthening exercises), heat, ice, and anti-inflammatory medications. If these measures fail, surgical treatment may be indicated, consisting either of removing the necrotic and/or inflammatory tissue, or release of the tendon from the humerus. This can be done as an open operation or through a stab wound as an office procedure. Tennis players can use larger racquet grips, looser strings, and, probably most importantly, tennis lessons to decrease the forces at the elbow. top

Medial Epicondylitis (Golfer's Elbow)
Similar to the more common lateral epicondylitis, tennis elbow involving the medial, or inner, aspect of the elbow, consists of inflammation, degeneration and/or small tears of the tendon that attaches to the medial epicondyle, the small bony prominence just above the elbow (See Anatomy). The inflamed tendon is one of the attachments of the muscles that flex the wrist and fingers, and can be inflamed by unusual or repetitive gripping and/or forearm rotation. Although tennis is a frequent inciting cause, more often it is normal daily activities which are at fault.

The symptoms and signs of medial epicondylitis are pain with grip and tenderness over the medial epicondyle and/or the tendon. Treatment can be as simple as rest, ice/heat, and anti-inflammatory medications, such as aspirin or ibuprofen, but may require splints, tennis elbow straps, cortisone infections into the inflamed area, physical therapy, or, ultimately, surgical release or repair of the injured tendon.

For tennis players with medial epicondylitis, correction of poor stroke mechanics via tennis lessons should be considered, especially regarding techniques of applying spin on forehands and serves. Decreasing the force on the elbow with a larger grip and looser strings can also decrease the forces applied to the elbow. top

Radial Tunnel Syndrome

A cause of lateral, or outer, elbow pain which may accompany lateral epicondylitis, and from which it must be differentiated, is pain coming from compression of the radial nerve as it goes through the tight area in the proximal forearm, just past the elbow (see Anatomy). The nerve can be compressed by the supinator muscle as it passes between the two parts of the muscle and/or by the overlying fibrous bands in the finger and wrist extensor muscles. The pain and tenderness associated with this condition is usually localized to the upper, lateral forearm area and made worse by middle finger extension. Although it may be caused by repetitive gripping activities or trauma to this area, the cause is frequently idiopathic (unknown).

Treatment should be conservative, with rest, heat/ice, anti-inflammatory medications and physical therapy tried prior to surgical release of the offending structures over the nerve. top

Cubital Tunnel Syndrome (Ulnar Nerve Compression)
Numbness in the hand can be caused by pressure on the ulnar nerve at the elbow. This numbness is felt in the ring and small fingers, which receive their innervation from the ulnar nerve. The nerve is compressed as it passes through the cubital tunnel, located just behind the medial epicondyle (see Anatomy). In the cubital tunnel, the nerve is covered by a thickened portion of the fascia, or muscle covering, called Osborne's ligament, which can cause excessive pressure on the nerve, leading to numbness, tingling, and even weakness of the hand muscles. In severe cases, there may be atrophy, or shrinking, of the hand muscles, which may be not improve even after surgical treatment.

On examination, tapping over the cubital tunnel usually causes tingling in the forearm and affected fingers, a sign of irritability of the ulnar nerve. There may be decreased sensation to testing in the ring and small fingers and over the top of the hand just above these fingers. Atrophy may be seen in severe cases. Often, in order to make the diagnosis and to quantify the severity of the nerve compression, diagnostic testing by stimulating the nerve (nerve conduction velocities), may be done. This testing can be important to exclude nerve compression in the cervical spine by disk or bone spurs.

The causes of cubital tunnel syndrome may be as simple as frequent application of pressure over the "funny bone" by placing one's elbow on tables, armrest, etc., or it may be due to thickening of Osborne's ligament for no apparent reason. Trauma to the inside area of the elbow or repetitive elbow motion may be responsible in some patients.

Treatment of ulnar nerve compression may require only instruction to the patient to keep the elbow off armrests and the like. Changing occupational activities may be helpful. If symptoms persist or are accompanied by worrisome electrical testing, surgical release of the pressure of Osborne's ligament, with or without transposition of the nerve, may be required. Transposition of the nerve is done to move the nerve from behind the medial epicondyle, where it is subject to injury and pressure, to a location in front of the epicondyle. The nerve can be simply placed under the skin, but more frequently is placed in a tunnel under or within the muscles of the upper forearm. If the nerve is not moved, it may be protected by removing the medial epicondyle so it does not irritate the nerve with elbow motion. top

Olecranon Bursitis
The olecranon bursa is a fluid filled sac behind the point of the elbow which will sometimes becomes inflamed from pressure or a blow to the olecranon process, resulting in the swelling of the bursa due to fluid or blood collection within it. Treatment consists of needle aspiration, cortisone injection, protective wrapping, and, if these fail, surgical removal of the bursa. top

NOTE: The information on this site is informational only and is not intended to be medical advice. NO ANSWERS TO MEDICAL QUESTIONS WILL BE GIVEN BY E-MAIL OR OTHER CORRESPONDENCE. Contact your physician for advice about specific medical conditions.

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